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Category: Written Blogs

PTA’s in an outpatient setting continued

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on PTA’s in an outpatient setting continued

“Low back pain syndromes (LBPS) affect more than 65 million Americans…For approximately 16 million people (8%), back pain is persistent or chronic…”

If you have a little bit of free time, you can read about back pain here.

“…a quarter of all referrals for outpatient physical therapy and one-half of all outpatient physical therapy visits are related to patients with LBPS.”

Hey New Grad ✊ are you 👂?

If you want to get really good at something and ensure job stability, then you should learn as much as you can about back pain.

If one out of every two visits per day is related to back pain, we should all be very comfortable with this diagnosis.

In my first job, I’d say that I had 2,500 visits per year with about 95% of those pertaining to the spine.

“Resnik et al reported that patients who spent more than half of their treatment episode of care with a physical therapist assistant reported worse functional outcomes and utilized more visits compared with patients with less physical therapist assistant involvement.”

Again, this is the second post in the series on PTA’s usage in the outpatient setting.  You can find the first post here.

“It is generally assumed that practitioners must possess many years of clinical experience to achieve the best results with patients and that years of experience are associated with better clinical outcomes.”

What?! I don’t agree with this.

Unfortunately, not all experience is good experience. I’ve read Tony Delitto state in an article that one year repeated twenty times is it ideal. I would much rather have a PT with two years of experience and two years worth of learning from mistakes.

“Almost half of the sample had chronic low back pain.”

This is in line with some of the statistics that I’ve heard stating that back pain makes up about 40% of all chronic pain.

“The top 3 diagnoses were pain (34.8%), sprain or strain (25.5%), and herniated disk (19.3).”

About 90-95% of all back pain is “non-specific”, meaning that we can’t attribute it to a specific tissue strain or sprain. Herniated did a are common in the population, but we can’t always attribute a herniated disc (HNP) as the cause of pain.

“On average, patients in the best clinic performance group improved 19.2 OHS points, while patients in the worst clinic performance group improved an average of 16.4 OHS points.”

This is great news!

This means that on average people get better. I used to work in a clinic in which the manager would try to schedule people with back pain as soon as possible. If we know that they will likely improve and they improve on our watch, then they are likely to use post hoc reasoning and attribute improvement to seeing the PT.

I used to joke with patients and say that they simply need to breathe the city air in the basement of the hospital in order to improve. Obviously, it’s a joke, but we have to tell patients that most injuries improve with time.

“Patients in the best clinic performance group utilized, on average, 7.7 (SD = 4.1) visits per treatment episode compared with 7.9 (SD = 4.1) in the middle clinic performance group and 9.3 (SD = 4.9) in the worst clinic performance group.”

This is where it gets interesting. There wasn’t a major difference in outcomes on the scoring improvement, but some clinics needed an extra 2 visits compared to other clinics, on average.

If an average PT sees 5 evaluations per week and it takes an extra 2 visits, then that ONE PT is averaging an extra 20 visits per month (assuming half of the evaluations are back pain). This means that the therapist keeping patients for more visits is making the clinic an extra $2,000 per month from taking longer to discharge patients.

“…clinics that were lower utilizers of physical therapist assistants were 6.6 times more likely to be classified into the high effectiveness group compared with the low effectiveness group, 6.7 times more likely to be classified into the low utilization group compared with the high utilized group, and 12.4 times more likely to be classified into the best performance group compared with the worst performance group.”

This is essentially stating that clinics that use PTAs with a lower frequency in outpatient tend to be better in terms of outcomes and faster to discharge. This mirrors the link to the study from above.

For me this is interesting because I would have never thought to ask the question in the first place. It’s good to see that someone is doing this research to help clinicians in their decisions to 1. Choose between PT and PTA school and 2. Utilize PTAs and how to best utilize PTAs in an outpatient setting.

“Our strongest finding was that clinics that had lower utilization of physical therapist assistants were much more likely to be in the “best” category of each type of group (i.e. highest effectiveness, lowest utilization, and overall performance).”

Link to article

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Rejection

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Rejection

To anyone that has ever felt rejected, you understand.

To anyone that was raised in a single/no parent home because of decisions, you understand.

This scene hits home for me because I have felt that rejection, along with many other kids. This scene plays out in homes regardless of race, income and religion. This scene still affects those that lost parents to addictions, divorce, jail, and choice.

Know that you are not alone and there are many of us that understand. We have been there.

What I still don’t understand is why scenes like this break some people and creates chips on others.

I’ve seen many overcome these situations and go on to become Uber successful due to that chip and having something to prove.

On the flip, I’ve seen some people become so broken that they continue the cycle that broke them.

We all feel rejected at some point.

My wish for the world is that people build resilience and grit in their personality so that these major hurdles become but small bumps as they grow into beautiful people that allow others to love them and be part of that circle of trust.

Check out the video that still makes me tear up.

Efficient and Effective Care

Dr. Vince Gutierrez, PT, cert. MDT1 Comment on Efficient and Effective Care

“Proliferation of these staffing models (increasing the use of PTA’s and aides) has been driven by managed care organizations, the introduction of prospective payment systems, and low reimbursement rates, as well as workforce shortages in allied health.”

For those that are unfamiliar with physical therapy and what the titles mean lets do a quick refresher:

PTA = licensed physical therapist assistant (high school + 2 years)

PT = licensed physical therapist (Bachelor’s or Bachelor’s + years)

aide = no required degree with on the job training (no degree needed)

MPT = Master of physical therapy degree (Bachelor’s plus 27 months)

DPT = Doctor of physical therapy degree (Bachelor’s plus 33 months)

Based on the above, one can see that the aide would be paid less than the PTA.  The PTA would get paid less than the PT based on education level alone and all other things are equal.

When insurance companies cut pay to professionals, companies have to decrease their costs in order to continue to make margin.  One way to cut costs is to have fewer PT’s and more PTA’s or aides.  The ethics/legalities of the decision are for a different day.

Some insurance companies are refusing to pay for services provided by PTA’s.

The reason that I bothered to look at this research was a large discussion that took place on a professional FB page in which PTA’s were arguing that the care shouldn’t change from PTA to PT, seeing as PTA’s can perform most treatments that a PT can perform.

I decided to look into this to see if there was a difference and I was shocked by what I found, based on my own experience working in a hospital system.  On the same note, I wasn’t shocked based on some of the reports that I hear from patients and others in the profession.

“Use of support personnel in outpatient therapy settings can double the number of patient visits a therapist can manage per day, thus increasing clinical productivity.”

If I am a PT making $50/hour (using round numbers to keep it simple) and in a typical day I could treat 10 patients with an average reimbursement rate of $95 (please go watch all the videos from Dr. Ben Fung ), then I would cost the company $400 dollars, but make the company $950 dollars.  A gross profit, with the removal of only the PT salary, of $550 dollars per day.

Now, if we have that same PT making $50/hour and a PTA making $30/hour (again round numbers to keep it simple), with each therapist seeing 10 patients per day, then the following numbers are the result.  The salaries would cost $640, but the therapists would generate $1900/day.  A gross profit, with salaries of the therapists removed, of $1260/day.

As you can see, the company would be able to generate more money by hiring PTA’s instead of a second PT.  The question then becomes is it cost effective to have the PTA compared to the second PT.  The answer at a glance is “of course”!, but looking a little deeper may force a company to weigh values (i.e. profit or outcomes) before making that second hire.

“While some advocate use of support personnel to increase productivity without loss of quality, others warn that an over reliance on support personnel can negatively affect outcomes and compromise quality.”

This is essentially the discussion that occurred on FB.  Some people say that PTA’s provide the same quality of care as PT’s and others state that PTA’s offer less quality care than PT’s.

I’ve worked with rockstar PTA’s (plus my wife is a PTA so I am already a little biased) and I’ve worked with some PT’s that I would never refer a patient to (no offense if you think that this is you).

“Three dependent variables were analyzed: high PTA utilization, number of visits per treatment episode, and patients FHS (functional health status) at discharge…high PTA utilization, defined as a patient seen by a PTA 50 percent or more of the treatment time”

High PTA utilization, in this study, meant that the PTA was seen by the PTA for over 50% of the visits.

Again, I have worked in locations in which this was true and locations in which we had no PTA’s, so I have seen the results from both.

Looking at treatments per episode is a means of measuring efficiency of treatment.  It may not be the best measurement, but is one way of looking at treatment efficiency.

Looking at outcomes is one way of looking at effectiveness of treatment.  Again, it may not be the best way, but it is one way.

“…less than 2 percent of patients were treated by the PTA for more than 75% of the treatment time, and 8 percent were treated by the PTA 50% of the time or more.”

I’ve been in clinics without PTA’s and with PTA’s.  This stat will be correlated with the amount of PT’s/PTA’s in the clinic.

In private practice, it was 0 PTA’s.  In the hospital we had 1.5 PTA’s for 4 PT’s.  Currently, in my practice there are 2 PTA’s for 1.5 PT’s.

“The second dependent variable, number of visits per treatment episode…We believed that fewer visits per treatment episode were a marker of greater efficiency of care”

This is debatable by people.  I’ve actually been involved in these on-line debates.  Some people will fight that more visits equals better, but more is not always better.

If we can get patients better in shorter visits, then this seems to be ideal to me.  If additional visits would correlate with increased function, then I would be all for increased visits if the patient is willing and able to pay for increased visits (time and money).

“The majority of physical therapy care was delivered by PTs with no reported assistance from PTAs.”

Again, in a clinic without PTA’s, there will be no reported assistance from PTA’s.  This study used data from FOTO, which included private practices and hospital based practices.

“PTAs were involved in the care of patients only 35% of the time. High PTA utilization was relatively uncommon, with only 7.7 percent of the patients seen by PTAs more than 50% of the time.”

This is interesting.  It is becoming more and more common to find clinics advertising/marketing that the patient will only be seen by a PT, or even a step further a Doctor of Physical Therapy.  I don’t know how well this marketing is going.

When seeing it, it subconsciously implies that a DPT is better than a PTA.  I think that this is very individualized.  For example, a PTA that has continued to improve over the years through independent study may be a better clinician than a PT that never sees patients (administration/teacher/manager).

“Medicare patients who were seen in private practice were 48 percent less likely to have had high PTA utilization.”

Some insurance companies require that a patient be seen by a PT and prohibit PTA’s from treating patients.  This will skew numbers towards the PT in private practice.

“Treatment with a therapy aide for 1-25 percent time and greater than 25 percent compared with 0 percent, and high utilization of the PTA were associated with 1.8, 2.6 and 2.0 more visits, respectively.”

Lets break this down.

Being treated by a therapy aide for 1-25% of the time resulted in 1.8 more patient visits per episode.

Being treated by a therapy aide for > 25% of the time resulted in 2.6 more visits per episode.

Being treated by a PTA for greater than 50% of the time resulted in 2.0 more visits.

Remember, an aide is someone that may not have any college experience or degrees.  The aide is not legally able to treat patients that are payed by the government.

Utilizing an aide only results in slightly more visits than using a PTA! Why is this?!

An aide is paid much less on average than a PTA.  For example, the aide may only cost the employer $12.50/hour.  The PTA will cost the employer $30.00/hour.

I see employers trying to cut costs by hiring more aides (not ethical to call it physical therapy if it is not provided by a licensed physical therapy professional IMO).

If it doesn’t change the outcomes though, who’s to argue against it?

I can see both sides of the coin.  Margins (profits) in physical therapy is small, so cutting costs is a business decision.

Providing quality care is something that IMO we should all strive for.

“Greater than 50% time spent with the PTA was predictive of lower discharge scores as was time spent with a therapy aide.”

This part may be the most important statistic in the article.  Seeing someone other than the PT led to worse outcomes.

This is the statistic that I was looking for because of the original question asked.

In other words, the PT will get a patient better than a non-PT and do it faster in an outpatient setting.

Strong words for businesses and people looking to go to PT school.

What is the future of PTA’s?  I don’t know.  Medicare just announced that they will be reducing reimbursement rates for PTA’s in an outpatient setting.  Pair this with the small margins in physical therapy and the question becomes is it profitable to hire PTA’s in an outpatient setting, seeing patients according to Medicare rules?

“…our analysis shows that Medicare regulations for continuous in-room supervision of PTA’s in private practice are associated with a decreased likelihood of high PTA utilization.”

 

“High utilization of PTA’s, and use of therapy aides were each independently associated with more visits per treatment episode, and lower functional health. Thus our findings suggest that use of care extenders such as PTA’s and therapy aides in place of PT’s is associated with more costly and lower quality care delivery in outpatient rehabilitation.”

 

I advise all people to look to the source:

link to article

 

Physio and whiplash

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Physio and whiplash

“Whiplash-associated disorders (WAD) is the term given to the variety of symptoms often reported by people following acceleration/deceleration injury to the neck.”

Most people understand the term whiplash is related to an auto accident. After the basics, everything else is like the teacher from the Charlie Brown An acceleration/deceleration injury is exactly what it sounds like.  I’m sure that if you have an older sibling you understand this concept.  My friends, I won’t say any names (Tom and Carl) used to brake abruptly to see if they could get someone to spill their drink.  It’s kind of like that, only more forceful.

When the car comes to an abrupt stop, the body will continue forward thanks to the laws of inertia.  It will typically be stopped by a seatbelt.  Some though, may be stopped by a windshield.

“Cardinal symptom is neck pain but neck stiffness, dizziness, paresthesia/anesthesia in the upper quadrant, headache and arm pain are also commonly reported.”

I have seen a plethora of patients after a motor vehicle accident (MVA).  Neck pain and stiffness seem to be the most common complaint anecdotally, but I have also seen the headache and arm symptoms.

Part of the problem with such diffuse symptoms is that not every professional will treat the patient, but instead will treat the situation.  This means that when a patient presents with symptoms that may not make sense, the professional then inserts individual bias and believes that the patient must be making up the symptoms.  I have seen this over the years in which the PT/PTA/PA/MD believe that the patient is FOS (not a medical abbreviation).  Be that the case, it is still our job to try to help that patient.  If the patient is exaggerating symptoms, we still have to sift through the exaggerations in order to determine what is organic (with a physical cause) and what is non-organic (without physical cause).

“…whiplash injuries comprise (about) 75% of all survivable road traffic crash injuries.”

Just this year I was involved in two MVA’s.  Neither of which were my fault.  As an aside, I have never met anyone that said an accident was his/her fault, in the clinic at least.  Luckily, both MVA’s that I was involved the other person admitted fault immediately.  The first accident involved me T-boning another car doing 45 mph (someone tried making a U-turn on a 4 lane highway). I experienced shock during the first accident and it took me a while to calm down.  I had back pain and neck pain, but as a professional, I knew that it would subside on its own.  This is exactly what happened, over the course of a month.  The best thing that I did was return to lifting and normal activities.  The second accident involved me being rear-ended with the other person going 40-45 mph.  Again, I had some back and neck pain.

Body heal thyself.  Father time is a powerful motivator and I was back to 100% within a couple of months.

“Consistent with international data indicate that approximately 50% of people who sustain a whiplash injury will not recover but will continue to report ongoing pain and disability one year after the injury”

There are so many variables that go into a person experiencing chronic pain.  Extent of tissue damage is not the only variable that needs to be assessed.  Sometimes people just feel wronged by life and this stress of life may contribute to symptoms.

We know that most tissue damage heals relatively quickly (at least quickly when relative to a lifespan).

“…recovery, if it occurs, takes place within the first 2-3 months following the injury with a plateau in recovery following this time point”

We know that most healing takes place over the course of weeks to months.  With this, we have to question the cause of this roadblock to recovery.  Is it truly tissue damage or is there something else at play?

“…good recovery, where initial levels of pain-related disability were mild to moderate and recovery was good, with 45% of people predicted to follow this pathway”

Glass half empty/Glass half full?

About half of the people with WAD will experience a good outcome.  Considering that not much has to be done with this group, I can see some healthcare providers taking responsibility for good outcomes.  I used to work for a clinic that tried to get people into the clinic as fast as possible with the idea being that if we don’t get the patient in fast enough, then the patient may get better on his/her own.

Think about that? We know that most things get better with time, so we want the patient to believe that it was us and our treatment that helped them the most.  As much as I can see this from a marketing perspective, from a global health perspective…it just ain’t right.

Sometimes the patients just need some advice to stay active and come back in 4-6 weeks if there is no change in symptoms.

I was in a course once talking to a PT and I asked that therapist, who also happened to be a business owner: “how do you know that you have had a successful episode of care?”

That therapist’s answer was: “The insurance has been exhausted”

Whether the therapist was joking or not, the fact that this perception is out there that the patient should be bled dry (at least monetarily) is disturbing.

Remember this when you are working in a clinic (if you’re a healthcare professional) or when you are going to see your healthcare professional.

“…initial moderate to severe pain-related disability, with some recovery but with disability levels remaining moderate at 12 months. Around 39% of injured people are predicted to follow this pathway.”

Now we are starting to play.  I use this term “play” as a measure of patient severity.  For instance, when playing basketball with my 4-year old, it’s not really playing the game as much as it is just toying around.  When playing the game against someone that I have never beaten before, I have to study the player, understand the player’s moves, his/her strengths and weaknesses, tendencies when under pressure, establish my game plan against their moves etc.  This is how I perceive a patient and symptoms when they enter the clinic.  I am studying that patient and the symptoms in order to best understand what that patient is experiencing.

I believe that only through understanding the tendencies of the symptoms are we truly able to help/assist the patient in this journey to reduce pain and return to full function.

“…involves initial severe pain-related disability and some recovery to moderate or severe disability, with 16% of individuals predicted to follow this pathway”

I love listening to this guy. He has a way of explaining severity of pain that is just not taught in most healthcare programs.  Understanding that pain is an experience is more important for the healthcare providers, because without this understanding, we can not explain this phenomenon to the patient.

“The most consistent risk factors for poor recovery are initially higher levels of reported pain and initially higher levels of disability.”

With this, the thought exists that we may be able to affect recovery with WAD if we can simply reduce pain.  We may be able to reduce pain in some populations through education.

Maybe we should attempt to use education as a means to reduce pain before we try other interventions such as heat, cold, manual therapy, etc.

It may go something like this:

Therapist: You know Mr. Smith, I have done my evaluation and there is some good news; you’re going to get better.

Mr. Smith: How do you know?

Therapist: There was nothing in my exam that showed that there was any major structural damage and we know that tissue injuries tend to improve on their own over the course of weeks to months.

Mr. Smith: That is good news!

“lower expectations of recovery have been shown to predict poor recovery”

This may be the factor that healthcare professionals should focus time trying to change.  As much as we speak to patients about tissue damage and injuries, we need to spend time in conversation understanding what they believe the barriers are to a successful recovery.

Taking the extra 10 minutes per session to have these conversations and together problem-solving ways to overcome these barriers may be more important than an extra 2 minutes on an arm bike or an extra set of banded rows etc.

Patients are people first and foremost and not a sum of body parts.  Breaking through perceived barriers is an important first step to providing the right interventions to patients.  Sometimes the intervention is only education and other times it may be more integrative of exercise, manual therapy and other modalities at our disposal.

“Some factors commonly assessed by physiotherapists do not show prognostic capacity. These factors include measures of motor and sensorimotor function such as the craniocervical flexion test, joint repositioning errors and balance loss”

We all learn tests and measures in school.  A great world would be inclusive of tests that actually mean something.  Testing balance and strength and positional awareness are all good tests to take time and give information to physicians or insurance companies, but in the end they don’t actually do much to tell the story of the patient.

We need to identify patients that will respond to therapy and those that may need for than just PT.  With that said, we also need to be able to identify those patients that will get better on their own.  Not all patients need to see a physical therapists, we just don’t have a way of telling one subset from another at this time.

“The QTF classification of whiplash injuries was put forward in 1995 and it remains the classification method still currently used throughout the world”

This is the Quebec Task Force Classification:

I No neck complaints and no physical signs
II Neck complaints of pain, stiffness or tenderness only and no physical signs
III Neck complaints and MS signs including 1. Decreased ROM 2. Point tenderness
IV Neck complaints and Neuro signs including: 1. Decreased or absent DTR 2. Muscle weakness 3. Sensory deficits
V Neck complaint and fracture or dislocation

“Current clinical guidelines for the management of acute WAD recommend that radiological imaging be undertaken only to detect WAD grade IV and that clinicians adhere to the Canadian C-Spine rule when making the decision to refer the patient for radiographic examination”

For those that are unfamiliar with, or forgot, the C-Spine rules (including myself), here is the link.

“…the same general examination procedures usually adopted for the examination of any cervical spine condition but with some additional procedures based on research findings of WAD”

When a patient presents to therapy, with complaints of neck pain, after a motor vehicle accident here are some things that a patient can expect (if you are a PT, then these are the things that we should be doing as an at least)

  1. Range of motion using a large compass
  2. Assessing strength in the arms/neck
  3. Assessing any loss of sensation
  4. Assessing loss of reflexes
  5. Assessing grip strength
  6. Assessing patient perception of symptoms using an outcome meaure
  7. Assessing joint integrity using special tests and symptom change
  8. Assessing nerve irritability

“…many patients with WAD will report diffuse symptoms of sensory loss or gain and generalised muscle weakness, both of which may be bilateral, but these findings do not necessarily indicate peripheral nerve compromise and may be a reflection of altered central nociceptive processes.”

Some clinicians think that if a symptom doesn’t match what was learned in school that the symptom must be made up.  We’ve all been around these clinicians that believe that patients must be “faking”, “malingering” or just out for the $$$ after an accident.

Truth is that we have no reliable way to tell if a patient is “faking”.  We may be able to tell if a patient is providing full effort during our examinations, but we can’t know anything beyond this.

The first thing that we need to understand is that the nervous system is complex.  Now, when I see a patient that reports increased sensitivity in an area, I report it as such.  Previously I would report a decreased sensation in the opposite side tested.  I didn’t understand, at that time, that a person could experience hypersensitivity in an area.

“…strong evidence for the presence of augmented central nervous system processing of nociception in chronic WAD and moderate evidence that cold hyperalgesia is associated with poor recovery from the injury”

The nervous system appears to be boss. When it is experiencing stress, it can drastically change how the person perceived different stimulus. I recently had a patient that was so sensitive that she noted her pain increased with the breeze from a ceiling fan.

Think of a car alarm set to really sensitive. We all have seen a car alarm that goes off from a sideways glance. This appears to be happening with the nervous system. The system has difficulty processing what is a real threat to the system and what is a normal stimulus.

Patients that have difficulty tolerating cold appear to have a heightened car alarm, which may indicate a poor overall recovery.

“The clinical course of WAD, where most recovery occurs in the first 2-3 months”

In my opinion there are too many of us in healthcare with big egos. We tend to use this basic rationale:

Patient got better. Patient was in physical therapy during this time of improvement. Physical therapy must be the reason the patient got better. 🤔

This type of logic is unfortunately mislead.

Other variables, such as time may have a role more so than the interventions performed during this time.

“The mainstay of management for acute WAD is the provision of advice encouraging return to usual activity and exercise, and this apprpach is advocated in current clinical guidelines.”

ADVICE!? That’s the mainstay?!

Not ultrasound?!

Not massage?!

Not electrical stimulation?!

How can this be?!

Body heal thyself. 💪🏼👊

“…recent systematic reviews concluding that there is only modest evidence available supporting activity/exercise for acute WAD. It is not clear which type of exercise is more effective or if specific exercise is more effective than general activty of merely advice to remain active.”

The 🥖 and butter of PT may or may not be affective for treating patients immediately post accident.

Lately, I have been seeing many of these patients and there is much education that goes into time based healing on the first few visits.

“…six sessions of physiotherapy was only slightly more effective than a single session of advice from a physiotherapist”

As much as it pains the many wallets of our profession, I definitely agree with this. Some patients that I have seen actually get some relief just from knowing the clinical expectations post WAD.

“…a graded functional exercise approach and advice demonstrated greater improvements in pain intensity, pain bothersomeness and functional ability, compared to advice alone.”

Think of those six sessions from above.  A traditional clinic may use 6 sessions in 2 weeks.  A clinic that understands the research may use those visits over the course of 6-8 weeks.

A graded functional exercise approach means that the patient is slowly performing more work load over the course of time in order to improve function.  This time period is probably no less than 6 weeks since we know that we see significant changes in strength and movement ability over the course of 6 weeks.

“…the recommendation to clinicians is that health outcomes should be monitored and treatment continued only when there is clear improvement.”

It’s unfortunate that this has to be said.  I have seen some patients treated in a clinic for months without appreciable improvements.  At some point, we have to do what is in the best interest for the patient first and foremost.  Having a patient continue to come into the clinic, in the absence of improvement, is a red flag that there may be something else causing symptoms.  Also, continuing to treat a patient may do more harm than good because the patient takes on attributes of a “sick” person.

It’s a case in which the medical system may actually cause problems through the use of treatments and information.  This type of change in the patient has been labeled as iatrogenic (caused by the medical system).

“Analysis revealed no significant differences in frequency of recovery between pragmatic (medication/physiotherapy/CBT) and usual-care groups at 6 months. There was no improvement in non-recovery rates at 6 months, indicating no advantage of the early interdisciplinary intervention.”

I read previously (I’ll have to go back and look for the article) that early aggressive therapy may actually increase symptoms of patients after a motor vehicle accident.

“Education and advice to return to activity and exercise will still remain the cornerstones of early treatment for WAD”

This year I was rear ended on the highway and T boned on another highway.

Excerpts from:

Sterling M. Physiotherapy Management of Whiplash-Associated Disorders (WAD). Journal of Physiotherapy. 2014;60:5-12.

Symptoms may or may not change

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Symptoms may or may not change

“It is clearly stated that the mechanisms underpinning any reductions in symptoms using the SSMP are not known”

The Shoulder Symptom Modification Procedure is studied and taught by Jeremy Lewis, out of England. I am a fan of this method because I like systems. Both systems that work and systems that tell tell the user when the system doesn’t work. I was able to watch Jeremy Lewis assess and treat patients on stage in front of a crowd of over 500 MDT trained clinicians. The patients that he treated were not just any patients off of the streets though, some of these patients were MDT trained clinicians that failed to improve with the MDT approach. When I saw that he was able to go from one patient to another and abolish symptoms over two days, I was sold!

I wanted to know what he was doing. After I got back from the conference in Austin, I emailed him to ask some questions. He was gracious enough to not only answer all of my questions, but to also send me all of his research and articles on SSMP.

I obviously read through the research and started using the format within my own MDT evaluations. I personally found that this method blends very well with MDT because aside from names, the principles were the same, but he provided additional information for treatment that wasn’t provided in the text booms or course work for MDT.

We know that patients get better. It may not necessarily matter which methods are used, but many patients improve with treatment. How they improve…we have no clue! No one can give the exact mechanism by which patients improve symptoms because there is not one mechanism alone by which symptoms are produced.

For all you reading at home, if your therapist is pompous enough to give you an answer that is an absolute, you may not need to find a new therapist, but you better watch your ears for they may be taking in false information.

“A common aim is symptom reduction,which, if achieved, allows the individual to move with less pain. How this is achieved is unknown”

For the most part, we all have the same goals. Get the patient better. Mind you, there are some that have goals clouded by $$$, but hopefully you find someone that is pure of heart.

I want my patients not only to be able to return to what they were doing prior to an injury, but to inspire them to do more. When a patient gets better, I’d love to take the credit, but I also know that Father Time is pretty good at what he does also.

In the end, the patients get better and we have to be able to say 🤷‍♂️ how it happens sometimes.

“Symptom reduction might not be possible, and attempting symptom change that does not achieve its goal may create hypervigilance or unreasonable patient expectations that ultimately become demotivating and sensitizing.”

We work in a team. We always work in a team. That team is either with the other professionals or with the patient. We can’t allow our biases to infect the patient and we must be vigilant to notice when our own preferences are frustrating the patient.

Enjoy! Any questions you can find me on FB at Dr. Vince Gutierrez.

Excerpts from here

Ways to mitigate burnout

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Ways to mitigate burnout

“Burnout…is a syndrome of depersonalization, emotional exhaustion, and a sense of low personal accomplishment leading to decreased effectiveness at work…primarily affected those in ‘helping’ professions”

Hey!…  Hey!…  You!… PT’s!…Are you listening?!….

Does this sound like someone you know?

“The high prevalence of burnout among physicians results in lowss of engagement and commitment…5 out of every 10 physicians affected by burnout”

Loss of engagement and commitment with patients.  Hmmm? How many therapists do you know that are “punching the clock”?

I have a problem with a lack of engagement.  It just isn’t something that I tend to do often and I have a short attention span.  Maybe not as short as the new average of 9 seconds, but pretty darn short.  I just shift the engagement to something different.

A therapist that isn’t engaged with the patient is problematic.  Patients are coming to us for our professional opinion and placing trust in us to help them along their journey of pain or functional restoration.  To have loss of engagement places that trust at risk.

Not only is trust lost between the patient and the physical therapist, but also between the patient and the profession of physical therapy.

Remember young Jedi, YOU REPRESENT THE FORCE (by force I mean the PT workforce).  Your burnout makes me look bad.  Not that it’s all about me, but really…it’s all about me.

50% of physicians are affected by burnout?!

I haven’t seen any studies on prevalence in our profession, but I hope it’s not that high.

“Many factors contribute to burnout, including high workloads; an inefficient environment; problems with work-life integration; lack of flexibility, autonomy, and control; and loss of meaning in work.”

I’ve seen research showing that treating 20 patients per day may lead to burnout.  I don’t know if it’s the 20 patients or the notes that come along with the 20 patients, but….20 patients!!! REALLY?

At my busiest time, I was only seeing about 15 per day.  This may be why I have yet to experience burnout from treating patients.

An inefficient environment.  I have experienced this multiple times.  Sometimes people and companies are just set in their ways and don’t see a good enough reason to change.

Problems with work-life integration: this is what I am struggling with right now.  Is the juice worth the squeeze?  This is a phrase that I am thinking of more and more currently.  When I think of how many hours that I am away from my kids and wife, I have to think (or my wife makes me think) about where do I want to be in life 5 years from now.  Managing a clinic takes a ton of time.  If you have never tried to build a “brand”, it takes a lot of time and work in order to get a personal brand out to the community.

Autonomy and control: I haven’t personally experienced a loss of control in the clinic,  but I hear from PT’s all over the country that their boos/manager/director almost dictates the care in order to create a “comprehensive care plan”. Now this sounds all good and nice and all, but in the end the question has to be asked…Why? Why does the boss want a comprehensive plan?

The reason is no different than any other business and it has to do with money.  Clinics make more money by doing multiple different treatments than providing one treatment that may have the best outcomes.  It’s sad…but I hear it frequently.

“Physicians who suffer from burnout are impaired and they and their organizations are at risk of having higher rates of medical errors, less professionalism, lower patient satisfaction, and lower productivity, as well as more turnover and suicidal ideation”

Does burnout sound good?

Not like the burnout that I would do on my BMX bike as a kid or in my F-150 as a teenager.

Burnout leads to major issues at a personal and corporate level.  I wonder though if the companies care about burnout.  Turnover happens in physical therapy.  Although it costs money to train a new therapist, it may not matter since many companies see a PT as a widget instead of as an autonomous practitioner.  If one therapist can easily be swapped out for another, is burnout an issue at the corporate level?

Rhetorical questions of course.

“Organizations that make investments in leadership development experience substantially higher returns than those that do not.”

This is a great quote. Invest in your people, more so than seeing your people as an investment.

For instance, when you put money into an IRA, it sits there and you hope it grows (at least matches the 10% historical APR). You are passive in this role. Hopefully money makes money. This is what typically happens in a company. The employee is expected to go out and grow individually, which benefits the company, although the company may not take part in that individual investment.

I would like to see it more as owning a home. This is an investment also. It averages about a 2% gain per year, but the individual living in the home has to actively care for the investment in order for it to keep growing. I would love for more businesses to see employees as an investment for which they should foster care. High tides raise all ships. When the employee is successful both on an individual and business sense, everyone wins.

“Clinician engagement is empirically linked to more effective organizations, with outcomes including lower turnover rates, superior clinical outcomes, better patient experience, and superior financial performance”

Does this sound like a positive experience for clinicians and patients alike?

If the clinician is engaged in not only treating patients but also regarding the health of the business everyone wins.

Some therapists don’t see themselves as business people, which is a shame because if we don’t get the patient in the door, then we can’t help that person. We have to feel confident in attracting our customer (someone with functional complaints that may or may not relate to pain), educating our customer, selling to our customer and then accepting their money. Sales doesn’t have to be a bad thing. I have been reading Rabbi Daniel Lapin and have learned that money is just as much a show of appreciation and gratitude as it is a financial transaction.

“Physicians experience highest levels of engagement when they have a degree of control over their work environment. Engage Physicians tend to receive higher patient satisfaction ratings.”

This is an indication of autonomous practice. When a clinician gets to dictate care, instead of having care dictated to the clinician, then everyone wins again.

“Combating physician burnout is a twofold process that involves 1. mitigating the structural and functional drivers of burnout and 2. bolstering individual resiliency.”

This is the Mayo Model to try to reduce burnout in physicians. This appears useful for many other health professionals also.

Quick Link to the article here

Healthcare fraud and abuse

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on Healthcare fraud and abuse

“During Fiscal Year (FY) 2017, the Federal Government won or negotiated over $2.4B in health care fraud judgments and settlements…$2.6B was returned to the Federal Government or paid to private persons.”

Put this into perspective.  If you were born today and started counting one…two…three…four, you would get to 2B right around retirement age.  This is of course assuming that you don’t sleep.

That’s a lot of money!

What’s important is to read that the money was returned to the government or paid to private persons.  This means that the Government is at least paying this much out to health care providers in order to recover the money at a later date.

There is a saying in health care…”it’s not about how much you make, but how much you keep that matters”.

“In FY 2017, the Department of Justice (DOJ) opened 967 new criminal health care fraud investigations…filed criminal charges in 439 cases.”

Again, I’d love to say that health care is a field full of altruistic people, we we know that some people suck!  They just suck. They take advantage of people.  They may have been bullied as a child and feel the need to get payback.  They may have been the bullies and just continue to try to take advantage of others.  It doesn’t matter the why, but they can’t be trusted to do the right thing when placed in a situation in which personal gain is an option.

“HHS-OIG also excluded 3,244 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs.”

When a health care provider attempts to defraud a federally funded program, the health care provider can be excluded from seeing any patients that participate in these programs.  For instance, if I were to be a shady individual and overbill or bill for services that I didn’t actually provide, the government can then say that I am no longer allowed to see these patients.  The government could also enter into a corporate integrity agreement with the person or company and allow them to see patients, but the company would have to prove that steps are being taken in order to minimize abusing the system.

“Under the joint direction of the Attorney General and the Secretary, the Program’s (Health Care Fraud and Abuse Control Program) goals are:

  1. To coordinate federal, state and local law enforcement efforts relating to health care fraud and abuse with respect to health plans;
  2. To conduct investigations, audits, inspections, and evaluations relating to the delivery of and payment for health care in the United States;
  3. To facilitate enforcement of all applicable remedies for such fraud; and
  4. To provide education and guidance regarding complying with current health care law. “

Imagine that you have the full force of the Federal Government tracking you as a health care professional.  How confident are you that you are doing everything correctly? We are responsible for complying with health care laws and regulations.

It’s unfortunate, but there are many therapists that still struggle with how to bill appropriately and will just take the word of another health care provider instead of looking up the rules and regulations.

“Relators’ Payments: $262,095,000…are funds awarded to private persons who file suits on behalf of the Federal Government under the qui tam (whistleblower) provisions of the False Clams Act”

In my opinion, this is where it gets interesting.  If anyone sees an injustice of abuse or fraud and reports it to the government, the government may pay that person(s) a percentage of what is recovered from the abusing person or company.

About 10% of what was recovered was paid out to individuals and groups that reported this fraud.

Someone is hitting the lottery by doing the right thing and reporting on those that are taking advantage of the system or are ignorant of the rules of the system.

“The return on investment (ROI) of the HCFAC program over the last three years is $4.20 returned for every $1.00 expended.”

If you are the federal government, “would you put more or less money into trying to recover more money from those committing fraud or abuse?”

I don’t see these recovery attempts to slow down over the years.

“Health Care Fraud Prevention and Enforcement Action Team (HEAT)…The Medicare Fraud Strike Force teams are a key component of Heat.  The mission of Heat is:

  1. To marshal significant resources across government to prevent waste, fraud, and abuse in the Medicare and Medicaid  programs and crack down on the fraud perpetrators who are abusing the system and costing us all billions of dollars.
  2. To reduce health care costs and improve the quality of care by riding the system of perpetrators who are preying on Medicare and Medicaid beneficiaries.
  3. To highlight best practices by providers and public sector employees who are dedicated to ending waste, fraud, and abuse in Medicare.
  4. To build upon existing partnerships between DOJ and HHS, such as our Medicare Fraud Strike force Teams, to reduce fraud and recover taxpayer dollars. “

If you are in healthcare…are you listening?!

Does this sound personal?

This is to crack down on perpetrators costing us billions of Dollars.

“DOJ and HHS have expanded data sharing and improved information sharing procedures in order to get critical data and information into the hands of law enforcement to track patterns of fraud an database and increase efficiency in investigating and prosecuting complex health care fraud cases…enables the DOJ and HHS to efficiently identify and target the worst actors in the system.”

As a therapist, you should be shaking in your boots…if you are breaking the rules.  When the DOJ gets involved, it gets serious.

If you aren’t sure if you are one of the “worst actors in the system” you should check out the statistics.

Scary statistics for some

“In January and February 2017, 4 defendants pled guilty…conspiracy to commit health care fraud and conspiracy to commit money laundering…submit false claims to Medicare and Medicaid for among other things, fraudulent physical and occupational therapy services…patients received medically unnecessary services that were later falsely billed to Medicare and Medicaid…totaling over $55 million were submitted to Medicare and Medicaid in connection with the scheme”

This may be more than most people can perceive regarding fraud, but it doesn’t always start this way.  I’ve heard that it starts with overcharging by a couple of minutes and when a person doesn’t get caught, then the billing becomes more and more unethical.  Before you know it, the person is billing for thousands of dollars of services that weren’t actually performed.

“In March 2017, an owner of several physical and occupational therapy clinics in the Central District of California was sentenced to 5 years and 3 months in prison after pleading guilty to health care fraud conspiracy…ordered to pay more than $2.4 million in restitution to Medicare…instructed therapists and others to bill Medicare for physical and occupational therapy services that were medically unnecessary and not provided”

This is unfortunately all to common.  I received calls just in the past year from PT;s in Minneapolis, Houston, NYC, and San Diego describing similar situations.  This is happening all across the country, but very few people are saying anything about it.  It is much easier to ask opinions of others that have no vested interest in the topic than it is to actually call the compliance officer for the company or call the office of inspector general.

“In July 2017…a 2-count indictment against 5 high-billing medical professionals who worked at a network of Brooklyn-area clinics where patients were paid illegal kickbacks in return for subjecting themselves to purported physical and occupational therapy, diagnostic testing and other medical services.”

Kickbacks are illegal.  Kickbacks come in many forms.  Money is the easy one, but there are others.  I’ve heard of free sports tickets, free trips to medical conferences, paying patients to show up for sessions, waiving co-pays for all patients in order to keep them in the clinic, etc. etc. etc.

If you are a patient, this is illegal and needs to be reported.  If you are a therapist, this is illegal and needs to be reported.

“In October 2016, the owner and medical director of Christian Home Health Agency in New Orleans were sentenced to 8 years and 6 years in prison, respectively, after being convicted of health care fraud for billing Medicare for home health services that were not medically necessary or were not provided.”

People go to prison.  Some worry about whether they will be shunned by their job, so they don’t report the wrongs noted in the clinic.  Some people worry about whether they will lose their job, so they don’t report it.  People are going to prison.  Jobs come and go, but time served isn’t something that one can just walk away from.  Walk away from a negative situation while you still have time…or you may find yourself doing time.

To see the report in whole click here

To learn more click here.

Burnout in Canadian physios

Dr. Vince Gutierrez, PT, cert. MDT3 Comments on Burnout in Canadian physios

This post may be the most important post that I have done in the past year.  This topic has piqued my interest since a person on a PT FaceBook page wrote about regretting becoming a PT.

My passion for this profession has grown in the 11 years since starting the profession.  I never…ever…thought that I would be able to impact people from all over the world with my content, but it is happening.  I never thought that I would be voted among the most influential therapists, but it is happening.  I laughed the first time that someone told me that they follow my content, but it is happening more and more.

This profession is awesome…if you let it be.  This profession can be very destructive to those in the profession…if you let it be.

Today’s post will cover burnout and will take quotes from the paper “Burnout Among Alberta Physiotherapists”.

“Burnout is defines as ‘…a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity.'”

Is this the healthcare practitioner that you want as a patient?

Is this the healthcare practitioner that you signed up to be when you graduated from PT school?

No?  Well then what are you going to do about it?

If you don’t make a change in your life situation, then life situations won’t change around you.

I have more zeal for my profession now than I did 10 years ago, 5 years ago and even 2 months ago.  I am meeting new people on social media and engaging in meaningful conversations with the “big dawgs” of the profession.  You know what…so can you!  You just have to take that first step from behind the keyboard or phone and just reach out.  Everyone that I have interacted with, from across the world, has been very awesome to talk to and at no point did I ever feel like I was a burden or a vampire on their energy or time.

These relationships help to prevent emotional exhaustion for me.

I love people! Really, I do…most of the time at least.  I don’t understand the depersonalization portion of burnout, because we signed up for working with people.  This is an inherent part of the job.

Reduced personal accomplishment….hmmm…what do I say about this?

This is inherent.  I don’t understand how an external force can allow for reduced personal accomplishment.  Each day we have choices to make.  One choice could be to stay in the situation that you are in, but another could be to just make a different decision.  I have worked with many people that weren’t satisfied with their job or their career, but when asking them why don’t do something different, the answer was always the same…I can’t afford to.

When the money becomes to good to leave, there is a problem.  When the money over rides personal accomplishment and satisfaction, there is a problem.  The problem is that the person may no longer recognize the person looking back at him in the mirror.  I’ve made 6 figures in this profession.  I took a major pay cut and essentially started over.  I have to work multiple jobs in order to try to accomplish a goal of being my own boss and creating an army of PT’s that have similar goals and wants in the profession.  I will try to keep this dream alive as long as possible.  This is what I am trying to accomplish.

“The concept of work engagement is also relevant and is considered the opposite of burnout. Individuals may demonstrate a high degree of burnout if they report high levels of emotional exhaustion and depersonalization and low levels of personal achievement.”

here is so much that I struggle with in these papers.  I come from a blue collar family.  My dad served as a Medic in the 101st Airborne during the Vietnam War.  When he returned home, he went to work as a laborer putting in water and sewer lines.  He nearly died multiple times at his job and he showed up he next day.  He had multiple broken bones from accidents and he showed up the next day.  Work ethic seems to be a lost trait.  For years, I just put my head down and worked.  I made my first boss look good.  I made my second boss look good.  At not time did I ever worry about making myself look good.  I always assumed that if I made the organization look good that I would reap the benefits.

I had to leave my last job because there was too much of a gap between the highest producer and the lowest producer not only in terms of productivity, but also in terms of patient satisfaction and outcomes.  That’s when I realized that I could no longer continue to work for the same company and decided it was time to put my work ethic to use for my family and my community.

This is work engagement.  When I realized that I needed to shift places of employment, I really learned about professional engagement.  In the year of deciding to leave the comfort of a fairly high paying hospital, I since became one of the most influential people of 2017, simply by putting my head down and working.  I am hosting my first CEU course in the next month and I have found a way to piece together enough hours through other opportunities to cover the lost income from leaving the high paying cushy job.  I will continue to put my head down and work.   I feel like I am accomplishing more at this point in my career than I did during the previous decade.

“Research has demonstrated that burnout and work engagement are negatively correlated”

This is not earth shattering information, but serves to demonstrate that loving your job and actively engaging your work can combat depersonalization and emotional exhaustion.  My previous cushy job had me working from 9:30-6 M-F without any forced weekends or need for overtime.  I was paid higher than the median salary, but I realized that the company as a whole was full of donkeys.  This is a Dave Ramsey reference.  Don’t get me wrong, my immediate team had some thoroughbreds, but they were definitely outnumbered by… you guessed it!

I saw myself climbing the ladder at this location and when I got near the top rung, there was no place left to grab onto.  Some of the people that had the position that I was gunning for had no intention of retiring.  At that point, I knew that if I stayed it would only have been for the $$$$$.

“37.3% of survey respondents were estimated to demonstrate a high degree of burnout based on thier EE (emotional exhaustion) subscale sore.”

Overall, the scores for burnout were average to low, but there were some aspects of the survey that demonstrated high burnout levels.  Being emotionally exhausted is a topic that was recently discussed in a FB post.  One PT posted that he was emotionally drained from the treatment of patients.  This is an issue and should throw up a flag for some employers.  When looking at work engagement and burnout being negatively correlated, there is research that states that high burnout rates may lead to compromised care.  Hopefully, this is actually a concern, but in reality I’ve learned that many corporate based therapy clinics care more about the Benjamins than patient outcomes.

“Respondents 61 years of age and older reported statistically significantly lower mean EE (emotional exhaustion) scores than respondents in other age categories…there was a decreasing trend in depersonalization scores with increasing experience”

There is a light at the end of the tunnel…and it’s not an oncoming train! If you can make it in this field for at least 30 years, then you will no longer let it get to you.  (I’m trying to make a funny).  Why should we have to wait until almost retirement age before we experience less emotional exhaustion and depersonalization.  I have personally seen this in practice, but from my experience, it is due to the therapist just not caring as much.  It’s like some of them have started counting down the days to retirement.  I’ve seen therapists that are more focused on the upcoming vacation than they are on the patient in the present.  They anticipate the vacation for weeks and then leave for a week or two and when they return they talk about it for two months until they start to anticipate the next vacation.  Work is just a way to pass the time while waiting for vacation.  Nothing wrong with that if it’s your style, but that’s not the Doctor that I want treating me!

We have to do better, otherwise the newbies in the profession won’t last until they can reach the age in which they can stop caring about the stresses of the profession.

There were some flow sheets from the paper that I will put in at the end.  I highly recommend reading this paper as a whole if you are interested in burnout.

“The most commonly reported symptoms of burnout related to fatigue and exhaustion”

It’s not uncommon to hear that therapists are staying after hours to complete documentation.  If you are a patient and you have read this far…kudos to you.  After your visit with a PT, the note may take anywhere from 5 minutes to 30 minutes to complete.  If the therapist is spending 100% of the time with you, then the note will have to be completed after you leave.  If the therapist is seeing 12 patients per day, then there could be as much as 2-3 hours of paperwork left at the end of the day.  In many places, this time is unpaid since it is part of the salary.  If it is paid, then it may count against the therapist because the time is “unproductive”, which means that the company is not making any money although they are paying a therapist to work for that time period.  This is a no-win for the therapist…unless they are over 61 years-old, of course.

“Respondents identified many perceived work-related causes of burnout including work overload, unrealistic expectations, lack of recognition from management and client demands.”

Ours is a profession that is consistently ranked in the top 10 professions in the country.  Why would there be people feeling burned out?

We get into this profession with dreams of helping people and fixing the world.  Those dreams are quickly crushed when corporate greed takes precedence over patient care.  It’s not uncommon to see a therapist trying to manage the circus of “treating” (I use that term loosely here) multiple patients at once.  I have talked to therapist that take pride in “treating” 30 patients per day.  I don’t know how much “treatment” actually gets accomplished when there are three patients in the clinic at the same time.  They actually wear it like a  badge of honor.  sometimes these therapists don’t understand that specific insurance companies require that a patient be treated one-on-one.  This means that the therapist is legally required to only charge the patient for the time that the therapist is actually working with the patient.  We are not allowed to charge insurance companies for having a technician (usually a high school or college that wants to be a therapist).

Patients: If you are unsure if the person treating you should be treating you, simply ask if the person has a license

Therapists: if you are allowing technicians to treat patients…why? Does it benefit you, corporate PT or the patient? If you can answer the patient, I follow with one more question…Is there ever a time in which you believe that the patient is in better hands with an unlicensed professional than with you?

Unrealistic expectations? Never!

I’ve seen therapist that are expected to do their paperwork at home for 2-3 hours per night.  I used to be one of those therapists.  You essentially are working 60 hour weeks for 40 hour pay.

If a patient is doing well and is ready for discharge, good luck with that.  There is pressure from some supervisors to keep patients longer than they need to be in therapy.  This too is illegal, but I hear about it on a monthly basis from therapists all over the country.

Client demands! The client is the boss.  There are very few demands from the client that we shouldn’t attempt to accommodate. The chief demand is accessibility.  Patients want access to therapists essentially around the clock.  This is to be expected in a social driven by social media and access to news/information and advice.

“…burnout prevention…maintaining a healthy lifestyle, and the importance of social relationships.  Within the work environment, flexible hours, career change, positive workplace relationships and continuing education were perceived to help prevent burnout”

All you new grads………

Re-read that paragraph!

Get out there an move! Be an example that your patients can follow.  It will not only give you more authority with your patients, but it may save you from burning out in the long term.

Flexible hours are a plus, but the positive workplace relationships is what kept me in a position for 10 years.  I was able to work with the thoroughbreds for a majority of my career.  I started at that location taking a pay cut from the previous job because I was impressed with some of the people with whom I would be working side-by-side.

Recommendations for employers:

identify burnout early

improve communitcation

address flexible work hours

provide recognition

provide professional development

These are paraphrased from the article and I find some of them overkill.  Zig Ziglar repeatedly stated that people would quit jobs because they were underappreciated.  I have never felt this way in my over a decade long career.  I have always been the work horse in the company, whichever company I worked for, and have never felt unappreciated.

Work hours are important for family and life balance, but goals have to be determined.  If work-life balance is the chief goal, then the flexible hours are extremely beneficial.  If work and learning your craft is important then so be it and make your choice from there.

This is by far and away the most important post that I have done in the previous 2 years of posting.

I hope that all those that read this learn from this and don’t allow themselves to get eaten up by this profession and fall to the wayside due to burnout.

Excerpts from:

Bainbridge L, Davidson K, Loranger L. Burnout Among Alberta Physiotherapists: A White Paper. Physiotherapy Alberta. 2017:

The importance of sleep

Dr. Vince Gutierrez, PT, cert. MDTLeave a Comment on The importance of sleep

“Humans spend roughly a third of their lives sleeping.”

Some people say that there will be time for sleeping when we die.  Unfortunately, by having this attitude, one may get to test it sooner rather than later.  There is no shame in sleeping.  Some wear it as a badge of honor that only 4 hours of sleeping is needed, but as you’ll see later this is not a good idea.  Here’s a list of power people that sleep less than the 6-8 hours per night recommended.

“…it has been recommended to consider sleep as another vital sign, as sleep can give insight into the functioning and health of the body.”

There have been multiple suggested vital signs such as pain, walking speed and now sleep.  I am not saying that sleep isn’t important, but to call it a vital sign may be over-rated.

“…between 50 and 70 million adults in the US experience chronic sleep disturbances, and 62% experience a sleep problem several nights a week.”

Sleep is vital, but maybe not a “vital sign”.  If you are having a problem with sleep, this could be a sign of something more serious, if not it could lead to something more serious.

For instance, my daughter has Down Syndrome.  This is a genetic mutation of the 23rd chromosome, which leads to multiple physical changes.  One of the changes is a larger than average tongue and smaller air passages.  This is in combination with low muscular tone.  The incidence of sleep apnea in kids with Down Syndrome is 50-100%.  One of the side effects of sleep apnea is right sided heart failure, pulmonary hypertension, and delayed growth.  These are some serious effects of a lack of sleep.  I can speak for my daughter, but she will undergo a sleep study around the age of 3-4.  I have some patients that have sleep issues and this is what I hear about doing a sleep study:

“It will be too inconvenient”

“I don’t want to know the results”

“I don’t want to have anyone watch me sleep”

In the grand scheme of things, I will not let ego override my daughter’s long term health.  I don’t understand this belief system, but will always try to educate the patients in order to ensure that my patient’s health is as good I know that it has the potential to be.

“Costs associated with insomnia, which is the most prevalent sleep disorder, are over $100 billion per year due to health care costs, accidents, and decreased work.”

Difficulty falling asleep or staying asleep is termed insomnia.  Think of how much money we spend in health care related costs.  Add musculoskeletal pain costs to isomnia costs and the total is 340 billion.

If you could save $100,000/year, it would take you 3,400,000 years to save 340 billion dollars. If you could save $10,000 every single day, then it would only take you 93,151 years to save 340 billion.

As you can see, if we can start to improve national health, then we have the potential to save more money than I could count to in a lifetime.

“…proposed that knowledge about sleep and skills to screen sleep disorders and to promote quality sleep are important components for physical therapists to promote health and wellness.”

I’ll be honest.  We don’t learn much about sleep in school.  At least we didn’t 10 years ago.  It’s hard to say if this has changed much in the previous decade, as I don’t hear many new graduates talking about sleep.  Everything that I learned about sleep and health has come from a few podcasts from people like:

  1. Dr. Kirk Parsley
  2. Tim Ferriss
  3. Dave Asprey

It’s great that there is more research being published in the field of PT regarding sleep, but this is a population health issue and needs to be addressed by all health care professionals.

“Of the 43% who reported that they do not routinely assess their patient’s sleep habits or sleep quality, the most frequently reported reason was: ‘I do not know how to assess sleep habits or sleep quality.'”

I am not surprised by this number…actually I am.  I am shocked that it is not higher.  I am shocked that half of all therapists are actually assessing sleep habits or sleep quality.  I think that most of us, in orthopedics ask whether or not sleep is disturbed, but I don’t know if this qualifies for asking about quality and sleep habits.  Actually, I hope it doesn’t because this is a basic question that doesn’t assess much other than sleep or no sleep due to pain.

I ask my patients about urinating during the night, how many hours of sleep is achieved during the night, what the environment (room) is like regarding electronic devices and lights.

This is stuff that I had to learn on my own and wasn’t even mentioned in a Doctorate program.

“sleep is critical for immune function, tissue healing, pain modulation, cardiovascular health, cognitive function and learning and memory.”

We already talked about heart health and sleep quality in the personal story of my daughter.

There is some published research regarding a lack of sleep and an increase in Substance P.

Dr. Kirk Parsley speaks frequently of the effects of a lack of sleep on cognition.

“Without adequate sleep, people can experience increased pain perception, loss of function and reduced quality of life, depression, increased anxiety, attention deficits, information processing disruption, impaired memory and reduced ability to learn new motor skills, and are at an increased risk for accidents, injuries and falls.”

I don’t think that too many people will argue about the importance of sleep.  We absolutely need it, but some can go days without sleep.  Albeit, there will be some side effects.

“People with sleep disturbances report increased sensitivity to pain, but also those experiencing high pain intensity have reported significantly less total sleep time, delayed sleep onset, increased nighttime wakening, and decreased sleep efficiency.”

As a therapist, this part plays an important role in my care.  I would estimate that about 90% of my patients are coming to me for some sort of pain complaint.  Sometimes this pain can keep the patient awake.  Knowing the role of Substance P regarding pain and sleep, I ask 100% of my patients about sleep.  If sleep is disturbed, then I know that I have to attempt to understand the problems with sleep.  If the problems go beyond sleep hygiene, then the patient is referred out to a doctor that specializes in sleep studies.

“providing interventions to improve sleep may impact pain and thus improve outcomes”

This is why it is so important for PT’s to ask about sleep!  It may affect our outcomes!

We are all (I’m an optimist) trying to get patients better and we have to look at all of the variables that we can manipulate in order to achieve this goal.

“understanding the important relationship between sleep and pain could profoundly influence the treatment interventions targeted toward changing the patient’s experience of pain”

Just by improving sleep, we may be able to decrease a patient’s pain experience and improve function as a result.

“long duration of sleep (>8-9 h per night) was associated with an increased mortality due to cardiovascular disease and increased risk of developing coronary heart disease…short sleep duration (<5-6 h per night) was associated with an increased risk of developing or dying from coronary heart disease and weakly associated with developing other cardiovascular diseases.”

This is the paradox of sleep.  Get too little and no bueno, but get too much and equally no bueno.  Looks like 6-8 hours per night appears to be the right amount.  Reading this paragraph makes me think of the three bears.

“Sleep apnea…increases the risk of developing cardiovascular disease…heart failure and stroke…breathing stops temporarily, which decreases the level of oxygen in the body alerting the brain to excite certain receptors.”

Fight or flight? When a person stops breathing, the body becomes excitable and stresses out.  This stress can raise BP, increase heart rate and cause other neurological responses.

“About 75% of people with depression experience symptoms of insomnia…almost 20% of those with insomnia have clinically significant depression and anxiety.”

This is a quick question that we can ask when someone notes that they have anxiety or depression, which is typically asked on a history intake form.

“sleep may play an important role to the development of Alzheimer’s disease”

This has to do with neurofibrillar tangles in the brain.  This is another topic of concern for me and my family.

We are doing a lot of studying in order to understand the ramifications of Down Syndrome and there is a high likelihood of developing Alzheimer’s disease.

We put some coconut oil in her cereal and oatmeal.

“…sleep hygiene has been associated with improved sleep quality in college students and in patients with low back pain…reduce pain and fatigue in people with fibromyalgia”

Sleep hygiene is ensuring that the environment and other factors surrounding the act of sleep are ideal for sleeping.

 

Sleep hygiene education

  1. “Go to sleep and wake up at the same time every day and exposure to bright natural light is helpful to set your natural biological clock”
    1. some people will use blue lights in the AM to try to help with waking or to prevent the “winter blues”
  2. Use your bed only for sleep and sex. Do not eat, work, or watch TV in bed.
    1. Getting a little graphic, but the bed needs to be a place meant for things done horizontal.
  3. Develop a relaxing bedtime routine
  4. Avoid moderate to vigorous activity at least 2-3 hours before bedtime
  5. Avoid caffeinated foods and drinks at least 4 hours before bedtime
  6. Refrain from drinking alcohol or smoking at least 3-4 hours before bedtime.  It can cause you to wake up during the night and smoking can act as a stimulant
  7. Do not take un-prescribed or over the counter sleeping pills
  8. Avoid daytime napping so that you are tired at night and can fall asleep easily.
    1. Some people advocate for polyphasic sleep
  9. Make your sleeping environment comfortable and relaxing. Avoid light, wear earplugs and use a mask if needed
  10. Avoid eating a large meal or spicy food 2-3 hours before going to bed
  11. Talk to your doctor or health professional if you still have trouble sleeping.

Thanks for reading.

You can find me at movementthinker on Itunes and if you have questions can also send me a message at Goodliferehab.com.

Excerpts taken from:

Siengsukon CF, Al-dughmi M, Stevens S. Sleep Health Promotion: Practical Information for Physical Therapists. Phys Ther. 2017;97:826-836.