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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.

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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.



Outpatient Therapy Services Payment System

Physical therapy services are performed by someone licensed in the physical therapy profession. This can either be a licensed physical therapist (either a Bachelor, Master, or Doctor of Physical Therapy) or a licensed Physical Therapist Assistant (Associate degree).

Aspects of our profession that are performed in the clinic are as follows:

therapeutic exercise: exercises performed in order to help a patient improve function, strength, endurance, range of motion and/or reduce pain

Neuromuscular re-education: training movement patterns, balance, coordination, kinesthetic sense (where the body is at in space during movement), posture, and proprioception (where the body is at during one moment in time)

Manual therapy: using ones hands or tools to perform massage, joint mobilization (moving individual or groups of joints), traction, passive ROM (using hands to move a joint through its range) in order to improve pain, range of motion, swelling or other restrictions

These are the most common interventions used in my clinic. Other interventions used are modalities (which may or may not have evidence to support the intervention and may or may not be covered by an insurance plan). Some are as follows:

Ultrasound

Electrical stimulation

Heat/cold

Mechanical Traction

Iontophoresis

Laser therapy/light therapy

This is still a grey area for many Physical Therapists (PTs). Although the rules are very straightforward, some clinicians never read the rules that insurance companies impose to the clinicians. When a clinician is treating a patient and is in-network with the insurance company, the PT is accepting the rules imposed by insurance companies. Medicare will pay for medically necessary services.

It is up to the PT to establish this necessity in the documentation. The PT the. Needs to have a physician or other allowable non-physician provider (think nurse practitioner) sign off on the initial documentation, which establishes the PTs plan of action/treatment/care. This plan of action must establish a few details and is valid for up to 90 days.

Let’s talk numbers. Our spending on outpatient therapy services (occupational therapy, speech therapy, physical therapy) is more than many countries spend to run the entire country. This is a very large number and insurance companies, both public and private, are trying to cut down on the total expenditures over time.

It makes sense, because expenses have increased by 6% year to year for the previous years.

It may come as a shock to many patients, but “outpatient” benefits can be used in an inpatient setting 🤫.

If you were in a nursing home, they may have used your outpatient benefits to pay for part of your rehab. This may not be the best use of your funds as seen Here and Here.

Surprisingly hospital outpatients use fewer funds than I suspected. It has been documented that many physicians are pressured to keep a patient “in-house”. This means that physicians are not “supposed to” refer a patient out of the hospital network. This keeps all of the money within the hospital to find profits. This was highlighted in a previous news Article

In a way, I’m not surprised that private practices see such a large amount of the Medicare pie, as it’s been noted how many are abusing the system for large payouts. Such as this company that settled for $7M for performing abusive practices. These practices are very common to see in the field of PT.

Patients with Medicare are only to be billed for non-group services (which by the way pay at a much lower rate), when they are actually seen one-one.

Also, patients are only to be seen by licensed professionals. This means that technicians (techs) or aides are not allowed to guide a patient through their exercise program, at least if the company plans to bill for these services. Don’t believe me…here’s another Example.

So I guess that I am not surprised by how much money is spent in outpatient settings.

Many patients don’t understand that sessions are typically billed by the “15 minute rule”. This essentially means that for every 15 minutes, or at times the better half of 15 minutes (8 minutes), that the patient will see a charge on their explanation of benefits or receipt for services.

For example, a patient may see 3 separate charges for a session if the patient was seen in the clinic for 45 minutes. It can get messy if this is not explained to the patient.

The amount of money that Medicare reimbursed is different for different areas of the country. This is based on how much the cost of performing business is within a certain locale.

Those that have Medicare have to pay 20% of accepted/fee schedule amount.

This is where things can get confusing. For instance, I’ve seen an average visit (1 hr) be charged from $360-$1200 to the insurance company. This is a huge range in charges, which is also a problem with our healthcare system because it makes it difficult for patients to understand the actual charge.

Out of the charge for an hour, Medicare will allow close to $100 depending on how that hour was broken up into charges. The other $260-1100 is written off as an “adjusted” amount based off of insurance “savings”. (This savings number is also arbitrary to make it look like you get a great deal from having insurance).

Of the $100 that is allowable, the patient is responsible for 20% of that charge. The patient can choose to have another entity, a Medicare supplement or secondary, pay the other 20%. Of course the patient has to pay a monthly premium, unless on state aid, for that other 20%.

This is a way for business to start gaming the system. They will start to shorten session lengths so that they don’t lose as much money per session. There are three separate components that go into what is allowable by Medicare. They cut one of the three components by 50%.

Companies are then shortening sessions to the least allowable to maximize charges, such as shortening sessions to 25 or 40 minutes in order to maximize their reimbursement per session. They will then keep the patient coming in for more sessions per week in order to maximize payment.

Sometimes it’s what’s best for the patient, but many times it’s only what’s best for the company.

Those companies that charge more, or are in the upper tier of chargers in our profession. For instance, in our state their was a company that was audited and asked to pay back over $600K to Medicare due to inappropriate charges.

The article can be found Here

Start Back Screening Tool

“Lifetime prevalence for LBP (low back pain) has been reported to be between 60% and 95% and 34% of the participants in a large population study in Norway reported to have had LBP last week”

These numbers are scary, but are consistent with other published research that notes about 80% of the population will have back pain at some point in life. Think of how lucky you would have to be to go an entire lifetime without having back pain based on these numbers?

It can happen, as I’ve seen patients in their 80’s with a first time occurrence of back pain.

The part that is sad for me, as a PT, is that less than 10% of these people will ever get in to see a PT for back pain.

“Due to the lack of diagnostic tests that can identify objective signs of the condition, most of the patients are characterized as having ‘non-specific LBP'”

If you’re not familiar with the numbers, it has been said that any diagnosis trying to name a specific tissue (disc herniation, arthritis, spondylisthesis, spinal stenosis etc) is only correct about 10% of the time. The more severe the diagnosis the more likely that the specific tissue is the correct diagnosis (such as a tumor, spinal cord injury, infection).

Because of this, a majority (90%) of back pain is just labeled as “non-specific low back pain”. The problem with this is that the treatment for a non-specific problem tends to be…non-specific.

Don’t get me wrong, a majority of back pain doesn’t need much treatment, if any at all, and tends to improve over the course of 6 weeks. Some pains from the back require a specific treatment and a treatment outside of this Specific treatment can worsen symptoms.

This means that we have to actually attempt to classify a patient’s presentation. Understand please that a classification is not a diagnosis but instead more of putting the symptoms into a non-specific “bucket” that most resemble that presentation. For instance, there could be a bucket for fast changing, slow changing and unchanging. There could be buckets for a primarily psychosocial component, chemical component or a bio mechanical component.

“Based on the SBT (Keele Start Back Tool) scores, patients can be categorized into three subgroups: patients with low, medium, or high risk for developing persistent LBP and activity limitations….the low risk group should receive minor attention from health professionals and self management strategies are recommended for these patients. The medium risk group should be offered physiotherapy. For the high risk group more psychologically informed interventions are recommended”

This statement may upset some of my colleagues in PT, but we aren’t always needed for patients that experience back pain. For instance, it is advocated to see a PT if you have pain lingering more than a couple of Days. I’m not sure I completely agree with this, as much back pain reduces spontaneously. The last thing you, as the patient should want is to pay for unneeded treatments. The last thing that I want to do as a PT is to take a patients money if I am not needed at that time.

Again, don’t get me wrong there is a group of patients, with back pain, that should be treated by a Physical Therapist. These patients will score higher on the Start Back Screening Tool.

With that said, it is important that the patient be classified correctly within the first 6 weeks of experiencing symptoms. Some research demonstrates an early classification is beneficial and others demonstrate that it should be done within 6 weeks of symptoms. The reason for this is that the patient may benefit from more psychologically informed interventions, which should be performed by someone with

“To be useful as a screening tool in physiotherapy practice, it is important that the SBT-scoring is reliable and that the allocation to risk groups reflects the severity of the patients back problems.”

There are two things that we look at in terms of performing testing. One, is the test valid. This means does the test actually tell us what we think it tells us.

The second thing is reliability. This means that if I have multiple therapist from different settings performing the same exact task, would I get similar or exact scoring if performed on the same exact patient by different therapists.

“The SBT consists of nine items; referred leg pain, comorbid pain, disability, bothersomeness, catastrophizing, fear, anxiety, and depression…. The total score range from 0 to9, with nine indicating worst prognosis. The last five items are summarized into a psychosocial sub scale with five as the maximal score, indicating high risk for development of chronic LBP”

For more information about scoring, I personally like to use the Shirley Ryan website of outcome measures found here.

“Patients with a total score of 0-3 are classified as low risk (minimal treatment, eg self-management strategies).

I use this tool frequently in PT. I rarely have patients score a 3 or less, but this may be because they are already filtered out by the physician in primary care.

I recently had a patient score a 3 and lo and behold his symptoms were abolished in 6 weeks without intervention.

It’s a small sample size, but it seems to match the research.

To summarize: the STarT Back Screening Tool is an option to utilize in practice in order to determine if a patient

1. Requires little/no intervention and will return to prior level of function (PLOF) through regression to the mean (time > interventions).

2. Requires PT/Rehab only

3. Requires a more psychologically intensive approach to care.

Click here for original research article.

STarT Back Screening tool revisited

“…changes in psychosocial risk factors during the course of treatment may provide important information for a patient’s long-term prognosis”

As professionals, we should be performing repeated assessments of patients during the plan of care (POC) and not waiting until the patient is ready for discharge (either because their benefits have been exhausted, the insurance company dictates that an assessment needs to be performed or the patient self-discharged). Performing repeated assessments throughout the POC allows us, as professionals, to understand if the patient is improving, worsening or remaining unchanged with care and to assist us in modifying the POC.

The STarT Back Screening Tool is one method of assessing psychosocial factors that may impede rehab potential.

“… repeated assessments during an episode of care can also provide valuable information about changes in a given variable that can be used for treatment monitoring”

Utilizing a standardized approach to assessing a patient will enable the professional (PT in my case) to determine if a patient is catastrophizing, losing hope, or requires the assistance of a more psychologically focused treatment approach.

“The STarT Back Tool (SBT) is a Screening questionnaire consisting of nine items related to physical and psychosocial statements that are used to categorize patients based on risk (low, medium, or high) for persistent LBP-related disability.”

Here is a copy of the tool in question.

“Wideman et al found that early changes in SBT scores were predictive of four month treatment related changes in several relevant psychological and clinical outcome measures.”

This is a little different than what is expected from an outcome tool. For instance, many tools are utilized to tell the clinician where the patient is at currently and if this patient Hs a risk of developing chronic pain.

When we utilize multiple scores instead of a standalone score, this is indicative of how a patient will progress over the course of time.

“all patients (in this study) were referred for physical therapy by a physician and did not seek physical therapy services through direct access… this setting was considered secondary care.”

This is an important topic. For instance, the previous blog post indicated that the tool gives us information when read minister over a 4-week time period. This indicates that there are changes that occur over the course of 4 weeks.

Many complaints of low back pain improve independently over the course of 6 weeks. If a patient is issued this test at the first visit and classified as low, medium or high, this may lead to an inaccurate classification. Seeing as this study issued the tool to patients in a secondary care (meaning that the patients were referred by a physician) indicates that the patient is not being seen within the first few days of injury.

“1. Aged 18-65 years,

2. Seeking physical therapy for LBP (symptoms are T12 or lower, including radiating pain into the buttocks and lower extremity), and

3. Able to read and speak English”

“treatment was not standardized or tracked in this study and was provided at the discretion of the physical therapist.”

This may also be an issue, as there is a newer study that indicates the treatment interventions may have a role in the patient’s scoring.

Please see the previous post about how to utilize this tool.

“…123 patients (84.2% of the entire sample) who completed the SBT at intake and 4 weeks…The percent of patients for each SBT risk category who were classified differently at intake and four weeks was 81.8% for SBT high risk, 76.0% for SPT medium risk and 11.3% for SBT low risk.”

This indicates that a patient’s initial score should be interpreted with caution because there is a high probability that it will change over the course of 4 weeks.

“most patients either improved (48.8%) or remained stable (40.6%) based on changes in SBT categorization.”

“Thirteen (10.6%) patients were categorized as worsened based on changes in SBT categorization, with six of those patients categorized as SB team high-risk at intake and four weeks later.”

This is interesting to me. Typically, in PT, a therapist will cite regression to the mean. This essentially states that given time the patient will transition from an extreme score towards a more moderate score. This doesn’t account for those that transition from a moderate score towards a more extreme score. To me, this indicates that the episode of care had an effect, albeit a negative effect, on this patient encounter.

Primary findings of this present study were as follows:

1. At over 4 weeks, approximately 11% of patients worsened SBT risk;

2. Clinicians should be less confident in the stability of an intake SBT categorization of high risk than that of medium and low risk;

3. Prediction of 6-month pain intensity scores was not improved when considering intake or 4-week change for SBT categorization; and

4. Prediction of 6-month disability scores was improved when considering intake, 4-week, and 4-week-change SBT categorization”

This indicates that the first measurement may not be a good indication of what will take place with the patient regarding disability over time and some patients can be made worse with therapy. We already knew the second part from previous blog posts.

Excerpts from:

Beneciuk JM, Fritz J, George SZ. The STarT Back Screening Tool for Prediction of 6-month Clinical Outcomes: Relevance of Change Patterns in Outpatient Physical Therapy Settings. J Orthop Sports Phys Ther. 2014;44(9):656-664.

Clinical Practice guidelines for Bell’s Palsy

Let me start by saying that I have seen few cases of Bell’s palsy comparatively. I can say I’ve seen no more than 10 cases in 12 years and reading this practice guideline, I can understand why it’s not a large percentage of patients seen in the clinic.

This post will be linked to the next blog post on Bell’s palsy because there are some conflicting recommendations, but not dramatically different.

“Bell’s Palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mononeuropathy…most common diagnosis associated with facial nerve weakness/paralysis”

I enjoy history. I didn’t know about Sir Charles Bell and I found this piece informative. Whenever a new disease or species is found, sometimes the discovered of the new xyz gets to name the new xyz. It is one way to keep their name alive. It could’ve also been described according to the actual dysfunction, as facial nerve palsy would indicate to everyone what is happening to the patient.

Once you see a patient with Bell’s palsy, it is never forgotten. The dysfunction can have dramatic effects on patients in terms of livelihood and willingness to go out in public.

People close to me know that I am a huge wrestling fan. One of the greatest, if not the greatest announcer in the history of professional wrestling is Jim Ross. His was the first time that I can remember learning of Bell’s palsy and it’s possible that his diagnosis cost him his job. It’s at least written about in other forums that there is a relationship. It was a long time before I got to hear about slobberknockers on tv again. Jim is back to work and his disease is visible to those that look close enough at his face.

“…rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause.”

I have seen this run the gamut from barely noticeable to unable to close the eye or mouth. At the worse end of the spectrum, the person had major issues with drinking because there was incomplete mouth closure, which caused liquids to spill out of the mouth. Also, the same person was unable to move the eye or cheek muscles. An eye patch was required.

“…may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential injury”

With issues of mouth and eye closure, imagine how hard it is to keep the eye moist. Blinking assists in lubricating the eye, not to mention that the eye has difficulty producing moisture from the gland in the corner of the eye in the presence of Bell’s palsy.

“Treatments are generally designed to improve facial function and facilitate recovery”

The patients that I have seen, remember only a handful, I believe that only one person improved. At no point in time do I take credit for that, as a majority of patients improve over the course of 3 months. This patient was referred to me at the 6 week mark and time may have been more important than anything I did regarding the patients recovery.

“…the following should be considered:

-Bell’s palsy is rapid onset (<72 hours)”

I’ve had patients associate Bell’s palsy with a cold breeze blowing on them at night. They say this because the onset is so quick that some literally woke up with it. The patients attempt to find answers for why things happen. As a healthcare provider we have to do our best to educate and reassure the patient that it was nothing that they did to cause this phenomenon.

-“Bell’s palsy is diagnosed when no other medical etiology is identified as a cause of the facial weakness”

This is a diagnosis of exclusion. As mentioned at some point in this article, differential diagnosing needs to be performed in order to ensure that there is nothing sinister or other diagnosis causing this problem.

-“bilateral Bell’s palsy is rare”

I have personally never heard of bilateral Bell’s palsy and have obviously never seen it with my low level of experience treating this issue.

-“Currently, no cause for Bell’s palsy has been identified”

This has to be stated to patients. They will matrix and try to come up with a cause, which can create a change in behavior and the spreading of “old wives tales”. The most common one I hear is that the window being open caused a breeze while sleeping, or a fan was blowing on my face causing a breeze, to cause the symptoms.

-“other conditions may cause facial paralysis, including stroke, brain tumors, tumors of the parotid gland or infratemporal fossa, cancer involving facial nerve, and systemic infectious diseases including zoster, sarcoidosis, and Lyme disease”

These are all major issues that require a thorough history and possible imaging to determine if Bell’s palsy is the true diagnosis or if there is something obvious causing symptoms.

-“Bell’s palsy may occur in men, women, and children, but is more common in those 15-45 years old; those with diabetes, upper respiratory ailments, or compromised immune systems;or during pregnancy”

It affects both genders (I’ve seen both men and women), a wide age spectrum (I’ve never seen anyone older than 50) and multiple comorbidities can increase risk.

“…paresis/paralysis typically progresses to its maximum severity within 72 hours of onset of the paresis/paralysis”

This is good to know as a PT. It’s rare for us to see these patients in the acute, or immediately after it starts, stage. Because of this, should we see a progressively worsening condition, it would be prudent to refer the patient back to the physician in order to rule out any other medical concerns.

“Facial paresis or paralysis is thought to result from facial nerve inflammation and edema”

This is one of the explanations, but again there is no known cause.

“The facial nerve carries nerve impulses to muscles of the face, and also to the lacrimal glands, salivary glands, taste fibers from the anterior tongue, and general sensory fibers from the tympanic membrane”

This can cause the corners of the mouth to droop. The person may be unable to fully close the mouth to suck out of a straw.

The lacrimal glans is the little pink thing on the inside of the nose-side of the eye. This gland is responsible for keeping the eye moist.

“…may experience dryness of the eye or mouth, taste disturbance or loss, hyperacusis, and sagging of the eyelid or corner of the mouth”

Because it also supplies “power” to the tastebuds, this can affect taste. I’ve known many patients of those that I treated that lost weight because food was no longer appetizing.

“Most patients with Bell’s palsy show some recovery without intervention within two to three weeks after onset of symptoms, and completely recover within three to four months”

This is a very important statistic. Without knowing this, a patient referred to PT within days of the diagnosis, whom shows improvement within weeks, may lead the PT to believe that physical therapy has more significant effects than actually occurs.

“… facial function is completely restored in nearly 70 percent of Bell’s palsy patients with complete paralysis within 6 months and as high as 94% of patients with incomplete paralysis”

This information must be highlighted with patients. The effects of this diagnosis can be dramatic the first few weeks and hope needs to be restored in these patients.

Good ol JR is back to announcing wrestling!

“…as many as 30% of patients do not recover completely”

This needs to be addressed, but the education needs to be flipped to show that 70% recover partially or fully.

“Long-term, the disfigurement of the face due to incomplete recovery of the facial nerve can have devastating effects on psychological well-being and quality of life”

Two patients that I have treated in my past avoided going outside. Not to paint them in a negative light, but they lived like the Hunchback of Notre Dame. These two needed positive reinforcement in order to return to a life outside of the home.

I felt bad that these two have excluded themselves from the community because they wanted to return to normalcy, but didn’t want to be stared at in the process.

“…patients with facial paralysis can have impaired interpersonal relationships and may experience profound social distress, depression, and social alienation”

“The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell’s palsy”

As a PT, I will only discuss the information that is relevant to my profession or scope of practice.

1. “Clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute onset unilateral facial paresis or paralysis”

A thorough history is important regardless of the ailment. When paralysis is the end result, a thorough differential needs to happen in order to rule out other factors that could affect the facial nerve.

For instance, using the objective portion of the examination can help to rule out a stroke. The history can help to rule in cancer.

As a PT, ensure that you are taking a good history and physical exam in order to ensure that nothing is being missed.

2. “Clinicians should not obtain routine laboratory testing in patients with new onset Bell’s palsy”

“Risk: Missing a potential cause of Lyme disease, which is considered based on a thorough history.

Benefit: avoiding unnecessary testing and treatment, false positives and cost savings”

This is outside of the scope of PT and I will defer.

3. “Clinicians should not routinely perform diagnostic imaging for patients with new onset Bell’s palsy.”

“Benefit: avoidance of unnecessary radiation exposure, incidental findings, contrast reactions and cost savings”

“Risk: missing other causes of facial paresis”

“Opportunity for patient education”

4. “Clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell’s palsy patients 16 years and older”

“Benefit: improvement in facial nerve recovery, faster recovery”

“Risk: steroid side effects and cost of therapy

Exceptions: diabetes, morbid obesity, previous steroid intolerance and psychiatric disorders.”

5. “clinicians should not prescribe oral antiviral therapy alone for patients with new onset Bell’s palsy”

“Benefits: avoidance of medication side effect, cost savings”

Risks: none

6. “clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell’s palsy”

Benefit: small potential improvement in facial nerve function

Risks: treatment side effects, cost of treatment

Patient preference: “significant role for shared decision making”

Exceptions: same for corticosteroid use

6. “clinicians should implement eye protection for Bell’s palsy patients with impaired eye closure”

Eye protection is standard of care.

Risks: costs of eye protection implementation, potential side effects of medication.”

This falls into the plan of care for PTs. Sometimes the amount of time that the patient has with a physician is less than 10 minutes. (I’ve read that an average patient physician visit is 11 minutes).

Because of this, the patient may not fully understand what to do once diagnosed with Bell’s palsy, and this can be within the role of the PT.

7. “Clinicians should not perform electrodiagnostic testing in Bell’s palsy patients with incomplete facial paralysis”

8. “Clinicians may offer electrodiagnostic testing to Bell’s palsy patients with complete facial paralysis”

Benefit: provide prognostic information for the clinician and patient, identification of potential surgical candidate

Risks: patient discomfort and cost of testing

8. “no recommendation can be made regarding surgical decompression for Bell’s palsy patients”

“Concerned about the facial deformity may make it some patients willing to pursue a major operation for a small increase in the chance of complete recovery while others may be more willing to except the chance of poor outcome to avoid surgery”

“The group was divided as to whether the evidence supported no recommendation, or an option for surgery. This difference of opinion derived from controversy regarding the strength of evidence”

9. “No recommendation can be made regarding the effect of acupuncture in Bell’s palsy patients”

“The GDG was divided regarding whether to recommend against acupuncture, or to make no recommendation.”

10. “no recommendation can be made regarding the effect of physical therapy in Bell’s palsy patients”

There are conflicting statements regarding varying clinical practice guidelines.

I have only had one patient with Bell’s palsy that demonstrated significant improvement greater than 90 days since the diagnosis. Is it possible that time had a strong let effect than PT…sure…it’s possible.

Typically, the recovery would’ve taken place by three months, but the patient made progress while in therapy.

Don’t get me wrong, I don’t think that PT is the end all be all for many diagnoses or patients, but I do believe that the interventions had an effect on this particular case.

There may be some patients that could benefit from therapy. In saying this, my experience would tell me that it is a small percentage of patients.

“patient may benefit psychologically from engaging in physical therapy exercises”

11. “clinicians should reassess or refer to a facial nerve specialist those Bell’s palsy patients with 1. New or worsening neurologic findings at any point, 2. Ocular symptoms developing at any point, or 3. Incomplete facial recovery three months after initial symptom onset”

“Identifying alternate diagnoses in the absence of recovery, and potential assessment for rehabilitative options…However based on the natural history of Bell’s palsy, the majority of patients will show complete recovery three months after onset.”



Click to find the Article.