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Medicare for all

Are you paying attention?

Medicare for all would not be a great option, since we can barely sustain Medicare for some.

Government has to get more and more creative in order to make the đź’° last longer.

Part of that creativity is to reduce output.

Another part of that will be to increase revenue to this system.

Reducing output is easy. They are simply paying less for services and taking less risk than previous years.

For instance, ACO (hospitals and other entities) are seeing less reimbursement than previous years for the same procedure.

Less income means that the hospitals have to find other ways to generate income or to become “leaner” in their operations. This may mean less one-one time for PTs.

What do you think the solution should be?

See some of the comments to understand why we are running into problems.

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Functional movement screening: the use

“The rehabilitation professional must realize that in order to prepare individuals for a wide variety of activities, screening of fundamental movements is imperative.”

I agree with this statement. I disagree that we yet have a tool that can screen all individuals from all sports. This screening tool has yet to prove its worthiness of use on athletes.

I recently was certified by USAW as a weightlifting coach. I really like what they use to screen participants before allowing them to train the weightlifting lifts of the clean and jerk and snatch. They use the basic movement patterns, without load or speed, that are needed in order to perform the entire lift safely.

This makes logical sense, but I don’t think a study has been performed to see if this is a good/bad thing to do prior to allow safe lifting.

The FMS is proposed to be a screening tool for athletes and tactical workers. I’m not sure this one tool can encompass all of the movements required in life.

It’s still a good thing to learn about, not for use as a screen, but instead to better understand how the body as a system can move through the spectrum of very stiff and weak through very mobile and supportive.

“Many individuals train around a pre-existing problem or simply do not train their weaknesses during strength and conditioning (fitness) programs.”

If a person is unaware of a problem, this is also a problem. I would be all for a low cost screening tool, which everyone is required to have tested on a yearly/decade basis.

For instance, someone that lacks ankle mobility may not know that they are unable to squat without something under their heels. They may not know that this leads to increased use of the anterior chain, which increases knee stresses. They may not utilize their hips and may round their back when performing their repetitive squatting activities.

There are so many possibilities for a person to lose mobility, that this should be screened. The problem is that we have yet to know an effective screening tool.

“The perception of many past researchers is that no set standards exist for determining who is physically prepared to participate in activities”

If there are no standards, then everyone can participate in a physical training program. This is only partially true. There are some standards, but not many.

1. The person must be breathing

2. The person must not be at a major risk of death if participating in an exercise program

3. Start exercising!

“…the main goals in performing pre-participation, performance, or return to sport screening are to decrease the potential for injury, prevent re-injury, enhance performance, and ultimately improve quality of life”

This is what makes a universal screening tool so hard to find. I don’t even think we have a tool for different positions of the SAME sport because the requirements are so diverse. I keep bringing up the USAW screening tool, but that’s because the athlete, in the end only needs to be safe enough to perform TWO movements. The screening tool has more movements than needs to be performed. If this were to hold true for any other sport, the screening tool would be too long to be useful.

“…intended purpose of movement screening (1) identify individuals at risk, who are attempting to maintain or increase activity level (2) assisting in program design by systematically using corrective exercise to normalize or improve fundamental movement patterns (3) providing a systematic tool to monitor progress and movement pattern development…(4) creating a functional movement baseline”

I can agree with all of the above stated. Im not sure if research supports these statements, but they sound pretty good.

I do like the idea of creating a movement baseline, but that baseline measurement will need to be extensive enough to capture relevant information to that patient.

“The FMS (TM) is comprised of seven fundamental movement patterns (tests) that require a balance of mobility and stability (including neuromuscular/motor control)”

This is true. The seven movement patterns tested are adequate tests for ADL’s but I don’t know if it goes far enough to test anything other than a persons baseline movement.

“The term ‘regional interdependence’ is used to describe the relationship between regions of the body and how dysfunction in one region may contribute to dysfunction in another region”

I speak with many PTs throughout the week that know this term and can recall this term, but don’t apply this term on a daily basis when working with people. For example, a significant loss of dorsiflexion (ankle flexibility) will keep the knee from bending and shifting towards your toes. This will in turn cause you to learn more forward with your hips.

A loss of movement at your shoulder can make you move your back more when reaching overhead.

This is the term regional interdependence at play.

“Programmed altered movement patterns have the potential to lead to further mobility and stability imbalances, which have previously been identified as risk factors for injury”

This is where I start to deviate a little from the article. There are way too many logical jumps being made without proof that a screening tool is predictive of injury.

“…an important factor in prevention of injuries and improving performance is to quickly identify deficits in symmetry, mobility, and stability because of their influences on creating altered motor programs throughout the kinetic chain”

I don’t agree with this.

Everything here forward is my opinion and I don’t have any proof that it’s true: we live in an asymmetrical world. We start off as one handed or one footed. We play sports that drive this asymmetry. It’s hard to say that moving towards a more symmetrical society will improve performance in asymmetrical sports or activities.

I personally don’t think it happens.

There are many saying that at a young age that kids shouldn’t specialize, and I would agree with that, but at what age does specialization become more appropriate. I remember hearing stories about Ken Griffey Jr (one of the greatest baseball players of all time with baseball being a very asymmetrical sport) playing basketball in order to improve mobility and hand eye coordination.

It’s a theory that working towards symmetry improves performance, in just not at that point yet.

“Scores serve to tell the professional when a person needs more investigation or assessment”

The score on the movement screen does not predict injury. It just states that the person doesn’t move like the ideal.

For instance, my shoulder mobility for the internal/external rotation test is not ideal. That’s expected for me because I have shorter arms and am overweight. The investigation of this test is that I have to lose weight in order to see if that has an effect on my testing. The same “problem” of being overweight can affect the rotary test in quadruped as the belly can get in the way of the test. “Problem” solved. It may not be a muscle/joint problem at all.

Read the article to see the testing and what the authors propose that the test is measuring.

Link to article

PT and tendons: where are we at?

“Complicating matters further is the mismatch between reported pain (and disability) and imaging (and pathology), as well as evidence of widespread sensory nervous system sensitization in some tendonopathies.”

A little background. Pain is not always viewable. This is a large debate even among the highest level of pain organizations. The IASP (Thanks to Colin Windhu for catching a mistake) is looking to change the definition of pain to include tissue based problems, or at least perceived problems.

Not all pain has a tissue based component, as some have a cognitive and emotional based component. For instance, I treated a person that was so afraid of performing activities that this person developed a pain from the thought of movement. After establishing that movement was safe, this person more than 10X increased the ability on a functional test…in less than 6 weeks.

This person, and others that I’ve worked with, have a “stinking thinking” type of pain. This may not be the fault of the patient, but instead it may be the fault of the faulty medical system. One that drives fear.

How many people have heard a physician say

“This is the worst spine I have seen”

“You shouldn’t squat/run because it’s bad for your knees”

“You shouldn’t work with heavy weights because it’s bad for your back”

“Your knees/hips are bone on bone and you will need a new knee/hip in the future”

Your pain is because you have a rotator cuff tear/disc herniation/arthritis etc”

These types of interactions do more to hurt the patient than help the patient and can start the cycle of inactivity out of fear of breaking oneself.

Don’t buy into the hype. A little stat, when a physician diagnoses your back pain as a herniated disc, arthritis, muscle strain, stenosis, etc do you know that the diagnosis is only right about 10% of the time?!

People are hanging their health habits in a guess that has a worse chance of being right than flipping a coin. You would have better odds of getting 4 of a kind in Texas Holdem.

Let’s start by not placing too much weight into the diagnosis because it’s a best guess at best.

Here’s what we think may happen. Some pain can cause more pain. Nerves can communicate with each other.

It’s similar to an infection. Any nerve that comes in contact with the nerve that is irritated can then become infected (irritated). Hmm?

I’ve seen many patients that experience widespread pain even though “everything is healthy”.

Yet another reason not to hang your hat on one specific tissue problem.

“… A diagnosis of tendinopathy is reasonably easy to make clinically, on the basis localized pain over the tendon that is associated with loading of the tendon.”

If you hurt your biceps and you ask your biceps to work, it makes sense that it may not like that.

If you hurt/injured your biceps and it hurts when you make your ankle muscles work, we wouldn’t expect that to create a problem in the biceps if the problem is localized to the biceps.

Make sense?

In other words, when a tendon is injured, we expect specific behaviors like

1. Pain with contraction under load that may increase with increasing loads

2. Pain with compression of that area

3. Pain with stretching that specific area

4. No issues when that area is not moving.

If the symptoms operate outside of this narrow set of parameters, it may not be only a tendon issue. This is not to say there isn’t a tendon issue, but instead is meant to say that the tendon may only be a part of the problem and we have no idea how much of a part it is until more assessment is done.

“…management of tendinopathy should optimally involve addressing loading of the tendon”

A tendon connects a muscle to a bone. It doesn’t have a ton of blood flow and can be slow to heal.

It needs to work in order to get back to its normal function.

This is what it means to load the tendon. Make it work, but don’t irritate/create harm. As long as the tendon/pain is not worse following an activity…awesomesauce…no harm done.

“Management of load…usually commenced with complete removal of offending activities and the introduction of appropriate and graduated loading activities”

If you break your leg, you will expect to be on crutches. This is to allow the bone time to heal. This stage lasts anywhere from 4-6 weeks. Loading before then one is ready to accept load can result in worsening the injury. You would know this because the pain worsened or you would break it further.

Loading a tendon before it is ready to be loaded OR more than it is ready to accept will lead to increased pain in that area, pain that is lasting and worsening function over time.

These are the clues a patient needs to give their attention towards.

Sometimes you need to remove all load from a tendon to allow it to rest and others you can perform your normals daily activities, but any more would result in increased pain that lingers.

When the pain no longer lingers after an activity, it is time to do more activities and create a new norm.

It doesn’t have to be any more complicated than this. Some research shows that 1200 repetitions of calf raises should be performed weekly, but it doesn’t have to be this structured.

“…requires patient buy-in…involves the clinician educating the patient about the nature of the tendinopathy, its relationship to loading, and a likely recovery trajectory.”

This is by far and away the most important detail.

If the patient is not educated on how the body should respond AFTER performing the activity, then the patient may be reluctant to continue anything that creates transient (short-lived) pain.

This is one of those issues that only gets better with direct loading. It doesn’t “fix” with time because it needs to be strong enough to handle the loads that you would throw at it on a daily basis.

“This exercise program should be adequately supervised, reviewed, and progressed to ensure adherence and resolution of the tendinopathy.”

SOAPBOX: ADEQUATELY SUPERVISED DOES NOT MEAN THREE TIMES PER WEEK FOR SIX TO EIGHT WEEKS. THE PATIENT SHOULD BE PERFORMING THE HOME PROGRAM AND THE THERAPIST IS IDEALLY ONLY A PHONE CALL AWAY. THE PATIENT SHOULD RETURN IF SOMETHING U EXPECTED HAS OCCURRED OR THE PATIENT NO LONGER IS ABLE TO REPRODUCE THE SYMPTOMS WITH THE LOAD THEY ARE USING AT HOME.

“(a) symptom-guides management, (b) symptom-modification management (c) compressive versus tensile load (d) stages of loading through the rehabilitation process (isometric and isotonic strengthening, energy storage and release, return to play), and (e) what I will refer to as movement competency…in a way that does not provoke pain.”

This doesn’t need to be summarized and is great advice for most soft tissue disorders.

“In the lower limb (Achilles tendon, patellar tendon), it appears that pain up to 5/10 on a numeric pain rating scale during and after training is not harmful and may be desirable”

This is a little more aggressive than I go initially, but the patient’s response gets to dictate how hard we push.

If there is a 3 point change and the patient is no worse after repeatedly creating a 3-point change, the. They have earned the right to go to a 4-point change. At some point, we would predict that too much of an increase would lead to an inflammatory effect, but we just don’t know what that number is for that specific patient.

The only way we will ever know is to test it.

“The fad of giving all patients with tendinopathy an eccentric exercise program from the onset has largely abated; however, after adequate strength of the muscle has been achieved, it is necessary to use eccentric exercises to reinstitute the energy storage/return capacity of the musculotendinous complex”

Not sure if this is any different than just load the tissue. The tissue needs to be able to contract under load and stretch under load. That’s normal mechanics for a muscle.

“Movement competency…is mainly about the form and shape (posture and alignment) with which physical activity is performed.”

This is consistent with what Dr. Kelly Starrett has been preaching for years through his books, videos and interviews.

A squat should look like a certain shape and many things look similar, such as a lunge (squat with one leg), clean start position, deadlift start position, standing up from the toilet etc.

Of course I know there are nuances between the squat and deadlift regarding hip height and back angle, the clean and lunge regarding shin angle etc, but in the end the basic shape still applies (knee bent and hip bent with shoulders forward and back fairly flat with head looking straight ahead). The similarities are where most people need to function and the nuances are what make the exceptional athletes different.

Link to article

Life purpose and changes

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

Adam Robinson

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

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

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

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

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

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

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

Love your life or change it

Dr. Vince Gutierrez, PT

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

 

Prone lying

I hear it frequently…this is an exercise?!

Sure, if it fulfills the purpose of making one more mobile, more resilient and more awesome!

This position is called prone lying and just means that you are lying face down.

For people with back pain, this has been referred to as the rescue position.

This position can be highly effective in reducing back or leg pain in 49-64% of people with symptoms.

Is it for everyone?

No..of course not. There is not a single exercise that is beneficial for 100% of the population that has pain, but there are patterns.

If your pain worsens with sitting, bending or twisting then this may be beneficial.

If your symptoms worsen withstanding or walking, this position may not work well for your symptoms.

Some things to note:

1. If you get into this position and your symptoms move further away from your spine…no good and you should stop and seek a full evaluation

2. If your symptoms move closer to your spine, you should pick up the book “Treat Your Own Back”.

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.

Car 54

Do we see a problem with this picture?

How far do we have to go still in order to educate the public?

When people think back pain, they don’t think of physical therapists. When people think concussion, they don’t know where to turn.

As a professional, I do all that I can to educate the public, but in the end still have to apologize for our profession’s apathy.

We have no brand…better yet we have a brand, but not a consistent one.

I believe it was Therapy Insiders that did an episode of asking people on the street what they thought of when they heard the term physical therapy. Our roles in the SNF and acute care hospitals seem to be cemented in people’s mind because these answers were given, but we weren’t the first ones thought of for pain or back pain.

We have to do a better job folks. Get out there and educate the public on SoMe, in person, small groups or online. Every little bit helps. Let’s hope that if this same survey were done again in a year that the number would be far less.

Online presence

I think that this sums it up. If we aren’t posting online on our personal websites, on social media (SoMe) or on a work website then we are missing out on contact points with over a third of the population. Our role has to grow larger than treating the patient that walks in the door with a referral. We, as a profession, have to go out there and educate the public, medical doctors, podiatrists, dentists, laborers, plumbers, and at times other therapists.

We don’t get to sit in our offices anymore and wait for patients to come to us, but we have to go out and educate!

How are you establishing a presence in your community, your workplace and your profession?

Leave comments below.

HOW PT CAN HELP WITH FMS

HOW CAN PT HELP WITH FIBROMYALGIA?

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

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

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

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

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

“…prevalence rates between 0.5% to 6%”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thanks for reading and I hope it was helpful.

Excerpts taken from:

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