Tag: Wilmington physical therapy

Grit

Talent x Effort = Skill

Skill x Effort = Achievement

There’s an old saying, “hard work beats talent when talent doesn’t work hard”.

I preach this to my daughter now that she is old enough to understand.

Growing up, I was a chubby, 5’10”…ATHLETE!

I’ll be damned if anyone was going to outwork me. I couldn’t make a lay-up for the life of me, but could shoot lights out behind the arc.

I was always picked for three on three games though because I was going to hustle, didn’t need to score and would defend like a pit bull.

In baseball, I never was the most talented or the fastest, but after a game I would always be the first at the concession stand for the free pizza and soda. There wasn’t anyone faster than me for the sprint to food…do I mention I was chubby?

I was always taught to be the hardest worker in the game and I didn’t get to sit back and coast. I didn’t have the talent for that.

The one area that I have the talent to coast is school. I could just show up and get A’s in school.

A couple of quick stories before I get back to the above equations.

When I was in undergrad, I had the honor of being kicked out of a biology class…by my Advisor at that! I have an excellent memory and am very much an auditory learner. This means that I can memorize lectures and then school just required a regurgitation of the material in most cases and rarely an assimilation of material meaning, I just had to recall the information and not put it to practical use. For someone with a great memory, it was just a matter of showing up for lectures and tests. Anyhow, Dr. G (not me Dr. G, but a biology professor Dr. G at Governors State University) told us to read a chapter of the designated book. I read the chapter. I highlighted the chapter and I wrote notes within the margins of the book for the chapter. Another detail that I don’t talk about is that reading is not my strong point. I can read, but have to be an active reader with a highlighter and pen in order to remember a little bit of what I read. Sometimes I would simply record myself reading the chapter and then go back to listen to the recording in order to memorize the material. After reading the chapter, I showed up to the next class in my usual style, popcorn and iced tea or Diet Coke. I never brought books, notebooks or even pens for most classes. Remember, I’m an auditory learner. I just needed to hear it. Also, I was kind of egotistical back then…okay I was a lot egotistical and never back downed when challenged. I now know that not all challenges are worth the time or effort.

Picture this: you are the professor of a college biology course in a lecture hall with about 40 students. There is one student that sits at the back row all by himself. No books, no pens, no notes and his feet kicked up onto the row in front of him. AND HE IS DRINKING SODA AND EATING POPCORN LIKE ITS ENTERTAINMENT.

In the class, Dr. G read the chapter to use that we were supposed to have read for the class. She had notes that were nearly exact to the book.

Well, Dr. G called me up front after class because she didn’t understand my learning style.

Dr. G: “Vince, are you bored in my class?”

Me: “well, you told me to read the chapter and I did. I show up today and you are just re-reading the chapter to me.” (I never said that I was bored, but also didn’t say I wasn’t)

Dr. G: “Vince, (anytime a teacher uses your name like this its like a mom using your full name) how would you like to never have to come back to this class again?”

Me: “I need this class to graduate with the biology degree, can I skip the class and still get the grade?”

Dr. G: “yes, you won’t ever come back (mind you this was my advisor) and you can take the tests in the library”

Me: “sounds good. See ya around”

I never saw this teacher again as she transferred me to another advisor.

In case you were wondering…I got an A (just to spite her and for no other reason).

Talent x Effort = skill

I have a good understanding of the human body. I remember in high school Spanish class, that I would be reading and studying Delavier Anatomy of XYZ books. I would read all of the bodybuilding and weightlifting books I could, including Arthur Jones, Fred Hatfield, Mike Mentzer, Arnold’s Encyclopedia of Bodybuilding, and too many magazines to mention. I had a passion for learning how the body moved. It was a talent to be able to see movement patterns and understand how to make a movement more efficient. That talent plus all of the reading and learning, plus the time that I spent in the gym enabled me to place in state competitions in both powerlifting and strongman.

That skill + effort enabled me to get a Masters degree in Physical Therapy and later the Doctorate in Physical Therapy.

Having seen part of my personality, I also later obtained the OCS (a Board Certification in Physical Therapy which is only achieved by a small percentage of physical therapists) just because I don’t want anyone thinking that they were better than me. That’s the chip on my shoulder from childhood issues.

This profession has treated me well. I have done my best to give back to this profession.

In life, I try to continue to move forward. I don’t know if I will always be a treating clinician, but while I am, I want to be among the best treating clinicians. I want my patients to walk away saying “that was worth it”.

The equation above is from Duckworth’s book Grit: The Power of Passion and Perseverance.

2007 Illinois State Strongman Competition

Physical activity after a stroke

Physical activity levels in people that experienced a stroke do not meet general activity guidelines.

After 20 years in practice, I’ve evaluated and treated many patients with a stroke. On the flip side, I have family that have experienced a stroke. I’ve learned that each person is unique. Each person has a unique personality and drive. Each person has a different “why”.

When I say “why”, I mean “why” try to get better”? “Why” go through therapy? “Why not” just sit around and get busy dying.

My uncle had a stroke. He was a pillar of health before the stroke. He was a gettr done guy. Why wait for someone to do that which I could do. I have major respect for my uncle because his life and my dad’s parallel each other.

With that said, after his stroke, is still determined to be independent and is back to living his best life. He has physical limitations, but he worked hard to figure out how to get around those limitations. He is back to volunteering and helping other veterans like himself.

On the flip side, I have seen those patients that fall into the “why…me” track. These patients struggle to get better.

My first patient as a student intern was in a subacute rehab. I was given the choice of two patients. I could’ve treated the patient that just had a total knee replacement (back when I first started in this profession, patients stayed in the hospital for days and then went to a skilled nursing facility or subacute rehab commonly after the surgery). Instead, I chose to take the patient that experienced a stroke. I knew in my career that I would see thousands of patients with knee replacements, but I wouldn’t be in the setting to see as many patients that experienced strokes.

I remember this patient vividly. He was a business owner and he had a name and business that used alliteration in his introduction. Once he introduced himself, the glitter in his eye disappeared. He started crying almost immediately.

THIS WAS MY FIRST PATIENT AS A STUDENT!

WTF!

I had a lot of experience working with people that had struggles, having grown up either at a private bar or local VFW.

This guy was told by his doctors that he would never walk again (doctors are not God). If you’re a physician reading this…be careful how you speak to patients. This also applies to physical therapist that are reading the blog.

The patient went on to tell me how he lost his business, his wife divorced him and took everything he had but the crucifix on his neck. His van broke down and he would have to live in his van (not down by a river for those old enough to get it).

Also, for my first day at the rehab unit, my clinical supervisor told me that she just got a promotion and wouldn’t be able to be with me at all during my internship and that she was sure I’d do well.

That sucked and added a little more pressure to my clinical. I almost got kicked out of this clinical twice, which is better than the time that I do get kicked out of an inservice later in my student career.

Back to the alliteration introduction patient.

He was crying, sitting in a wheelchair, and feeling horrible for himself because of what he was told by God…I mean the doctor.

I had a choice to make. We always have a choice to make when working with people. Which version of me dos the person in front of me need at that specific point in time.

I flipped the coin between empathetic shoulder to cry on and ear to listen and “eat lightening and crap thunder” (this is Mick from Rocky for those young whippersnappers).

I chose Mick. I was as hard as I could be without being an asshole (which was good that I didn’t have a supervisor because she may have thought I crossed the line on day one when I said “you want to cry or you want to walk!“).

This guy chose to walk. By the time he was discharged after 4 weeks, I took him for a walk around the outside of the hospital grounds. Realistically, I sat in the wheelchair and he pushed me for about 15 minutes.

This guy not only walked, but he regained his freedom in life. He changed his perspective. He didn’t have to live by a river, but was able to get a job and get back on his feet.

I’ll never forget alliteration introduction guy. He got that sparkle back in his eye by the time he was discharged.

THE PATIENT IS THE ONLY PERSON THAT MATTERS!

Not the stroke! The patient may always have disabilities, a limp, an inability to walk, but it’s sour job to help them find the “why”!

That “why” is what will help the patient to increase physical activity levels. We may not “fix” the problems, but we need to do our best to not let problems compound on problems.

How one book can change your pain.

Neck pain affects many, and treatments like spinal manipulation therapy, medication, and exercise can help.

A majority of the population will experience neck pain at some point in life.

Treatments commonly used for neck pain are spinal manipulation therapy, medication and a home exercise program.

Bronfort et al (2012) tried to answer the question regarding which option may be the best treatment for neck pain.

The manipulation group received mobilization and manipulation of the cervical or thoracic spine after an evaluation in order to determine if there were any areas of the spine that did not move well. These patients were assessed by chiropractors with at least 5 years of experience. The chiropractors could use any technique and see the patient for over a 12 week period. The patients in the spinal manipulation group could also receive light massage, assisted stretching, and hot/cold packs. The visits lasted 15-20 minutes.

The medication group received NSAIDs, acetaminophen, narcotics, and muscle relaxants. The visits lasted 15-20 minutes and the patient was seen based on a physicians recommendations.

The home exercise group received 2 sessions lasting an hour per session split over the course of 1-2 weeks. These patients were issued “Treat Your Own Neck” by Robin McKenzie. These patient’s sessions also discussed basic anatomy and advice regarding posture, lifting, pushing and pulling.

How’s this sound thus far? We all have our biases. Aside from medication management, as a PT, I am trained on both Spinal Manipulation Therapy and Mechanical Diagnosis and Therapy, which is the basis for the book used in the study.

Having treated patients for 20 years has allowed for perspective. My bias is that the exercises will have a greater effect than the manipulations, but I also believe that manipulations have value for patients. The thought is that if we spend our time with patients only doing hands on activities such as massage and manipulations, that we will never “ teach a patient to fish”. The patient will always be depending on the “hand out” or better described as the “hands on” from the therapist. In reality, spinal manipulation therapy and exercises are meant to be used as an adjunct to get the patient back to life and no longer need to grab their wallet to pay for healthcare services.

In the end, both spinal manipulation resulted in similar outcomes for patients except for one category in which spinal manipulation will typically be favored as explained above…patient satisfaction.

In my humble opinion, people like when things are done to them or for them instead of having to do the work themselves…especially when they are paying for it! This holds true for going out to dinner, oil changes, home repairs etc. There will always be a service sector making money by minimizing the work needed by the customer.

One result that favored the exercise group was neck range of motion.

The exercise group and manipulation group scored similar on their perception of function, but the exercise group moved more.

Let’s put this in perspective:

The manipulation group used 15 vists on average

The home exercise program used 2 visits on average

The medication group used 5 visits on average

Time is money. Would you rather pay for 15 visits to get similar functional results, but less range of motion if it saves you the effort of doing exercise yourself or would you rather save the time and money but put the effort in yourself?

The good news is that you have options and both lead to similar results.

If you have a high deductible, you may prefer to pay out of pocket for 2 visits instead of 15.

If you have met your out of pocket max, you may just see it as free healthcare and want to go for the hands on experience.

All of this is important and your physical therapist or chiropractor should be having this discussion with you at some point t in your care.

If you are in need of physical therapy in the South Chicago Suburbs, I’m here to help. I’m trained in both spinal manipulation therapy and the “McKenzie Method” and finally am a Board Certified Physical Therapist in Orthopedics through the American Physical Therapy Association.

If you are interested in the book that resulted in 2 visits, click the link below

https://amzn.to/3OYV7cN

Nose to wall touch

This was one of the exercises written about in a protocol post Achilles rupture. I had to call the surgeon to understand what this actually meant. Once I was educated on the exercise, I figured I’d pass it on, since I thought myself to be well versed in exercise but had never heard of this particular movement.

My journey is not your journey

“don’t you dare compare your beginning with someone else’s middle“

I can see how this happens frequently, even in my own profession as a PT.

I hear it from new graduates, “we can’t all know as much research as you do.”

I hear that and I get pissed.

I wasn’t born with research inputted into my brain.

I wasn’t spoon fed the research through lectures.

I spent hours per week reading.

When I hear others tell me that they can’t do it…I think that you have other priorities. That’s fine, but don’t attempt to demean my priorities. Don’t try to knock me down so that you feel better about yourself, because I won’t have it.

My need to become better at my profession was a stronger force than most other priorities in my life, at the time.

Needless to say, my priorities weren’t well organized for the person I am today.

The issue that I see is that I looked at others in managerial positions and thought, I could do that.

I looked at people that were owning businesses and thought, “I could do that”.

I don’t want to do that.

I don’t want to be tied to my profession with the same short leash that I had my first 5-8 years.

I want more freedom to spend time with the kids (in small doses of course).

I want more freedom to be able to watch 3-4 hours of wrestling per week (don’t judge, we all have our indulgences that we would rather not do away with).

Now, I only have to do what I need to do to take care of my family and what I want to do to be happy. It took decades to grow into this person.

Don’t compare your journey to mine and I won’t compare my journey to others.

Work/time = something

“ I mean that you focus in on the dream you have, you do the work, you put in the hours, and you stop feeling guilty about it!“

I quit the hospital the second time to move to Virginia. It was a great time! It lasted a whole weekend (seriously my address was Fairfax, Virginia for a whole two days). I quit the hospital on a Thursday. I was back on a train to Chicago and then the Rock Island to Mokena by Sunday.

Needless to say, I called FW at Palos Hospital and was back to work at the hospital the next week. Although it seemed like a short vacation that I was away from the hospital, because I put in my notice, I lost all of my seniority, which included vacation time. Not a huge deal though because they hired me at the hourly rate i was receiving when I quit. I got a 90 day raise after my probationary period ended.

Another small detail is that I returned home having filed for divorce.

This whole story was to tell one small detail. I actually obtained a job in Virginia, one in which I never started but did the interviews. Virginia was, at the time, a direct access state for anyone that had a DPT. Without a DPT (doctorate degree in physical therapy) a PT could not see a patient “off the street” unless he/she took a differential diagnosis course.

I realized that the DPT has a little value. At that point I decided that I was going to obtain a DPT degree. (In hindsight, I could’ve just as easily taken the differential diagnosis course, but having moved back to IL without any furniture or television set, I had nothing better to do with my time. Literally, I thought to myself…I got some time to kill and the hospital agreed to pay $3,000 per year…I might as go get a Doctorate degree). The coursework for the DPT was relatively easy, but time consuming. I am proud that I did this and obtained the DPT. Not because of the title, but because now I can argue both ends of the argument regarding the DPTs worth; it only cost me $5K over three years.

In the end, I keep it simple.

“Just keep swimming. Just keep swimming”

Taking a jump

“ in fact, when you understand that you don’t have to justify your dreams to anyone else for any reason, that’s the day you truly begin to step into what you’re meant to be.“

I’m going to agree to disagree on this one. As you heard before, I made quick changes in my career without consulting my then wife…that relationship ended.

Although I don’t have to justify my dreams, I have to justify my decisions to my family. Making a quick jump, or even a well-thought-out jump, to satisfy my dream may not be worth it if the dream adversely affects family finance or security.

For instance, I quit the hospital the third time (that’s right, they took me back a second and third time) in order to chase a dream of managing my own clinic. I took a stupid pay cut in order to do this. I chose to cut my own pay by almost 20%. Not only that, I quit the cushy hospital job to go manage a clinic that was easily losing $100K per year. After 6 months of following my dream…reality set in. My wife said that I had to make a decision of opening my own clinic and leaving this one or going to find a job.

That was a smart move on her part. Although I increased the number of patients that were coming into the clinic by a little over 10%, it still wasn’t enough to justify the overhead that I inherited and the salary that I was getting. I was averaging about 28 visits per week, but that amount of money barely covered the overhead. There was no chance of profiting any time soon. Because of that, there was no chance of getting a raise any time soon. Mind you, during this time period I was also ranked in an honorable

https://www.google.com/amp/s/www.updocmedia.com/2017-top-40-influencers/amp/

Class by my peers. This was my opportunity to advance my lot in life. I am now making about 10% more than when I left the hospital and this year will mark my break even point. Every week after this year marks a betterment than where I was when working for the hospital. The cool thing is that I am still following my initial dream because I now have my own company, am managing patients the way I feel appropriate, and have created close relationships with many physicians and the community I serve. This was what I set out to do when I initially left the hospital.

Don’t get me wrong, Palos Hospital was a great place to work. I worked with an unbelievable team in which we all respected each other’s strengths and there were no egos on the team. (I say that because I may have had the biggest ego at the time so no one else appeared to have an ego in comparison.) None of us would hesitate to reach out to another PT or PTA if we were stuck with a patient. I have always recommended anyone to take a job there if they have the opportunity. My chief complaint with the hospital was that there was no chance of advancing one’s career, and I was looking for more.

If I never took that chance to chase a dream, I would still be in a job that I was frustrated with, although more changes were made after I left which may have satisfied my need for change. If my wife didn’t have that conversation about the reality of finances, I may still be trying to steer a sinking ship that I inevitably had no control over.

I now am in a spot to have more control and am avale to support my family while advancing my career, community involvement, and education of peers.

Patients pay for services

Anyone that says that people won’t part with money are delusional. We know that people are paying cash for PT services. We know that people are meeting their deductibles and paying copays/coinsurance.

As professionals, we have to figure out how to educate patients on

1. Solving their problems

2. Understanding the true costs of healthcare.

Patients first purchase our services because of a few reasons

1. They were referred to us by their physician.

2. They are referred to us by their friends/family

3. They hear about us from internet searches

4. They choose us blindly

Regardless of how they find us, we have to give them value when they come to us.

For instance, my mom had therapy at one of the big chains a few years back. She said that she would only be able to attend PT twice per week, but the PT has her sign up for 3x/week. What do you think happened?

She canceled her appointment once per week…because that’s exactly what she said that she would do when asked about frequency.

Instead of listening to the patient and scheduling 2x/week, they scheduled 3x/week and after 3 weeks they discharged her for non-compliance.

Who was in the wrong? Was the clinic providing value…maybe? Did they listen to the patient and establish expectations and alliance…nope.

The value of the session always lies with the receiver and not the giver.

Many of us tho I ourselves to be rockstars…me included, but take this piece of advice from “The Rock“.

What matters is what the patients think and how they perceive the service. They are the ones paying for the service. We have to establish the expectation with the patient and then…deliver.

They will part with their money in these situations. We just have to follow the basics.

Cualquiera que diga que la gente no se separará del dinero es delirante. Sabemos que las personas están pagando en efectivo por los servicios de PT. Sabemos que las personas alcanzan sus deducibles y pagan copagos / coseguros.

Como profesionales, tenemos que descubrir cómo educar a los pacientes sobre

1. Resolviendo sus problemas

2. Comprender los verdaderos costos de la atención médica.

Los pacientes primero compran nuestros servicios por algunas razones

1. Nos los remitió su médico.

2. Son referidos a nosotros por sus amigos / familiares

3. Se enteran de nosotros por búsquedas en internet

4. Nos eligen ciegamente

Independientemente de cómo nos encuentren, tenemos que darles valor cuando vengan a nosotros.

Por ejemplo, mi madre recibió terapia en una de las grandes cadenas hace unos años. Ella dijo que solo podría asistir al PT dos veces por semana, pero el PT tiene su inscripción por 3 veces por semana. ¿Qué crees que pasó?

Ella canceló su cita una vez por semana … porque eso es exactamente lo que dijo que haría cuando se le preguntara sobre la frecuencia.

En lugar de escuchar a la paciente y programar 2 veces por semana, programaron 3 veces por semana y después de 3 semanas la dieron de alta por incumplimiento.

¿Quién estaba equivocado? ¿La clínica estaba aportando valor … tal vez? ¿Escucharon al paciente y establecieron expectativas y alianza … no?

El valor de la sesión siempre recae en el receptor y no en el donante.

Muchos de nosotros pensamos que somos estrellas de rock … yo incluido, pero tomo este consejo de “The Rock”.

Lo que importa es lo que piensan los pacientes y cómo perciben el servicio. Ellos son los que pagan por el servicio. Tenemos que establecer la expectativa con el paciente y luego … entregar.

Se separarán con su dinero en estas situaciones. Solo tenemos que seguir lo básico.

PT in the pandemic

The physical therapy profession is frequently ranked in the top xyz jobs in the country. Looking at the statistics above, we are seeing that the field may reach saturation in my lifetime.

The previous data doesn’t take into account new school openings, which in my state is projected to graduate an additional 120 PTs per year. This doesn’t take into account the 210+ PTs that already graduate in the set of IL per year.

I write this during the COVID pandemic, which sees many PTs out of work, furloughed or laid off. I can remember during the housing crises of 2008, I thought that I was in a recession-proof job. We are seeing now that this is not the case. I thought that even in the worst times that I would be able to keep my salary steady and have increased buying power during these down times…I was wrong.

There are only certain jobs, in our profession, that are safe during the pandemic. Outpatient physical therapy is not among those types of jobs.

This pandemic will change much in our profession. We are seeing the rapid growth of telehealth. We are seeing more patients agree to in-home PT. We are seeing “mill PT clinics” transition to one-one care because of safety concerns regarding seeing more than 1 patient at a time.

There are many opportunities for PTs that are not afraid of work. There are many challenges for those that haven’t accepted the fact that this profession has to be more than the 9-5.

How will you change your outlook for the career due to the pandemic?

What do you think will happen to our profession in the future because of the pandemic?

Finally, how are you improving your skills to make yourself more recession-proof in the future?

Go to Physical Therapy to be Physical…think again

“affecting 60% to 80% of individuals during their lifetime”

This statistic gets thrown around so much that all PTs should know this without thinking about it.

LBP is such a common occurrence that many non-healthcare professionals are giving advice about how to fix it.

I was at a fundraiser recently and I heard people talking about back pain as part of the conversations had between laypeople. This is how prevalent that it has become, discussions of back pain have made their way into everyday conversation. Everyone and their mother has a remedy for it.

I heard about cutting out sugars, rolling on tennis balls and soaking in Epsom salt. It wasn’t until someone in the group turned to me (they had a previous knowledge of the website) that people stopped giving advice and started asking for information.

The public wants information. On that note, if you’ve found any information from this website helpful…please share it so others can learn.

“total annual direct healthcare costs in the United States incurred by patients with LBP were estimated at $90 billion in 1998, 60% higher than individuals without LBP.”

🤔

Sounds like we can start to create a change in total costs if we could just be better at treating this issue.

Back pain is top 5 reasons a person seeks out a healthcare provider.

We are spending so much money on this problem…you’d think we’d be making a dent in the number of people with back pain, and the expenses incurred for this ailment.

Nope!

Reading the rest of this post will start to shed light on why our system, as a whole, has a lot of sucky (scientific term 👍) parts.

“Recent reports suggest that the use of physical therapy for patients with LBP is increasing.”

This makes so many people tho I that our profession (as a PT) is booming. Yes, there is a bigger pool of patients daily, but insurance payments have been decreasing for decades.

This is a different conversation, but it also plays a role in why clinicians may choose on intervention over another.

Soapbox

***For instance, if there are 3 people in the clinic at the same time (which could be considered fraudulent if this is occurring for patients using Medicare as insurance), the therapist has to make the patient perform some activities independently (which also should not be billed for patients with Medicare) or they would have to place the patient on a non-effective piece of equipment in order to be paid, while the PT works with another patient. ***

It then makes sense that the use of PT is increasing if we are performing ineffective techniques in order to maximize reimbursement. Not all PTs operate in this fashion, but if the above scenario sounds familiar…go get a second, third or fourth opinion.

“…Consistent in recommending an active approach to pair with emphasis on maintaining and promoting activity, while avoiding passive interventions such as bed rest or physical methods (heat/cold, ultrasound, etc.)”

Look folks, doing nothing gets you nothing. We know this in many aspects of life. Don’t work, don’t get paid. This is no different.

If the patient doesn’t play an active role in the process of rehabilitation, the results tend to be no better than doing nothing…because that’s exactly what the patient is doing in many cases.

For instance, if a patient goes to physical therapy and the patient lays there while “therapy” is performed on the patient, then the patient has little active role aside from showing up and paying.

This has become such a problem in our profession that our national organization had to come up with a short read to help patients understand what generic therapy look like during an episode of care.

“…Adherence to this recommendation for an active approach was associated with better clinical outcomes of physical therapy, with fewer visits in lower charges for care.”

If a patient learns a home program that has been shown, in the clinic, to be effective at reducing that specific patient’s complaint, why should that patient go to a physical therapy session to get unproven passive treatment or to simply repeat the same exercises over and over?

I’ll wait for your response…because I don’t know the answer to this question aside from the fact that increasing a patient’s frequency in therapy also increases the total profits of the company benefitting from the therapy.

“… it is now understood that the natural history of LBP includes subsequent periods of exacerbation and recurrence for most individuals.”

A high percentage of patients, anywhere from 25% up to 80%, experience multiple periods of low back pain during the lifespan.

How one defines recurrence has a huge role in how this number is determined. It used to be that researchers would look at a group of patients with low back pain and then see how many of them had back pain one year later. The problem with this approach is that for many of the patients, the pain never went away from the first episode.

How can this be classified as a recurrence if it never went away?!

Better questions were then asked and about 25% of patients experience at least a period of one month of relief before having a recurrence.

Because of this, it is prudent for the PT (physical therapist, not personal trainer) to teach the patient how to self-manage and to reduce as many risk factors that one particular patient has for developing back pain in the future.

“The ratio of active: passive codes had to be at least 3:1 for each phase, and every visit had to have at least one active code for the patient care to be considered inherent to guideline recommendations.”

I think that this is very conservative.

This means that for each hour a patient is seen, anywhere from 8-22 minutes are spent on manual (hands on) therapy, ultrasound, electrical stimulation, heat, ice.

The other 38-52 minutes are spent working on balance, exercise, returning to a functional activity.

This type of scenario would allow for 3 units of an active charge (75% of the session) and 1 unit of a passive charge (25% of the session).

Keep in mind, a clinician doesn’t have to follow this type of ratio, but a higher ratio of passive treatment is not consistent with the guidelines of treating patients with back pain.

“Consistent with previous studies, a successful outcome was defined as achieving at least 50% improvement on the 0SW – disability score.”

I’ve seen many patients that have gone through an episode of care without any relief before coming to see me in the clinic. For patients to get a 50% improvement in symptoms and ability to live the life they want, many would be happy with that outcome. In the research, we see as little as a 2-3 point change being considered significant when using the (pain scale). A 50% improvement is considered significant.

“471 patients with LBP met the criteria for inclusion. (18-60y, at least 3 visits of PT, duration of PT at least 10 days, initial OSW >10%, and no surgery recorded)”

This simply shows that there were a large number of patients that could be studied.

The inclusion criteria is important because it’s hard to take a study and apply it to a patient that doesn’t fit the inclusion criteria. For instance, this study included people from age 18-60. The results of the study may not apply to those under the age of 18 or over the age of 60.

Also, the study may not be applicable to those that experienced a back surgery.

“132 patients (28.0%) received adherent care and 339 (72.0%) received non-adherent care.”

Less than 1/3 received care that was consistent adherent to an active plan of care. This is disturbing!

This means that many patients going to therapy are having treatment DONE TO THEM instead of DONE WITH THEM!

There are many treatments that can be billed without the therapist directly treating the patient one-one. For instance, mechanical traction can be performed while the therapist is treating another patient. Other treatments that can be performed while the PT is treating another patient is “electrical stimulation”, moist heat and cold packs.

“Patient receiving adherent care experience greater improvement in disability, and pain intensity, and were more likely to experience a successful physical therapy outcome than patient receiving nonadherent care.”

This literally means that when patients are doing more for themselves, they get more from PT. It doesn’t have to be hard.

The PT should act as the guide in order to introduce the patient into a more pain-free, more functional and self-sustaining state. If the PT is acting as the “hero” of your story and not the “guide” in your story, it may be time to find another PT.

“Patient receiving adherent care also attended fewer physical therapy visits, had a shorter length of stay, and lower charges for physical therapy care.”

Fewer therapy visits = less money!

Is it getting easier to see why some clinics are more than happy to perform traction and electrical stimulation to patients?

💵💸💰

In the end, the patients are rarely at the center of care. Physical therapy is also is a business. Businesses function based on profit.

When you find a PT that treats you as a patient and not a $$$, then you have found the right person.

“296 patients (62.8%) had billed charges for additional healthcare related to the management of LBP in the 1-year period After completion of the physical therapy episode of care.”

It is common for patients with back pain to go to multiple providers, such as pain management, orthopedic surgeons, chiropractors and other PTs in order to seek treatment throughout the year.

“Receiving adherent care was associated with decreased use of prescription medication…also associated with a decreased likelihood of receiving diagnostic imaging procedures…associated with decrease use of MRI”

This is simply saying that when patients do more activity in physical therapy (PT), that the patient is less likely to seek out imaging.

There could be many reasons for this outside of just being active in therapy. This is purely conjecture, but if the therapist is able to educate the patient on when imaging is needed and the patient buys in, then it may have a rom in future imaging.

If the therapist demonstrates to the patient that they are strong and robust through the exercises or movements performed in therapy, then the patient may believe that the injury is less severe than initially believed.

If the therapist can change the patients belief system in order to understand that what is seen in imaging may not give them the answer they are looking for, the patient may be less likely to get imaging.

The one constant in all of this is the patient-PT relationship. It may be harder to foster that patient in an environment where multiple patients are being seen at the same time compared to when a patient is seen one-one.

These are great questions to ask when calling a PT clinic to inquire about treatment prior to actually signing up

1. How comfortable are your PTs at treating LBP

2. Do I need to use electrical stimulation and how many patients is this used on in your clinic?

3. Will the therapist be treating more than one patient at a time?

You have the right to this information prior to signing up. If you don’t care about this information, then don’t bother. If it is important to you that you have the individual attention you are paying for…ask away.

“Similar to other healthcare providers, it appears that physical therapy care for patients with LBP is characterized by widespread and unwarranted variations in practice”

We see PTs using craniosacral therapy , dry needling, MDT and other methods/interventions to treat back pain. Because of the variability, it is imperative that the PT ask about previous treatments because there is no common standard with physical therapy.

“…it may be surprising that adherence to an active approach has been reported to be low in studies of both primary care physicians and physical therapists”

Nope! ❌🙅‍♂️

When determining what interventions have the least amount of friction in order to get paid, the passive interventions win every time.

It’s unfortunate, but until insurance based physical therapy is linked to total costs for the treatment issued to a patient (such as a large lump sum issued to the clinic at the beginning of the year in order to manage a patients physical therapy needs and complaints), we will continue to see passive treatments as they reimburse with little time spent with patients.

Excerpts from:

Fritz JM, Cleland JA, Speckman M et al. Physical Therapy for Acute Low Back Pain: Associations with Subsequent Healthcare Costs. Spine. 2008;33:1800-1805.