When I began my Fellowship journey in January 2012, I decided to enroll with Sports Medicine of Atlanta. I decided this was the right program for me for several reasons.
- It had a large focus on “introspection“. To me, this meant a lot. Introspection is simply a self-reflection over my thoughts and feelings of particular situation. This program offered tools which allowed me to look at how I was thinking with each patient interaction. It reinforced the cognitive and metacognitive aspects of clinical reasoning.
- It was small enough that I could have direct interactions with the faculty on a regular basis. I was not looking to attend a bunch of classes or learn a bunch or “tricks”. I was looking for a program that could garner a significant amount of 1:1 interaction to challenge my reasoning for everything I was doing.
- The outcomes identified for my completion of fellowship were individually tailored to meld with my professional development plan. I had goals of not only becoming a better clinician (which was a large focus of fellowship) but an educator as well. Through mentorship, I was able to develop better educational courses and tools in addition to becoming a better manual therapist.
During the application process, there were several essays that I was asked to complete. Below I have pasted “My Reason for Being” (***Note this essay was written over 2 years ago during my application for fellowship). What is your professional reason for being?
My Reason for Being
By: Joseph Brence, DPT
As a young Physical Therapist, I can say that I am truly proud of what I do. Maybe this is because I have molded a career path in which I not only have attempted to treat patients, but also have attempted to understand why my treatments are effective. I have seen the rut that many clinicians get in, and have been determined to develop ways to better our profession and assist in forward thinking.
Growing up in a rural town, I was taught to work hard and appreciate the results one gets from fine work. I always had a business mindset and would look for ways which I could self-provide. At the age of 14, I negotiated a deal with a bus contractor, that I would clean his buses better than anyone else for $5 per hour. I won the bid. A year later, this contractor hired me to work on his farm, which I did for several years. I decided my new found laborious skills could be used elsewhere, and took on an additional role in an ice factory, as an assembly line worker in a -10°F freezer. These opportunities led me to gain appreciation of manual laborers and the physical toll these professions have on the mind and body (my boss at the ice factory only had 2 fingers on one of his hands; the other three were lost in machinery).
Today, I operate an outpatient Physical Therapy clinic in an urban atmosphere that treats a large workers compensation base. Despite many physicians and nurse case managers looking at these clients with skepticism, I believe every complaint my patients have. This is my job. My job is to help them get better. My job is to eliminate their pain.
Pain is a fascinating thing to me. The majority of the clients that present to me (as well as other outpatient therapists) have a primary complaint of pain. The majority of clients who present to any outpatient physical therapist present in pain. I differ from most therapists in the fact that I suspect that many simply don’t understand, the most common thing they say, they treat. I have worked with “joint-heads, muscle-heads, fascia-heads, and disk-heads (thanks Dr. Jason Silvernail for this terminology)” and have found that many clinicians erroneously blame a certain tissue for a patient’s pain. They ignore that pain is a complex output from the brain which can be modulated due to past experiences, the context in which the injury occurred, etc. Tissues do not cause pain. Pain occurs because the brain determines there is a threat or the potential for a threat to tissue, and pain is a means communication to protect it.
My professional reason for being is to help treat individuals in pain and to help other professionals better understand how pain occurs. Since a young teenager, I have always worked hard in an attempt to make a difference. As a professional, I not only believe that I have the obligation to help my patients, but any individual who experiences or interacts with pain.
I wanted to share that I just completed AAOMPT fellowship through Sports Medicine of Atlanta. Over the upcoming weeks, I will provide several posts regarding my experience but if any of the readers have questions about Residency or Fellowship, I would love to share my experience and you can email me directly at firstname.lastname@example.org.
The following is a guest post from one of my entry level DPT students, Matt Tuttle.
Regional interdependence is defined by Wainner et al. as “the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint”. This hypothesis is gaining support due to an increase in the literature linking joints such as the hip/knee, thoracic spine/shoulder, and cervical/thoracic spine. Much of the current literature focuses on relationships between adjacent joints however recent evidence is beginning to investigate joints farther away.
In the October issue of JOSPT Garrison JC et al published an interesting study investigating a possible relationship between balance and UCL tears in baseball players. They looked at sixty male high school and collegiate baseball players in a cross sectional study. The study compared thirty players with a UCL tear to thirty players without a history of UCL tear. Participant’s balance was assessed with the Y-Balance Test. The results showed significantly less balance on lead and stance legs as well as a decrease in total shoulder rotational motion in patients with UCL tears. The difference in composite Y-Balance Test scores between the two groups was 6.7 on the lead limb and 7.2 on the stance limb. The total rotation difference between groups was 5.6 degrees. A related study by Feigenbaum, LA also found a relationship between a distant body part (foot arch) and injury in baseball player’s upper extremities. As studies continue to emerge they may lead clinicians to investigate distant impairments that may have a relationship with their current complaint.
After a brief review of these two studies several questions come to mind. Is there an association present or is this simply a coincidence? If so, what are possible mechanisms for this association? A clinical question also comes to mind, should balance and foot arch posture be screened in baseball players and do you believe it could make a difference in upper extremity injury rates? Feel free to discuss these or any other questions in the comment section
Matt Tuttle, SPT
Matt is a third year Doctor of Physical Therapy student at State University of New York- Upstate Medical University in Syracuse, New York. He will be graduating this May following his upcoming clinical rotations based in Nashville, TN and Glens Falls, NY. Following graduation he plans on attending a sports and orthopedic based residency programs. He particularly enjoys treating a sports and orthopedic population and improving patients functional movements.
1. Wainner RS, Whitman JM, Cleland J a, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. The Journal of Orthopedic & Sports Physical Therapy. 2007;37(11):658–60.
2. Fukuda TY, Rossetto FM, Magalhães E et al. Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: a randomized controlled clinical trial. J. Orthop. Sports Phys. Ther. 2010;40(11):736–42
3. Sueki DG, Chaconas EJ. The effect of thoracic manipulation on shoulder pain: a regional interdependence model. Phys. Ther. Rev. 2011;16(5):399–408.
4. Cleland J a, Childs JD, McRae M, Palmer J a, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man. Ther. 2005;10(2):127–35
5. Kibler WB, Sciascia A. Kinetic chain contributions to elbow function and dysfunction in sports. Clin Sports Med. 2004;23:545–552
6. Garrison JC, Arnold A, Macko MJ, Conway JE. Baseball Players Diagnosed With Ulnar Collateral Ligament Tears Demonstrate Decreased Balance Compared to Healthy Controls. Journal of Orthopaedic & Sports Physical Therapy. 2013;43(10):752–758.
Please join me as I present my talk: The M.I.P. Algorithm: A clinically applicable model to motor control
So come on over: http://bit.ly/GOwI2t
I’ll be there with 19 other experts in physical therapy, business, mindfulness, and nutrition covering topics that will have a major impact on your professional and personal life.
My colleague Karen Litzy, MS, PT decided to take some of the amazing guests she has had on her radio show Healthy Wealthy & Smart, and put them all under one roof. Now is your chance to learn from some of the best in the business!
What: A one-time online gathering of 20 experts in physical therapy, business, mindfulness, and nutrition.
Who: Karen Litzy, MS, PT is joined by the following 20 experts:
Kelly Lynn Adams, C.P.C, ELI-MP
Dr. Laurence N. Benz, DPT, OCS, MBA
Dr. David Butler, PT, M.App Sc. EdD
Dr. Jarod Carter, DPT, CMT
Barrett Dorko, PT
Jerry Durham, PT
Lori Fields, LCSW
Sandy Hilton, PT, MS
Hillary Irwin, MS, RD
Diane Jacobs, PT
Dr. Adriaan Louw, PT, PhD, CSMT
Erica Meloe, P.T., OCS, C.O.M.T., M.B.A., M.A.
Dr. Francois Prizinski, DPT, OCS, DAC, COMT
Dr. Emilio “Louie” Puentedura PT, DPT, PhD, OCS, GDMT (Australia), CSMT
Dr. Michael M. Reinold, PT, DPT, SCS, ATC, CSCS
Hey Forward Thinking PTs. I wanted to make you aware of something really awesome…the upcoming Healthy Wealthy & Smart virtual conference for physical therapists.
I am happy to invite you to an online event that will bring together 20 experts in physical therapy, business, nutrition and mindfulness that will help to bring your physical therapy career to the next level.
My colleague Karen Litzy, MS, PT is interviewing 20 amazing thought leaders — including me — and she’s putting all of those interviews together in one week-long event from November 4th through the 8th.
Who: Karen Litzy, MS, PT is joined by the following 20 experts:
When: November 4th -8th (Put it in your calendar now!)
How much: Nothing. There’s no charge to attend. But there is a fee to purchase the Healthy Wealthy & Smart 2013 package (which is really awesome and worth the buy).
This conference was created because the future success of the physical therapy profession goes well beyond clinical skills. This conference will cover such topics as business, branding, mindfulness, pain education, critical thinking and of course clinical skills.
So if you’re ready to get access, or if you’d like to see more details, like the interview topics, you can do so HERE
In our presentations and writings on the M.I.P Algorithm, we introduce the concept of how providing a meaningful afferent INPUT, likely influences an output (diminished pain, altered action programming). As Physical Therapists, we often view “input” as “manual interventions” and we suspect that we can push, pull, thrust or scrape a tissue, to change the output. We often engage in dialogue with each other on which input is better. Heck, there are even rules telling us when certain types of input work. But how often do you consider the individual patient’s beliefs when determining the input? How often do you consider utilizing the patient in determining a treatment approach?
The self-determination theory (SDT) states that humans have basic psychological needs for autonomy, perceived competence and relatedness (feeling safe and cared for in one’s personal relationships). When a patient feels these needs are being met, their participation in treatment will be more autonomous and willing. A recent video posted by ForwardThinkingPT contributor Adam Rufa comes to mind when considering how to provide INPUT that takes into account the SDT.
Input is likely just that…Input. We must always consider that the input, which may influence pain and motor control, must be interpreted by an individualized brain. A brain must find that input meaningful to respond with a favorable output. And we must understand all of the “noise” being heard by the brain when we provide an input. The brain must ultimately sift through, not only the somatosensory input you provide, but a barrage of other externally regulated information. When was the last time you considered the prosody of your speech during a manipulation? Or the lighting in the room? Or the sound of a radio playing in a background? All of this “noise” (ie. sensory input) likely has an effect on how that manipulation is interpreted. They are all additional numbers added to a complex equation. It is never a “no brainer”.
Moving forward, we mustn’t argue over how many tricks we know or how deep our toolbox is, because the tool does not matter. The skillful ability to interact with our patients complex nervous system, does.
Don’t be a victim of The McGurk Effect (see below).
- Joseph Brence
Wanna see lectures, portions of our courses and how to apply PT interventions? Subscribe to our YouTube page below:
Here is a video of myself presenting the MIP algorithm at the 2013 AAOMPT conference. It was part of a 6×6 research presentation. The following questions and discussions were excellent but unfortunately, were not recorded (if anyone recorded them, send me an email so we can get them up). I would love to know your thoughts on “Does this concept make sense? In a couple of weeks, you will be able to view Francois Prizinski and myself discuss this algorithm a bit more in-depth with Karen Litzy for the Healthy, Wealthy and Smart Virtual Conference.
About a year ago I was at the IFOMPT conference in Quebec. Unfortunately, I won’t be making the AAOMPT conference this year. Have fun Joe! One of the most memorable presentations was by Michael Sullivan, a psychologist from McGill University in Montreal. He has done extensive work in the area of pain catastrophizing. He made the point that, in patients with high levels of catastrophizing, the most important first step is to ensure that the patient feels you are listening to them and that you understand what they are going through. If they don’t feel you truly understand their symptoms and suffering, it will lead to an increase in symptoms and catastrophising. This very funny video reminded me of that great point from his presentation.
Sometimes we have to deal with other issues before we can deal with the nail.
Friday’s AAOMPT conference started off very strong with a keynote lecture by Ali Rushton. Ali discussed the topic of the subjective examination.
She began her talk by discussing clinical reasoning frameworks and stating that clinical reasoning is supported by “cognitive processes or thinking used in the eval and management of a patient”. She further stated it employs “metacognition”, which is the “thinking about thinking”.
Moving forward, she transitioned into discussing “expertise”. She reported the ability to determine who is an “expert” is quite difficult but used this quote by Mark Twain: “Good decisions come from experience. Experience comes from making bad decisions”. She suspects the characteristics of expertise in OMPT are:
- Justification of decisions
- Criticality of practice
- Criticality of evidence
- Self analysis
- Supports of in-action activities
She stated, “Expertise is not just based upon a duration of time, but the quality of work performed during that time”. This quote is quite important for us who practice Physical Therapy. Many argue the time of practice defines expertise but it is actually the quality of work, and reflection during that time, is what truly defines an “expert”. It is suspected that 10 years of quality and reflective work defines this.
Moving on, she stated, “The subjective exam data is essential to clinical reasoning and processes and its theoretic support is strong. Understand why you ask every question. Every question should serve a purpose in your clinical practice.”
She went on to state evidence supporting the CPRs is lacking and discussed a potential better approach to care, stratification. She cited evidence on the STaRT back tool.
She wrapped everything up by discussing the importance of distinguishing the biological, psychological and social factors which impact practice and the importance of gathering hypotheses throughout the subjective examination.
One really interesting stat she offered: “Experts” spend more time and develop more hypotheses (12) during the subjective exam as compared to novices (9).
The next keynote, Duncan Reid, discussed the process of the Physical Examination. He discussed the importance of the physical exam and the importance of justifying why we do certain tests. “Is there evidence to support the test I use, and if the statistics are lacking, is the test still beneficial?” Does being a novice or expert matter? He then discussed how good are our tests?
In doing this, he looked at Laslett’s work on LBP (without nerve root compression). If during the examination, there was centralization or peripheralization, it’s likely a disc lesion. If there isn’t, perform the SIJ provocation tests and if 3 or more are positive, you are likely looking at a SIJ problem. If not, likely low back pain. He then stated, but in understanding Laslett’s research, have you ever thought about: “How hard did he push”? “What was the direction of force”? “How much pain was produced”? “Was the familiar pain produced”? “What do I do if the patient is bigger than me”? “Improving standardization of a special test will improve the ability to obtain a more accurate clinical diagnosis”.
Excellent quote: “We are victims of our own training unless we self reflect and critique our own practice”.
His views on CPRs were similar to Rushton’s by stating that most of the rules are still in the derivation phase, lacking validation.
He discussed the “Patient Response Method”, which is supported by the Maitland model and quotes work done by Cook and Hegdus . This type of approach to care is driven by a “patient’s response” and that most clinicians are moving towards this model, as our/their experience grows.
Best quote, “Do not follow gurus or be a product of your training”.
The third keynote address was given by Jim Meadow’s and it definitely got a response. He discussed the use of science in manual therapy. He believes we should be doing as much as possible to incorporate this into practice and the clinic. His first slide got a gasp when he stated, “Special Tests do not exist”. He said, “When do special tests become unspecial”?
To Meadow’s, there are two ways of coming to a diagnosis:
- Maximum information theory—very deductive method in which novices do every test possible, and then stand around like a deer in headlights, and then use the first piece of evidence that makes sense to them, and have difficulty letting it go. “Experts don’t do this”. He stated we need to stop teaching students this method.
- Minimum information theory—only taking in the information necessary.
Script focused deduction
- Minimum information theory
- Pattern recognition
- The illness script: the picture the patient has in their head about their condition. The clinician does this about every condition in which they have had “reflective experience”
- Hypothetic Deductive Reasoning: Generating and testing that hypothesis
He stated the first question always evokes a 100% sensitive response, “Where are you experiencing your pain”? “Being wrong is one of the only ways we learn—its ok to be wrong”—If the hypothesis isn’t correct, change it.
The keys to Script Focused Deduction:
- Generate an immediate hypothesis on the earliest symptoms report and test only that one
- Stick to the essential illness script
- Change hypothesis when the preceding once is invalidated or another is a better fit
To reduce bias, one needs to limit these four concepts:
- Anchoring: grabbing first piece of info and not letting go of it
- Framing: info prior to the exam that biases your thinking (ie. imaging reports)
- Premature Closure: finishing the exam premature
- Regression to the familiar
Provisional Diagnosis –> Bias Error Secession –> Treatment Planning (gut feeling, psychoscial functions. Etiological variables) –> If treatment works, you have your diagnosis.
Pathoanatomic Diagnosis vs. The Tick Box Method.
Great quote, “Classification schemes are only good if you are treating average patients. We don’t treat average patients. We treat individuals”. We should be thinking about what we are doing; not just checking off boxes or following a matrix.
More Great Points from Meadows:
- The place of the expert opinion is lower than any study we have (including case studies). We are at the mercy of “unreliable studies” and “confounding systematic reviews”.
- EBP in North America: Research Evidence, Patients Input and Clinical Expertise. Should be patient and clinician centric”. “Not everything that can be counted counts and not everything that counts can be counted!”
- The meat of our practice is about “people”. RCTs don’t give us insights about “individuals”.
- Not everything we do is quantifiable. EBPT is a paradigm; not a method, nor a tool. Is EBPT viable; is it scientific, does it work; is it being used? We have very little proof to know if EBPT works? Is the model liked? We need “theorists” more than we need “researchers”.
- The evidence needs to be extraordinary if the research claim is extraordinary. We should be evidence-influenced practice. It is patient-centric.
It’s a right of passage and a matter of practice…the glorious SOAP note. Subjective, Objective, Assessment (or Analysis) and Plan. Recall when we struggled to write our first several notes. We wondered what qualified as pertinent Subjective statements and how to keep O and A separate. Even P was a bit tricky out of school. Now, most clinicians have achieved SOAP wizardry. We can write these notes in our sleep. Even upside down and blind-folded.
However a nagging question presents — has S-O-A-P been the right order? This is a matter of perspective.
SOAP notes seem to be most beneficial for the writer. Perhaps this is why we’ve been trained in this format and why it has persisted. The SOAP format pulls the author through the note in accordance with the sequence of the therapy session. The logic makes sense.
However from the reader’s perspective, P-A-O-S notes seem far superior. To test this theory, we surveyed our PCPs who consistently confirmed PAOS is the order of interest as they review our notes. They seek actionable information first and are least concerned with Sally’s report of walking okay at the birthday party last night. This might sound trivial but remember PCPs are busy and may review 70 minutes of documentation each day. We owe it to our referral sources to make our information easy to locate. Help them avoid scrolling through EHRs and flipping paper pages in search of the P.
Also consider the benefit of a PAOS note for the covering therapist who needs a quick way to get caught up on the previous session. At our organization, we implemented PAOS with success. We added a robust P that includes a specific plan for the very next session. This helps easily convey information in the event a staff is unavailable or calls off.
So, assuming I’ve convinced you — why aren’t PTs writing PAOS notes? Writing the Plan first is not intuitive for the author. As a matter of fact it is quite challenging. Just as we learned the SOAP format we can adjust to the PAOS sequence.
Present this at your next staff meeting. Ask your PCPs and RN Care Managers for feedback. Start a pilot with an aspiring PT and let us know what you find.
Alan Petrazzi, MPT, MPM
The author is a licensed physical therapist with several years experience as a Rehab Director in large healthcare systems. Currently he is an administrator overseeing Primary Care services for over 35,000 unique patients. The opinions expressed are those of the author only and may not reflect the opinions of his employer.
I arrived at AAOMPT Thursday morning, just in time to check out a great lecture on the Three Pillars of the Mulligan Concept. This course was taught by two Canadian Physiotherapists, Jack Miller and Jim Millard, who did a great job at utilizing “Occam’s Razor” in their ability to explain why something may work. This course explored the Mulligan Concept (which is very similar to the Maitland philosophy) and stresses clinical reasoning and importance of patient reassessment. In essence they stressed an “interactive” approach in patient care and allowing the patient to move as we provide certain inputs (and this explanation does not do their teaching justice). Overall, this lecture was top-notch, and I would highly recommend checking these guys out…
After the Mulligan course Bob Rowe, AAOMPT President welcomed in the new fellowship courses and fellows. At ForwardThinkingPT, we would like to congratulate all of the new fellows!
Finally, we wrapped up the day at the exhibit booths (I was fortunate to be part of the Oakworks booth).
Overall, day 1 was filled with good learning experiences and I am excited to bring you guys more info tomorrow.
So tomorrow morning, I will be venturing to Cincinatti, OH, to attend the 2013 AAOMPT conference. If any of the readers are going, I would love to meet you and discuss how we can work together to move the profession Forward. You can connect with me through email @ email@example.com or connect through facebook or twitter (both located on the side of the page) . Just send a message and we can meet up (I will also be spending a bit of time at the “Oakworks” booth, so stop on over to see if I am there).
I will also be giving a very short presentation on Saturday @ 11am during the Platform Presentations. So come check out Francois Prizinski, DPT, OCS, COMT, FAAOMPT, DAC and myself present: The MIP algorithm: a clinically applicable model to motor control (I have pasted our abstract from JMMT below). If you miss it, no big deal, because you will be able to check out a discussion at the virtual Health, Wealthy and Smart conference in a few weeks…
For those not going, I am going to try to provide some presentation reviews and pictures from the conference over the next several days.
THE M.I.P. ALGORITHM: A CLINICALLY APPLICABLE APPROACH TO MOTOR CONTROL
Brence JB,1 Prizinski FA,2 Thomas P3
1 ForwardThinkingPT.com, Pittsburgh, PA; 2The Orthopedic Group, Pittsburgh, PA; 3Motion for Life, Pittsburgh, PA, USA
Corresponding Author: firstname.lastname@example.org
BACKGROUND: The neuromatrix model demonstrates that various inputs to a body-self neuromatrix results in changes in action programming, stress-regulation programming and pain. These inputs may affect the biological, psychological and social domains, and a significant amount of recent literature has suggested that one should use a biopsychosocial approach to patient care. PURPOSE: We suspect that many clinicians are having difficulty determining how to apply the biopsychosocial model, clinically. We are proposing a fundamental algorithm for the understanding of motor control that is scientifically plausible and easily applicable to patient care: Motivation, Input, Plan (MIP). THEORETICAL PROPOSAL: We propose that there are three fundamental qualities that lead to the appropriate facilitation of motor control: (1) First, we suspect that one must hold MOTIVATION, or a general desire or willingness to move efficiently. This motivation can be influenced by the clinician, and non-specific effects, such as expectation for recovery, will impact this; (2) Second, we propose that various INPUT, such as manual therapy and kinesthetic awareness training (such as breathing, taping, etc) can assist in the afferent feedback to recruit musculature. This step likely creates awareness and improved mapping of the somatosensory and motor homunculus; (3) Third, we believe that the individual must be able to properly PLAN for completion of the task. It is in this planning phase that an orchestrated complex of events occurs in the brain, which creates a neural blueprint for motor recruitment. (4) Once the first three steps are completed, the patient is ready for Motor Control.
After attending a recent lecture by Brian Johnson, MD I realize that I have been failing to consider a potentially important factor in many of my patients with pain system dysfunctions— Opioid induced hyperalgesia (OIH).
There is a growing number of studies which suggest even short term use of opioids can lead to a reduction in pain threshold. For example, studies by White and Hay found significant reductions in cold pressor test tolerance in people on opioids. Other studies demonstrated significant improvement in cold pressor times after detox from opioids.
So what should physical therapist do when the pain medication, which is supposed to be reducing pain in our patients, is actually leading to more pain? I know that I will be quick to send my patients who are on opioids and have signs of hyperalgesia to Dr. Johnson for detox. I will also include education on OIH to patients who take opioids or are considering taking them.
Here is a recording of the lecture by Dr. Johnson. I think it is worth watching.
This is a repost of “Just Zip It” originally posted to the website, Keith’s Korner. I highly recommend you check the site out (and follow) his writings and reflect on the messages he conveys. They are quite important for the rehabilitation community.
By: Keith P.
“He told me before i had my surgery that he was going to make me work hard to get 130° of flexion.”
My patient, 3 days after surgery, is excited about the prospect of returning to outpatient physical therapy. The outpatient therapist, who she has worked with previously, has already set the bar very high for her.
I am quite certain that he is a competent clinician. He has a tremendous reputation and I have no doubt that some of his patients do indeed achieve 130° of flexion after a total knee replacement.
Out of curiosity, i asked my patient what she intended to do with her 130° of knee flexion after she was done with her rehab. She told me that she was eager to return to exercise which included stationary cycling, walking on a treadmill and returning to her personal trainer for light strength training.
So what’s my beef? I have a problem with a 67-year-old woman with 120° of knee flexion (who successfully returns to cycling, treadmills and personal training while living her life without limitation) being led to believe that she didn’t work hard enough to achieve 130° of flexion after a total knee replacement and (as result) she is a failure.
His ego may not take a hit, but hers might.
Unless he is willing to take the blame if she doesn’t achieve her ‘new’ goal, he should keep his mouth shut.
National provider of rehabilitation services, Physiotherapy Associates Inc., appears to be preparing to file for Chapter 11 bankruptcy protection. According to Dow Jones and Company, Physiotherapy Associates, who carries around $325 million in debt, has begun the process of soliciting votes from creditors in a reorganization plan.
As a therapist, do you suspect this is the ominous beginning of the effects of healthcare reform or is this simply poor strategic management and projections from a corporate therapy giant? Would love to hear your thoughts in the comments….
As I stated in a recent post to APTA President Dr. Rockar, one of the biggest issues I face as a clinician in Pittsburgh, is the inability to accept a major regional insurance plan, UPMC (his response is here).
Here are a few questions I would like to pose to the readers of this site:
I would like to begin this post by thanking APTA President, Dr. Paul Rockar for replying to my last post in a timely manner. He has agreed that his formal reply be shared to the readers of this site and it has been inserted below. If anyone has any concerns or discussion points that you would like me to share with him during our follow-up discussion, please leave in the comments section below or email me directly @ email@example.com
As a Physical Therapist practicing in the Pittsburgh region for the past several years, I have observed the complex, evolving nature of healthcare first-hand. To those unfamiliar with the Pittsburgh market, there are ultimately two dominate healthcare systems: The University of Pittsburgh Medical Center and the Highmark’s Allegheny Health Network. In terms of insurances, there are a couple of dominate players, but for the focus of this request, I would like to focus on the plans offered by the University of Pittsburgh Medical Center (UPMC) (yes, the healthcare system also provides their own insurance).
In my several years of practice, I have not been fortunate enough to work for a company which is considered an “in-network” provider in the “UPMC” health plans. My family even carries UPMC insurance—yet I cannot treat my own wife. I am actually not aware of many providers in Allegheny county (the greater Pittsburgh region), outside of Dr. Rockars company (in which he is CEO), UPMC Centers for Rehab Services, who have been accepted. Unfortunately, this leaves many of us PTs in the dark. We want to accept this coverage. We want to get in-network (many of us have been told it’s a closed network). Many PTs have lost prior patients who have switched coverage. So that leads me to this: Dr. Rockar, as President of the APTA , I ask for your help. Will you assist non-UPMC Physical Therapists and practices, get in-network with UPMC insurance in Allegheny county? Nationwide we have taken a stance on physician owned practices. Locally, many of us have been faced with this.
Our profession has adopted the vision: Transforming society by optimizing movement to improve the human experience.
In our market, it feels like: Transforming society (if you are an in-network provider) by optimizing movement to improve the human experience.
Joseph Brence, DPT, COMT, DAC
Disclaimer: My request is not on behalf of any company or individual. It is simply a plea for the President of the APTA to assist PTs in his home market.
As Physical Therapists (in the United States), we have the ability to see patient via direct access, or without a Physicians referral. But with this professional privilege, comes responsibility, and determining if a patient is appropriate for our services is necessary. In addition, once determining appropriateness, screening for prognosis (when applicable) allows us to not only determine who is appropriate for our services, but who will ultimately benefit from them. In this post, I want to highlight several variables that we should be screening for (or with), because of their potential prognostic value over outcomes.
Pain Catastrophizing and Depression
A 2011 article, published in Physical Therapy, investigated the relationships between pain catastrophizing and depressed mood in patients seeking care for musculoskeletal pain. The investigators of this study collected data on 297 patients and found that elevated pain catastrophizing or depressed moods at baseline was related to an absence of improvement and elevated levels of disability following Physical Therapy care. When both variables were elevated, the level of disability was the highest. The authors state,
“Early identification of key differences could help clinicians make decisions about which patients should receive normally effective treatments. Moreover, combinations of modifiable prognostic factors could help identify which patients need another treatment approach and what this treatment approach should be.”
So if this article is correct, what do we do if patient presents with these variables? I suspect we should always consider the utilization of practitioners who can best address Psychological issues. Reaching out for assistance or referring to specialized practitioners (Physicians, Clinical Psychologists), such as those with PCH treatment (http://www.pchtreatment.com/), is likely necessary. Two quick and easy ways to screen for Depression and Pain Catastrophizing have been provided below:
Kinesiophobia, also known as a fear of movement, has demonstrated its ability to be prognostic over outcomes. This is generally measured on the Tampa Scale for Kinesiophobia (TSK) (one study did demonstrate that simply asking a patient “You visited your general practitioner because of complaints in your back or leg. How much ‘fear’ do you have that these complaints would be increased by physical activity (0= no fear to 10= very much fear” is just as, if not more, prognostic than the TSK). A recent article published in Manual Therapy demonstrated Kinesiophobia to be prognostic over short and long-term outcomes in those with sub-acute neck pain.
Clinical Prediction Rules (CPRs)
While I am not a huge fan (or believer) of allowing a CPR to guide a clinical decision making process, I do suspect they allow us to make better diagnoses and establish more accurate prognoses. This stated, we must be cautious in our interpretation of CPRs, because most have limited research behind them (lacking validation studies and impact analyses).
Now for my question of the day:
What tools or variables do you use to give a clinical prognosis?
Bergbom S, Boersma K, Overmeer T, et al. Relationship among pain catastrophizing, depressed mood, and outcomes across Physical Therapy Treatments. Physical Therapy 2011: 91; 754-764.
Verwoerd AJH, Luijsterburg PAJ, Timman R, et al. A single question was as predictive of outcome as the Tampa Scale for Kinesiophobia in people with sciatica: an observational study. Australian Journal of Physiotherapy 2012: 58; 249-254.
Pool JJM, Ostelo RWJG, Knol D. Are psychological factors prognostic indicators of outcome in patients with subacute neck pain. Manual Therapy 2010: 15; 111-116.
My colleague Francois Prizinski, went into work this morning, and his secretary, Donna, presented him with this 1872 Physiology textbook written by Dr. J. Dorman Steele.
He proceeded to text me the following passage of how Dr. Steele made sense of pain and phantom limbs. Dr. Steele may be one of the first individuals to realize that pain was a defensive response…
I am developing a virtual patient for a clinical decision making course I will be involved in this fall. I am still developing the case and was hoping to get a few practicing physical therapists to go through it. So if you get a chance follow this link www.upstatevirtualpatient.com and then click on the Jill Milkoswski-Clinicians link and try the case out.
I recently spent 2 weeks in a marathon course with 31 second year physical therapy students. As part of the course, we brought in real, live patients, and the students had the opportunity to evaluate and treat them over two visits. This was the first time that these students had the opportunity to try out their new skills on real patients. It was amazing to watch these students, who had been sleeping through my lectures, come alive. They were full of passion and excitement over their ability to connect with and help their patients.
Watching these students reminded me of how I felt when I first started my career as a PT. It also reminded me that it is so easy to lose that passion and excitement. I could picture the stagnant PTs I have worked with over the years who, in the words of ZdoggMD (star and creator of classic videos such as A Hard Docs Life, Hemorrhoids Rap, Diarrhea: The Musical and Manhood in The Mirror) had become disconnected burned out Zombies with a goniometer.
I am not sure exactly what causes this burn out. Perhaps it is things like the 8 minute rule, G codes, functional goals, plan of care, defensible documentation, practice act limitations, KX modifiers, Form C-4, C-4.2, C-5, high co-pays, productivity standards etc… which make us forget why we became PTs.
I have two (related) questions for you.
1)How do you keep yourself from becoming a thoughtless zombie physical therapist?
2) How do I help my students avoid becoming thoughtless zombie physical therapists?
Some numbers for you to ponder over the weekend…
100,000,000 Americans were living with chronic pain
In 2010, it cost the US $_______ to treat:
1. Heart Disease: $309,000,000,000
2. Cancer: $243,000,000,000
3. Diabetes: $188,000,000,000
4. Pain: Between $500,000,000,000 and $635,000,000,000
In 1996, it was estimated that we only spent $150,000,000,000 treating non-cancer related pain. That is 1/4 the price we would spend 15 years later.
To put things into perspective, we spent $102,000,000,000 fighting the Gulf War in 1991, $297,000,000,000 in the Afghanistan war in 2010 and $715,000,000,000 in the Iraq war in 2010.
This is why understanding pain is important. We haven’t got it right yet; but that doesn’t mean we can’t get it right now. We need to wage a war on understanding pain.
In my last article, I presented several videos and asked you if “they make sense”. Below I have posted several explanations of these tools (from originators/educators/researchers on each approach) and I want you to re-consider, “does the tool NOW make sense”? Again, I ask the polls are completed by licensed Physical Therapists.
Graston Technique (quoted from www.grastontechnique.com):
Graston Technique® is an innovative, patented form of instrument-assisted soft tissue mobilization that enables clinicians to effectively break down scar tissue and fascial restrictions. The technique utilizes specially designed stainless steel instruments to specifically detect and effectively treat areas exhibiting soft tissue fibrosis or chronic inflammation.
Originally developed by athletes, Graston Technique® is an interdisciplinary treatment used by more than 16,775 clinicians worldwide—including physical and occupational therapists, hand therapists, chiropractors, and athletic trainers.
GT is utilized at some 1,760 outpatient facilities and 43 industrial sites, by more than 260 professional and amateur sports organizations, and is part of the curriculum at 57 respected colleges and universities.
For the clinician:
- Provides improved diagnostic treatment
- Detects major and minor fibrotic changes
- Reduces manual stress; provides hand and joint conservation
- Increases patient satisfaction by achieving notably better outcomes
- Expands business and revenue opportunities
For the patient:
- Decreases overall time of treatment
- Fosters faster rehabilitation/recovery
- Reduces need for anti-inflammatory medication
- Resolves chronic conditions thought to be permanent
For employers and the healthcare industry:
- Allows patients to remain on the job
- Reduces the need for splints, braces and job-site modifications
- Contributes to reduction of labor and healthcare costs, direct and indirect
Trigger Point Dry Needling (quoted from http://www.kinetacore.com)
Dry Needling is a general term for a therapeutic treatment procedure that involves multiple advances of a filament needle into the muscle in the area of the body, which produces pain and typically contains a Trigger Point. There is no injectable solution and typically the needle that is used is very thin. Most patients will not even feel the needle penetrate the skin, but once it has and is advanced into the muscle, the discomfort can vary drastically. Usually a healthy muscle feels very little discomfort upon insertion of the needle; however, if the muscle is sensitive and shortened or has active trigger points within it, the subject may feel a sensation much like a muscle cramp — which is often referred to as a ‘twitch response.
The twitch response also has a biochemical characteristic to it which likely affects the reaction of the muscle, symptoms and response of the tissue. Along with the health of the tissue, the expertise of the practitioner can also attribute to the variation of discomfort and outcome. The patient may only feel the cramping sensation locally or they may feel a referral of pain and/or similar symptoms for which they are seeking treatment. A reproduction of their pain can be a helpful diagnostic indicator of the cause of the patient’s symptoms. Patients soon learn to recognize and even welcome this sensation, as it results in deactivating the trigger point, reducing pain and restoring normal length and function of the involved muscle. Typically, positive results are apparent within 2-4 treatment sessions but can vary depending on the cause and duration of the symptoms, overall health of the patient, and experience level of the practitioner.
Dry needling is an effective treatment for acute and chronic pain, rehabilitation from injury, and even pain and injury prevention, with very few side effects. This technique is unequaled in finding and eliminating neuromuscular dysfunction that leads to pain and functional deficits.
Cervical Spine Thrust Manipulation (quote below from Di Fabio RP. Manipulation of the Cervical Spine: Risks and Benefits. Physical Therapy 1999; 79: 50-65)
Manipulation of the spine (MTS) is a form of manual therapy that is used in an effort to reduce pain and improve range of motion.1 The use of manipulation of the spine to treat patients with pain involves a high-velocity thrust that is exerted through either a long or short lever-arm.2–6 The “long-lever” techniques move many vertebral articulations simultaneously (eg, rotary manipulation of the thoracolumbar spine),7–9 whereas the “short-lever” techniques involve a low-amplitude thrust that is directed at a specific level of the vertebral column. Manipulation of the spine differs from mobilization of the spine because, theoretically, during manipulation of the spine, the rate of vertebral joint displacement does not allow the patient to prevent joint movement.10 Mobilization of the cervical spine involves low-velocity (nonthrust) passive motion that can be stopped by the patient.10 The speed of the technique (not necessarily the amount of force), therefore, differentiates manipulation from mobilization. Manipulation of the spine has been used in the treatment of patients with head and neck disorders, including neck pain and stiffness, muscle-tension headache, and migraine.11
Joint Mobilization (quoted from http://www.ozpt.com/res2.php)
Joint mobilization (also known as non thrust manipulation) is a commonly used treatment for patients with a variety of neuromusculoskeletal disorders (Maitland 1985). The efficacy of mobilization in the treatment of both hypomobility and pain has been documented for many years in both peripheral and spinal conditions alike. This commentary deals primarily with the mechanisms of Pain Modulation and Pain Reduction effects of mobilization as demonstrated by various research studies.
Numerous authors have documented the potent Hypoalgesic (pain reduction) response to mobilization in symptomatic populations, the so called “neurophysiological effect”.
This effect has been shown in:
- Elbow pain (Vicenzino et al 1998)
- Cervical Pain (Sterling et al 2009)
- Knee OA (Moss et al 2007)
- Shoulder Pain (Teys et al 2008)
How Pain is Modulated: Two Neurophysiological Theories
Two different, yet complementary theories, have been developed to describe the neurophysiological effect. The two theories suggest different neurological pathways that may inhibit pain perception, thereby providing relief and/or modulation following mobilization. One is the “Gate Control” Theory and the other is “Descending Inhibition via the dPAG”. Some debate exists in the literature regarding exactly which mechanism of pain modulation is responsible for pain reduction following mobilization (Gate Control or dPEG Inhibition).
It is possible, if not probable, that both mechanisms work together interdependently to modulate pain. The exact nature of this interplay remains unclear at this time.
Neural Mobilization (quote from McKeon MM, Yancosek KE. Neural gliding techniques for the treatment of carpal tunnel syndrome: a systematic review. J of Sport Rehab 2008; 17: 324-341.)
Sometimes referred to as “neural flossing” or “neurodynamic mobilization,” the technique of neural gliding is movement based and attempts to take the nerve throughout the available range of motion, potentially affecting the nerve both mechanically and physiologically.23,24 Neural gliding may improve the actual excursion of the nerve, decreasing adhesions and reducing symptoms by allowing the nerve to move freely. This technique may also help to oxygenate the nerve, decreasing ischemic pain.
So in addition to the contributions to this site, I am a regular contributor to a Sports Medicine Journal called SportEx. Well these kind folks would like to gather a bit of data and it would really be awesome if you took this survey. It will literally only take a minute but will be very helpful to us. Thanks!!!- Joe
By Heidi Jannenga, PT, MPT, ATC/L
As a rehab therapist, HIPAA is something you think about and comply with on a daily basis. But if you haven’t reviewed the Department of Health and Human Services’ (HHS) recent HIPAA Omnibus Ruling, then there’s a chance you’re not really as compliant as you think you are—at least not beginning September 23, 2013, when the ruling actually goes into effect.
The new rules established in the Omnibus affect both “Covered Entities” (e.g., providers, health plans, and healthcare clearinghouses) and “Business Associates” (e.g., health data transmission services, medical record services, or health information organizations). This HHS executive summary lays out the main items that comprise the overall ruling. These changes will:
- Extend some direct liability for HIPAA compliance to Business Associates of Covered Entities.
- Prohibit the unauthorized sale of protected health information (PHI) and further limit the use and disclosure of PHI for marketing and fundraising activities.
- Give individuals greater authority in obtaining electronic copies of their health information and in limiting disclosures to a health plan of information related to treatment for which the individual paid out-of-pocket.
- Require Covered Entities to modify and redistribute their notices of privacy practices (NPPs).
- Amend certain requirements concerning disclosure of health information in an effort to facilitate research and the disclosure of child immunization proof as well as grant family members access to their decedents’ health information.
- Enact HITECH Act enhancements that were not adopted in the October 2009 interim final rule, including the enforcement of penalties for non-compliance due to willful neglect.
- Incorporate a tiered civil money penalty structure with augmented penalties.
- Establish a more objective standard for the breach notification rule’s “harm” threshold.
- Prohibit most health plans from using or disclosing genetic information for underwriting per the Genetic Information Nondiscrimination Act (GINA).
Now for the really important part: how all of this impacts you and your practice. According to this summary from the American Medical Association (AMA), providers should focus most of their attention on the following three areas:
1. Privacy, Security, and Breach Notification Policies and Procedures
- Once the Omnibus goes into effect, you must notify your patients of any PHI breach unless you determine—following a careful risk analysis—that there is a “low probability of PHI compromise.”
- If a patient who pays out-of-pocket requests that you do not disclose any information about his or her care to a health plan, you must comply unless the disclosure furthers treatment or is legally required (which is rare).
- If you would like to tell a patient about a third-party product or service, you must get his or her written authorization to do so unless—generally speaking—the communication does not result in you receiving compensation; takes place in person; involves medication currently prescribed to the patient (from which you are not profiting); involves general health promotion (not promotion of a particular product or service); or involves government-sponsored programs.
- You cannot sell a patient’s PHI unless you have his or her express written permission. This rule applies to licenses, lease agreements, the receipt of financial/compensatory benefits as well as research if there is an implication of any sort of profit. (It does not apply to reasonable cost-based fees associated with authorized disclosures.)
- You are allowed to disclose relevant PHI to the family and/or friends of a deceased patient in the same way that you would if the patient were still alive—that is, if the family member or friend was involved in, or financially responsible for, caring for the patient and the patient never gave any indication of another preference. (Note: HIPAA protection expires 50 years after a patient’s death.)
- You are responsible for supplying a patient with his or her PHI within 30 days of receiving a written request, regardless of whether the PHI exists in paper or electronic form. You are allowed one 30-day extension if you cannot reasonably fulfill a patient’s request for PHI. However, you must provide the patient with a written explanation of why it will take more than 30 days and when he or she should expect to receive the requested information. If you have electronic records, you must give the patient the information in the format he or she requests provided that the recorders are “readily producible” in said format. If they are not, you must come to a mutual agreement on an acceptable electronic format. If you cannot come to an agreement, then—and only then—can you give the patient paper copies of the information.
- You can charge the patient for copies of his or her information in the amount equal to labor and supply costs.
- You cannot send PHI in unencrypted emails unless you inform the patient of the associated risk and he or she still wants to receive the information via email.
2. Notice of Privacy Practices (NPP)
Make sure you incorporate all Omnibus directives into your NPP and distribute it to all new patients as well as any existing patients who request it. If your practice has a website, be sure to post it there, too.
3. Business Associate (BA) Agreements
Because this ruling amended the definition of a Business Associate to include Patient Safety Organizations and others involved in patient safety; health information organizations (e.g., health information exchanges); and personal health record vendors, you should take a second look at your relationship with any vendors that create, receive, store, maintain, or transmit PHI for your practice. You might need to enter into new BA Agreements before the Sept. 23 Omnibus enforcement date. Changes to BA Agreements include:
- Providers no longer have to report failures of BAs to the government because the BA is now liable for the violation.
- BAs are responsible for their own subcontractors.
- BAs must abide by the Security and Breach Notification Rules.
- Providers are liable for the actions of BAs who are agents, but not those who are independent contractors.
The ruling also established increased monetary penalties for civil (unintentional) violations, meaning you could incur a fine of up to $50,000 each offense. The table below (modified from the Federal Register) shows the range of penalty amounts for civil breaches. As for criminal violations—well, let’s just say you never, ever want to risk one of those.
TABLE 2—CATEGORIES OF VIOLATIONS AND RESPECTIVE PENALTY AMOUNTS AVAILABLE
|Violation category—Section 1176(a)(1)||Each violation||All such violations ofan identical provisionin a calendar year|
|(A) Did Not Know||$100–$50,000||$1,500,000|
|(B) Reasonable Cause||$1,000–$50,000||$1,500,000|
|(C)(i) Willful Neglect-Corrected||$10,000–$50,000||$1,500,000|
|(C)(ii) Willful Neglect-Not Corrected||$50,000||$1,500,000|
There’s a lot of dense legal jargon included in the HIPAA Omnibus Ruling, but the bottom line is pretty simple: protect your PHI, and protect it well. This is crucial not only to your patients’ well being, but also to the continued success of your business.
Heidi Jannenga was a scholarship athlete at the University of California, Davis. Following a knee injury and subsequent successful rehabilitation, Heidi developed a passion for physical therapy. She started her 16-year physical therapy career after graduating with her Master’s from the Institute of Physical Therapy in St. Augustine, Florida. In 2008, Heidi and her husband Brad launched WebPT, the leading web-based Electronic Medical Record (EMR) and comprehensive practice management service for physical therapists. As the company’s COO, Heidi is responsible for product development/management, billing services, and customer support. She resides in Phoenix with Brad and their daughter.
I am the first one to admit that treating patients with low back pain is not for sissies. There is no great way to sub-classify patients with low back pain and it is difficult to predict which intervention is going to be best for a given patient. However, there are some general recommendations which just about every up-to-date treatment guideline recommends. These are things like stay active, no need for imaging in most cases and avoid opioids.
Despite the solid evidence behind these recommendations, a recent study out of Harvard showed that primary care physicians are getting worse at treating patients with low back pain. Over a 11 (1999-2010) year period the study found a 106% increase in referrals to other physicians, 57% increase in advanced imaging, a 51% increase in the use of narcotics and a 0% increase in physical therapy referrals (20%).
It would be frustrating to see no improvement over 12 years, but this significant movement in the wrong direction is a hard pill to swallow. I wonder what it will take to change the medical culture in our society.
Apparently a 90 billion dollar a year price tag is not enough.
In my last article, I discussed the concept of the clinical toolbox and questioned if the number of tools we add, truly matter. Below I have posted several videos of tools that are often marketed and employed by Physical Therapists. I would love to hear your thoughts on each video and if you believe “they makes sense”. I have also added a few informal polls, to learn a bit about the readers of this site (I only ask they are completed by licensed Physical Therapists).
The Graston Technique
Trigger Point Dry Needling
Cervical Spine Thrust Manipulation
By: Jimmy Pajuheshfar, PT, DPT
2012 Rocky Mountain University Graduate
As a recent graduate, I wanted to write about something I feel needs to be addressed in how we educate our future professionals. Recent advancements in physical therapy research have helped place physical therapists on the forefront as the “movement experts” in healthcare. This has helped unlock doors to direct access and other career expanding opportunities as our healthcare system continues to evolve. With these increased opportunities comes a great responsibility to not only become lifelong learners ourselves but also to educate the future of our profession, a large portion of which are today’s DPT students.
In light of our rapidly growing roles in the healthcare system, it has never been more important that DPT programs pursue the most effective learning strategies in both the didactic and clinical education settings to optimally prepare students to reach and exceed their potential. I’ve had the opportunity to meet students from across the country, and unfortunately frequently hear criticism about the current clinical education model in particular. When a student says, “My clinical is so easy” or “My CI doesn’t really challenge me,” it should raise a red flag. The clinical experience is our time to absorb, to grow, and to be challenged. The internship phase isn’t when we’re supposed to get a break from the rigors of the classroom, but is a time for applying knowledge learned in the classroom. So what will it take to get the best clinical experiences possible, and how can we get it? Where can we find it? How do we know it when we see it? Unfortunately, we don’t know until it’s too late. What we need is a new age in physical therapy clinical education where we don’t have to blindly choose a clinical experience with the hopes that we learn enough to be competent and pass the licensure exam. In my humble opinion, as a debt ridden graduate student, is it too much to ask that our tuition dollars should afford us more than blind faith when it comes to clinical education?
Recent advancements in our understanding of new clinical standards of care in physical therapy, the results of which improve patient outcomes, reduce costs, minimize chronicity, and ultimately result in happier patients with an improved quality of life. Manual therapy, for example, is just a single example of a powerful group of interventions that has taken our profession to a higher level. As a physical therapy student, I fortunately had the opportunity to attend a program where evidence-based practice was the core of our curriculum. As the time neared for me to start my clinical rotations, I was eager to start putting what I had read and internalized into hands-on practice.
Six months ago I completed what I think could be the future of clinical education. I was lucky to be part of a “new” internship model as part of Evidence in Motion’s Clinical Education Network (CEN). This model will continue to evolve into the future, but I really appreciated specific elements, which make me wonder “why aren’t we doing something like this already?” The CEN model created an opportunity for me to be engaged in a structured, organized network of evidence-based instructors and students. This group learning environment really challenged me to learn the fundamentals and foundational skills that every entry-level PT should know how to do very well. The structure of the experience tracked my progress to ensure that I was actually learning what is important for me to be an evidence-based clinician and pass the board exam.
Some things I think are very important for the future of PT clinical education is having a connection between the didactic phase and clinical phase. Right now, other students aren’t well connected to their academic program once they leave the classroom. They are left to hope their one clinical instructor shares with them this essential knowledge. Outside of an informal phone call or the burdensome Clinical Performance Instrument (CPI), nothing currently exists to connect the two parties and ensure a quality experience is taking place. Why not? Why can’t these partnerships be improved? Similarly, why isn’t there a plan out there for us to follow while we are trying to “soak it all up” in the clinic? Are we really supposed to leave it by chance that we experience most of what will be on the board exam, or most what we will be expected to cover, and bill for in a professional setting once we are licensed?
My job right now as a physical therapist comes with many challenges. I am expected to know A LOT of information and be able to implement that information in a short amount of time working with a diverse group of patients. If I was left to guess during my clinical experiences as to what was important, or leave it to some other “qualified” clinician to teach me, I can’t imagine how much more difficult my job would be, and I would feel very badly for my patients who I care about very much. I would probably still be doing ultrasound and other completely ineffective treatments for my patients, and billing for them. Perhaps it is time we come up with a system where everyone works together in a collaborative setting so more students are able to engage with the “best” clinical instructors our great profession has to offer. Right now, according to CAPTE’s website, there are 214 existing DPT programs, and already 25 developing programs. Where are these students going to learn once they finish in the classroom? Are we going to be proud of these clinicians and actually want to work alongside them as PTs?
So to summarize my frustrations and recommendations, I propose a new way of thinking for clinical education. Let’s take a step back and realize how inconsistent our current methods of teaching really are. Let’s realize how unprepared some of our students, and so called “Doctors of Physical Therapy” really are coming out of school and clinical education programs. Now, let’s work together and actually do something about it.
It is time to wrap up this series I have called the “The Experience Wall.” The goal of these posts has been to highlight how, despite an illusion of accuracy, our experience can often be misleading and biased. This can lead to over confidence and experience can become a barrier to growth and development as a clinician. If you have not seen the first 3 posts check them out here, here and here.
Last but not least, this post will look at the judgments (namely cause and effect) that we make based on experience. To make sense of the world, our brains are constantly looking for patterns and associations. This can work really well in simple situations (limited variables) such as flicking a switch which causes a light to consistently turn on/off. However, in complex situations (as we see in the clinic) involving more variables, it is easy to miss real patterns and fabricate non-existing patterns.
Here is a common example I see from both students and clinicians. “I treated a patient with ultrasound (or insert any other treatment), the patient got better, so it must have been the ultrasound.” The problem with this statement is it ignores all the other potential relationships and jumps to a convenient conclusion. In order to accurately assess the likelihood of a cause and effect relationship we have to carefully consider all the possible explanations (or as many as we can think of) for the apparent change in the patient’s status. It is possible that the ultrasound caused the improvement; or it could have been the exercises, it could have simply been the natural course of the disorder, maybe it was placebo or maybe they really liked getting all that attention from you and that made them feel better. In this common clinical scenario, it is impossible to know why the patient actually improved. This is why anecdotes are not useful in determining the effectiveness of an intervention and it is why we need controlled studies.
The problem is that admitting we cannot reliably make cause and effect relationships based on our experience leaves us with uncertainty. As Joseph Brence discussed in his recent post, this uncertainty can be difficult to live with. However, it is this uncertainty which ensures that we do not let experience become a wall which blocks our growth as a clinician.
I don’t think that clinical experience is useless. However, clinical experience has lots of limitations and just like with research, we need to be critical consumers of our experience and the experience of others. I leave you with this video by Neil DeGrasse Tyson which sums up my last 4 posts with the word “brain failures”.
I hope that these series of posts were useful to read and look forward to hearing your thoughts on the subject.
This post is the second part on my series: Observations in Practice (part 1 here).
On his blog, NOIJam, Dr. David Butler introduces a great discussion on grade V manipulation and wants to know who is doing it, is anyone researching outcomes, ”And are there others like me who have moved to more educational/mobilising strategies – but in the back of their minds they don’t want to give it up completely and so they keep “cracking” as an option?” A great discussion has started in the comments section and I highly recommend you check it out.
While Dr. Butlers post leads to the debate of the use of manipulation, I would like to begin a discussion on a similar but broader topic…“The Clinical Toolbox” vs. “Clinical Reasoning“.
Over the past several years, I have interacted with, and observed, the practice of many Physical Therapists and students. I have been fortunate to take some great CEU courses and interact with some very bright minds in the field. Like many, I have enjoyed learning new “techniques”, but in the end, I have to wonder, is it about the “technique” or “the interaction?” What drives my outcomes?
I have written in the past about uncertainty, placebo, and expectations, and as we learn more about the therapeutic alliance between clinician and patient, how important is the infamous toolbox, really? In an age where literature has challenged the relationship between patho-anatomical abnormalities and patients symptoms, do we need to know 10 different ways to manipulate the spine? Is my patient not getting better because I only learned 9 ways? Is my practice not eclectic enough? Maybe it’s because the state of PA has yet to embrace dry needling?
Through my own observations and reflection, I suspect that the toolbox is only as deep as one’s ability to clinically reason. Great clinician’s are those who have an understanding of the human condition. They are those who are able to achieve outcomes with minimal amount of force, tools and rules. They are those who embrace the individual nature of a condition and can justify (cognitively and meta-cognitively) each of the interventions they employ. They are lateral thinkers who do not blame the individual or the tissue; they instead learn how to interact with it.
So all of this said, what would you prefer: To have an uncanny ability to clinically reason OR have every tool in the toolbox?
I haven’t written a formal post for a while and that is because I have been engaged in several new projects, including a position providing Homecare Physical Therapy. While this is a large change from the outpatient/chronic pain setting, my brain has been spinning with thoughts and observations regarding pain, motor control and the living experience. Here a couple of thoughts and empirical observations that have been made among environments.
Motivation is likely the primary determinant in predicting outcomes—regardless of setting.
In an outpatient setting, I often saw individuals who sought my care upon their own free-will, as well as those who were required to see me (workers compensation). I observed those who sought my care, required a lesser number of visits to achieve their goals. I suspect this is likely why individuals who are injured at work may be seen as “malingerers”. But who are WE to blame the patient? We should instead blame those who have taken an operational approach in determining a care plan. If someone is referred to receive my care, without an expectation for recovery from what I do, or with an expectation that I could make them worse, I can almost be certain they will not improve. But I do not believe this is intentional by the patient. I suspect it is a lack of understanding from the current referral networks which exist in the workers compensation field. What would happen if we instead gave more options to the patient? If we interacted with their views, understandings, motivations and expectations? I for one would suspect outcomes would improve (in a more timely fashion) and the amount spent on care would decrease. It comes down to the motivation and beliefs of the individual.
In the home care setting, I am observing a similar phenomenon. I am currently interacting with individuals who range from almost-independent to completely dependent, as a result of various diagnoses from Parkinson’s to dementia. I am observing those who are motivated to improve, are the ones who improve. Even if the patient has dementia, if I can find a way to engage with their nervous system, and motivate them to do something, a change is possible. Movement does not improve outcomes; Goal oriented movements improve outcomes.
This leads to my argument that motivation is a required variable of motor control. When we move within our external environment, we do so with a goal in mind. We move instinctively and as a whole, to achieve this goal; we do not move as individual segments. For example, when I wake up in the morning, I instinctively sit up, put my feet on the floor and stand. I do not consciously think about what to contract. This is important. As therapists, we often get caught up in the process of teaching individuals to contract muscles individually because we think it will correlate to function.
Our brain likely prepares and plans differently for each goal-oriented movement, so should we be spending so much time emphasizing localized muscle activity or global? Does core strengthening translate into work performed by a coal minor? Will the motor planning and output to perform a quadruped activity translate into lifting a heavy box? Should I be making an injured worker, with low back pain, get on all 4′s and lift their arms and legs? Does this make sense? Not sure…
It’s OK to be uncertain
This is a difficult thing for anyone, in any profession, to accept. We hate to admit we are “uncertain”. We like to be certain that “getting on all 4′s will help you co-contract the tA and multifidus which will help with local spinal stability while you are working, because your pain exists because the spine is moving around too much.” This is alot to assume.
We often equate uncertainty with a lack of knowledge. But as “Doctors” of “Physical Therapy” (as well as those with bachelors/masters degrees) we should know enough to know that we often don’t know. Do we truly understand why some can bend their knee after a replacement and others can’t? We may say its due to swelling, soft-tissue tightness, decreased scar mobility, perceived disability, etc. but do we know this is why they can’t bend? What if it’s due a smudge in the homunculus, of a brain that was overprotective of a knee, due to the development of central sensitivity, from years of OA, prior to the replacement? I am comfortable enough with myself as a professional to admit, I often don’t know. I treat individuals and their clinical presentations; not conditions.
What happens if we become “too certain”?
These are just a couple of my recent thoughts…
What are some thoughts and observations you have made recently?
This post is a continuation of “The Experience Wall” series of posts. You can check out the first 2 posts here and here. In the first post I spoke generally about experience and broke it up into 3 parts.
1) The perception of clinical events (seeing, hearing, feeling, etc)
2) The memories of those events
3) The interpretation of those perceptions (cause and effect, etc)
This post will look at memories in more detail.
Just like with perception, it is easy to feel that our memories are accurate and unaffected by our biases. However it turns out that memory is often inaccurate and influenced by beliefs, biases and perspective. In this article and this book Daniel Schacter describes “The seven sins of memory” These seven sins describe 7 ways our memories fail us.
Sometimes these failures of our memory are very obvious. For example, forgetting the name of someone you have not seen in years or losing your car in a mall parking lot. Other times, errors in memory go undetected. These hidden errors have been highlight by lost in the mall studies. These studies expose a person to fictitious stories about them being lost in the mall as a child. After hearing this enough times (often told by relatives) they adopt the memory and truly remember that it happened (even though it didn’t), sin #5.
These hidden errors in memory are dangerous because we are often very confident that our memory is accurate, even though it is not. This over confidence can lead to serious errors, such as those seen with eye witness testimony. The confident testimony of eye witnesses has resulted in numerous convictions, which have later been overturned by more objective information, such as DNA analysis.
These examples demonstrate that memory is incomplete, constructed after events and continually influenced and changed by our current needs, biases and expectations. Furthermore, extreme confidence in a memory is not strongly correlated with the accuracy of those memories.
Memory of past patients and past outcomes makes up a big part of clinical experience. We use our recollection of past cases to make judgments on diagnosis, prognosis and treatment effectiveness. Unfortunately, we may be more likely to remember patients who got better and less likely to remember those who did not (or vice versa). This can leave us with a skewed and biased view of our past performance. For example, a clinician may remember that in the past “correcting” an anteriorly rotated pelvis has been very effective. However, due to bias or other errors of memory, the clinician may have forgotten all of the cases in which this “correction” did not work.
As with errors in perception, errors of memory cannot be avoided. We have to understand that our recall of events is imperfect and adjust our confidence in memory accordingly.
In my last blog post “The Experience Wall” I spoke about the dangers of clinical experience and I broke up clinical experience into 3 parts.
1) The perception of clinical events (seeing, hearing, feeling etc)
2) The memories of those events
3) The interpretation of those perceptions (cause and effect,etc)
My next three posts will look at each of these three categories in more depth.
It appears that our perceptions of the world are accurate and objective. This however is an illusion. In fact, our brains are wired to see things that we expect to see and miss objects and events which are unexpected. Christopher Chabris and Daniel Simons provided us with a powerful example of this in their famous “invisible gorilla study“. If you have not tried this experiment yourself click on the link and give it a try before reading further (spoiler alert). In their study subjects watched a video of people passing a basketball and were asked to count the number of passes. In the middle of the game, A person in a gorilla suite walks out, pauses to beat his/her chest, then walks away. About 50% of the people watching the video missed seeing the very obvious gorilla (did you see it?). This phenomenon is called inattentional blindness and we are all susceptible to it. In fact, a recent experiment performed on radiologist demonstrated how they can miss unexpected objects on a film. The researchers inserted a picture of a gorilla into the CT images of a lung. 83% of the radiologist did not see the gorilla (even though it was obvious and they looked right at it). Another common example of missing obvious things occurs when watching movies. Just about every movie has continuity errors (despite the presence of a script supervisor) and most of us never notice it. Several website are dedicated to pointing out these errors.
We miss unexpected objects and events because our brains have a finite ability to focus. For example, if I am focusing on a phone conversation, I have a reduced ability to focus on driving. I have been driving long enough that my unconscious brain can handle most of the routine tasks of driving. However, if something unexpected happens (someone pulls out in front of me) I am less likely to perceive the pending collision. This is why hands free devices do not reduce the risk of driving while talking on a cell phone. The problem is not that our hands are tied up with the phone, it is that our minds are tied up with the conversation.
In contrast if we expect to see certain objects, events or patterns we are likely to perceive them, even if they are not present. This is why some will see Jesus in a cheese sandwich (we are programmed to see faces) and hear devil worshiping when listening to stairway to heaven backwards (we are programmed to hear words). It may also be why manual therapists think they can identify small differences in movement and position even though the research suggests that we can not. Michael Shermer talks about this “pattern seeking” tendency in his book and in this Tedtalk.
The take home message is that our perceptions are biased. No matter how hard clinicians attempt to avoid it, we will under perceive unexpected objects and events, and over perceive the expected. All we can do is take this bias into account when we are determining how confident we can be in the accuracy of our experience.
Mark Crislip over at the Science Based Medicine Blog wrote that “in my experience” are the three most dangerous words in medicine. I won’t go so far as to say they are the most dangerous words in the physical therapy world but I do think that they pose a threat. A common example of this danger is when physical therapists use “in my experience” to justify a particular treatment philosophy even though it is not supported by science. One examples of this is the use of palpation and movement tests to diagnosis and guide treatment of the SI joint. Despite a large body of evidence questioning the reliability and validity of this method I still see it used all the time. When trying to discuss this topic with believers, I often run into the experience wall. “The literature may say the supine to sit test doesn’t work but I know it is effective because my patients get better.” Or I will hear how the literature is biased, out of touch with clinical reality, not applicable to their patients etc….. Many of these criticisms of the literature have elements of truth, however we need to hold clinical experience to the same standard. It is easy to criticize the literature while blindly trusting our own experiences. It takes great effort to critically appraise our experience (and the experience of others), looking for bias and logical fallacies. If you are looking for more information on the limits of human experience I suggest you take a look at these book (this, this and this). Feel free to share other resources in the comments section.
To explore the dangers and pit falls of experience in more depth we first need to understand what experience is. Clinical experience is comprised of:
1) the perception of clinical events (seeing, hearing, feeling)
2) the memories of those events
3) the interpretations of those perceptions (cause and effect, etc).
For example, I examine a patient (looking, hearing and feeling) and determine he has an anteriorly rotated right innominate. I remember that I have seen several patients who look just like this and when treated with a specific MET they got better. After the treatment the patient improves so I conclude that I was correct in my diagnosis and the treatment was effective.
Unfortunately humans are prone to make mistakes in all three of the above categories. To make matters worse we rarely notice those errors so we become very confident in the accuracy of our experiences. As a result, experience can become a barrier to accepting new evidence especially if it goes against our beliefs.
In upcoming posts I will explore each of these three categories in more depth. Stay tuned!
The following is a letter from George Coggeshall, the president of the Mass chapter of the APTA. I originally saw this letter posted here and felt it was worth sharing. Kudos to our colleagues in Massachusetts who assisted those injured in this terrible attack.
Massachusetts Chapter Responds After Boston Marathon Incident
A team of 70 Massachusetts Chapter members, stationed at the Boston Marathon finish line on April 15 when tragedy struck, stepped in despite a chaotic scene to help injured people. These physical therapists and physical therapist students from local colleges and universities helped provide exceptional care for the critically injured. While there were no APTA members hurt in the blast, there are members whose family and loved ones were among the more than 170 injured people Massachusetts Chapter President George Coggeshall, PT, DPT, expressed sincere thanks to those who aided the victims and everyone who reached out to the Massachusetts Chapter. “Thank you for your many emails and calls expressing your concerns, caring, compassion and love,” Coggeshall said. “We will do our best to follow the footsteps of those chapters who have survived adversity and tragedy.” If your members are interested in helping people affected by this tragic event, or your component would like to make a contribution, Gov Patrick and Mayor Menino have announced the formation of The One Fund Boston.
Note: There is a bad echo until we got to 13:50. Sorry about that. – Joe
Today was a victory for Physical Therapists. In an overwhelming decision, California’s congress voted to NO to support SB381 which would exclude Physical Therapists from the ability to manipulate.
The vote: Senators Price, Corbett, Block, Hill, Padilla & Galgiani said NO. Senator Yee was the sole YES.
Abstains – Hernandez, Wyland, Emmerson
This stated, this CRAP needs to stop NOW! I understand that professionally, we pose a major threat to chiropractors. But bills of this nature, without unsubstantiated cause, demonstrate a child-like behavior by a so-called professional organization. I recommend every PT and DC reads the below transcript and decides if this was necessary:
BILL ANALYSIS ----------------------------------------------------------------------- |Hearing Date:April 15, 2013 |Bill No:SB | | |381 | ----------------------------------------------------------------------- SENATE COMMITTEE ON BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT Senator Curren D. Price, Jr., Chair Bill No: SB 381Author:Yee As Introduced: February 20, 2013 Fiscal:No SUBJECT: Healing arts: chiropractic practice. SUMMARY: Prohibits health care practitioners, other than chiropractors, physicians, surgeons or osteopathic physicians, from performing joint manipulation or joint adjustments. Existing law: 1) Establishes the California Board of Chiropractic Examiners (BCE), under the Department of Consumer Affairs (DCA), and authorizes the BCE to license and regulate chiropractors. (Chiropractic Act of 1923 (CA), § 1 et seq.; Governor's Reorganization Plan No. 2 of 2012) 2) Authorizes a chiropractor to practice chiropractic as taught in chiropractic school or college. (CA § 7) 3) Specifies the schedule of minimum education requirements to enable any person to practice chiropractic in California includes: (CA § 5) Group 1- Anatomy, including embryology and histology; Group 2- Physiology; Group 3- Biochemistry and clinical nutrition; Group 4- Pathology and bacteriology; Group 5- Public health, hygiene and sanitation; Group 6- Diagnosis, dermatology, syphilology and geriatrics, and radiological technology, safety, and interpretation; Group 7- Obstetrics and gynecology and pediatrics; and SB 381 Page 2 Group 8- Principles and practice of chiropractic, physical therapy, psychiatry, and office procedure. 4) Establishes the Medical Board of California (MBC), under the DCA, and authorizes the MBC to license and regulate physicians and surgeons. (BPC § 2000) 5) Establishes the Physical Therapy Board of California (PTB) under the DCA, and authorizes the PTB to license and regulate physical therapists and physical therapy assistants. (BPC § 2602) 6) Establishes the Osteopathic Medical Board of California (OMB), under the MBC, and authorizes the OMB to license and regulate osteopathic physicians. (BPC § 2450) 7) Establishes the Veterinary Medicine Board of California (VMB), under the DCA, and authorizes the VMB to license and regulate veterinarians. (BPC § 4800) This bill: 1) Defines "joint manipulation" and "joint adjustment" as synonymous terms that describe a method of skillful and beneficial treatment where a person uses a direct thrust to move the joint of a patient beyond its normal range of motion, but without exceeding the limits of anatomical integrity, as taught in chiropractic schools or colleges. 2) Prohibits a health care provider, other than a chiropractor, physician, surgeon or osteopathic physician from performing joint manipulation or adjustment. 3) Indicates that a health care practitioner who engages in the unlawful practice of chiropractic is subject to their license being revoked or suspended and/or other disciplinary action. 4) Specifies that the legislation will not prevent veterinarians from practicing within the scope of their license. 5) Specifies that the legislation is not intended to restrict providers working within their scope of practice from treating a dislocated extremity joint. FISCAL EFFECT: Unknown. This bill has been keyed "non-fiscal" by Legislative Counsel. SB 381 Page 3 COMMENTS: 1.Purpose. This bill is sponsored by the California Chiropractic Association (CCA) . According to the Author, there are currently health care practitioners performing manipulations that should not be, and that are doing so under the argument that their scope does not say they cannot perform these procedures. Scope is about what you can do, not what you cannot. There have been reports of physical therapists performing these manipulations, and even when reported to the Physical Therapy Board they are not being reprimanded. This bill would clarify that it is unlawful for those not trained and educated to perform these procedures. This bill is needed to provide additional consumer protection against providers who are currently operating outside their scope of practice by performing manipulation. 2.Background. a) Chiropractor Education, Training and Scope. Since 1923, California has licensed chiropractors. Chiropractors are health care practitioners who provide drug-free and non-surgical health care. Based on the beliefs that the body has an inherent power to heal itself and health depends on a properly-functioning nervous system, chiropractic care focuses on adjustment of the spinal column to remove hindrances to the nervous system. Chiropractors earn a four year doctorate degree and participate in a year long clinical internship. Chiropractors may also pursue post graduate specialty training. The scope of practice for chiropractors is defined in California Code of Regulations Title 16 § 302: 1) A duly licensed chiropractor may manipulate and adjust the spinal column and other joints of the human body and in the process thereof a chiropractor may manipulate the muscle and connective tissue related thereto. 2) As part of a course of chiropractic treatment, a duly licensed chiropractor may use all necessary mechanical, hygienic, and sanitary measures incident to the care of the body, including, but not limited to, air, cold, diet, exercise, heat, SB 381 Page 4 light, massage, physical culture, rest, ultrasound, water, and physical therapy techniques in the course of chiropractic manipulations and/or adjustments. 3) Other than as explicitly set forth in section 10(b) of the Act, a duly licensed chiropractor may treat any condition, disease, or injury in any patient, including a pregnant woman, and may diagnose, so long as such treatment or diagnosis is done in a manner consistent with chiropractic methods and techniques and so long as such methods and treatment do not constitute the practice of medicine by exceeding the legal scope of chiropractic practice as set forth in this section. b) Physical Therapist Education, Training and Scope. Physical therapists have been regulated in California since 1953. Physical Therapists help restore function, improve mobility, relieve pain and prevent or limit permanent physical disabilities of patients with injuries or disease. They treat patients including accident victims and individuals with disabling conditions for back conditions, arthritis, head injuries, carpal tunnel syndrome, hip fractures, as well as rehabilitation after surgery, a serious injury or a stroke. Physical therapists graduate from accredited physical therapist educational programs that offer degrees at the master's degree level and above. A physical therapist may also seek specialty certification offered by the American Board of Physical Therapy Specialties. The scope of practice for physical therapists is outlined in BPC § 2620 as follows: Physical therapy means the art and science of physical or corrective rehabilitation or of physical or corrective treatment of a bodily or mental condition of any person by the use of the physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive and resistive exercise, and shall include physical therapy evaluation, treatment planning, instruction and consultative services. The use of roentgen rays and radioactive materials, for diagnostic and therapeutic purposes, and the SB 381 Page 5 use of electricity for surgical purposes, including cauterization, are not authorized under the term 'physical therapy' as used in this chapter, and a license issued pursuant to this chapter does not authorize the diagnosis of a disease. c) Grade 1-5 Exercises. According to information obtained from the Physical Therapy Board and the Board of Chiropractic Examiners, both physical therapists and chiropractors are trained to utilize oscillatory and peripheral joint mobilization. Peripheral joint mobilization is defined as mobilizing the joints of the periphery or limbs. There is a grading system, created in the mid 1900's, for completing a mobilization. The mobilization technique used is based on the amount of available joint play. Thus, the clinician must know what the total range is by examination through passive movement. The first common mobilization techniques are sustained joint play movements that have three grades. These mobilizations aid in decreasing pain and increasing mobility. Within these three grades the stretch or hold is approximately five to seven seconds. A description of the three grades include: Grade 1. The clinician applies passive movement in a very small range, approximately 15-25% of the available joint play range. Grade 2. Bone is passively moved in a moderate range to 50% or half of the available joint play range. Grade 3. Passive force by the clinician causes one bone to move on the other to the end of the available joint play range. The other common mobilization technique is termed oscillatory mobilization. Oscillatory mobilizations have five grades associated with them. Grades one to two are used to help decrease pain within a joint. Grades three to five are used to increase mobility of joint play. Grade five mobilization is called a manipulation. The following are grades for oscillatory mobilizations: SB 381 Page 6 Grade 1. Slow oscillations within the first 20-25% of the available joint play range. Grade 2. Slow oscillations within 45-55% of the available joint play range, or from the beginning to the middle of available joint play range. Grade 3. Slow oscillations from the middle of the available joint play range to the end of available joint play range. Grade 4. Slow oscillations at the end of the available joint play range. Grade 5. Bone is passively moved to the end-range, and a fast thrust is performed. This technique is considered a manipulation. 3. Attorney General Opinion. In 1976, California Attorney General Evelle J. Younger was asked to provide an opinion regarding the Chiropractic Act. One question asked, "Are there any circumstances under which a physical therapist can manipulate or adjust the hard tissue (i.e., the spine)? If so what are those circumstances?" The Attorney General (AG) replied in his written legal opinion, "Adjustment is not a term used in physical therapy. It is a chiropractic word." He further stated, "?adjusting the spine by hand for the curing of disease constitutes the practice of chiropractic and under the Chiropractic Act is beyond the permissive activity of a physical therapist?Therefore, we believe that the adjustment and manipulation of "hard tissues," that is bones and bone structures, is peculiarly a chiropractic technique beyond the scope of authorized activity for a physical therapist." 4. Department of Consumer Affairs Opinion. In 1980, then Board of Chiropractic Examiners Executive Secretary, Garrett Cuneo, sent a letter to Richard Spohn, Director of Consumer Affairs at the DCA. Mr. Cuneo posed the question, "Can physical therapists engage in spinal manipulation which is the practice of chiropractic?" The Chief Legal Counsel at DCA's Legal Office, Mr. Gus E. Skarakis, received the letter and replied to Mr. Cuneo: Mobilization of the spine and other joints through the use of rotation and other SB 381 Page 7 physical pressure constitutes in our opinion the use of physical properties including passive exercise for the treatment of physical conditions and is specifically authorized in the physical therapist's scope of practice. Therefore, we do not believe that a physical therapist is practicing beyond his or her legal scope of practice by utilizing such technique? In our opinion the performance of joint mobilization by a physical therapist is not the adjustment and manipulation of hard tissues as a chiropractic technique. We primarily view this controversy not as a matter of legal interpretation, but an interprofessional squabble, often referred to as a 'turf battle.' 5.Confusion Regarding the Term "Manipulation." Though the AG and DCA opinions specify that chiropractors manipulate hard tissue and physical therapists utilize joint mobilization techniques, there remains much confusion about the term "manipulation." Many physical therapists describe their work as "physical therapy manipulation" or "joint manipulation" which reportedly differs from "chiropractic manipulation" of hard tissues. In addition, other professionals, such as naturopathic doctors, dentists, veterinarians and physician assistants use the term manipulation to describe some of the techniques they use with their patients. In fact, naturopathic doctors are also taught Grades 1-5 exercises during their training, but are prohibited by California law from performing Grade 5 exercises in practice. Dentists manipulate the jaw when treating Temporomandibular Joint Disorders (TMJ). Additionally, physicians and surgeons specifically use the term manipulation to describe the manual loosening a stuck joint often performed under sedation or anesthesia. Thus, it becomes quite difficult to allow any one profession to exclusively own or define the term. 6. Lack of Consumer Complaints. The CCA reports they have received "hundreds" of complaints from the chiropractors they represent. CCA purports that individual chiropractors report they see patients who complain about receiving "manipulation" or "adjustments" from professionals who are not licensed by the Board of Chiropractic Examiners. In response, the CCA has forwarded these complaints to the Physical Therapy Board (PTB). However, the CCA indicates that the PTB reports that they never received such complaints. The CCA is unable to provide any data regarding the number of complaints received which were reportedly forwarded to the PTB. SB 381 Page 8 According to the PTB, however, their Consumer Protection Services program rarely receives complaints that involve physical therapists performing manipulation. Since 1990, there have only been 5 complaints against physical therapist(s) performing mobilization or manipulation. The PTB indicates, "In all cases, the allegations were not substantiated as the physical therapist(s) were deemed to be practicing within a physical therapist's scope of practice. Moreover, the 5 identified complaints were not submitted as a result of patient harm, but rather by chiropractor(s) concerned with the physical therapist(s) practicing outside their scope of practice." Also, the Board of Chiropractic Examiners reports that there have been no complaints on record of a licensed chiropractor reporting that a licensed physical therapist in their practice setting is performing manipulations. There have also been no consumer complaints against physical therapists performing manipulations received by the BCE. Both the Physician Assistant Committee and the Massage Therapy Council report that there have been no complaints on record of a physician assistant or a massage therapist performing manipulation. 7.Arguments in Support. The Sponsor indicates, "Patients must be adequately protected from unauthorized, unqualified and improper application of manipulation or adjustment. By defining that only doctors of chiropractic, physicians and surgeons and osteopathic physicians and surgeons are allowed to perform joint manipulation or spinal adjustment you are ensuring that patients seeking this form of treatment receive it from providers best trained to perform it." 8.Arguments in Opposition. The Independent Physical Therapists of California (IPTs) indicate physical therapists have been training extensively to provide joint mobilization/manipulation. They note, "Physical therapists have been performing manual therapy safely for decades, including all degrees of joint mobilization/manipulation. IPT recognizes that some patients with spinal disorders prefer to seek care from chiropractors, some prefer acupuncture, some prefer physical therapy and some may prefer medications, injections and surgery. The physical therapy profession in California has never attempted to restrain the trade of any of these health care professions by attempting to pass legislation overturning the legality of their treatment methods." The California Naturopathic Doctors Association opposes the bill SB 381 Page 9 unless amended. They argue, "Naturopathic Doctors receive almost 400 hours of combined physical medicine joint manipulation in California?In fact, joint manipulation classes are often taught at naturopathic medical schools by Chiropractic Doctors?The lack of inclusion of NDs in SB 381 would serve as an obstacle for the newly opened Bastyr University California as it would prohibit naturopathic medical students from the ability to learn and train in joint manipulation, which is currently part of the required curriculum at all naturopathic medical schools." Mount St. Mary's College notes in their opposition letter, "MSMC strongly opposes SB 381 because research on manipulation supports physical therapists performing joint manipulation as among the safest of all health care providers? The physical therapy professional liability insurance program has not identified any trends relative to manipulation that would indicate the procedure presents a risk factor that should be considered in determining professional liability rates for physical therapists. The Legislature should require evidence of public harm or risk before introducing legislation that restricts previously authorized practice?further, graduates of physical therapy education programs are required to be examined with respect to their knowledge of joint manipulation in order to become licensed as a physical therapist in California?Treatment interventions do NOT fall under the exclusive domain of any one specific profession or group of practitioners?SB 381 is an attempt to legislate clinical practice, which is the purview of the Professional [licensing] Boards." 9.Policy Issues for Consideration. Though the Sponsor has stated that the intent of the bill is to protect the public from all unscrupulous professionals, there appears to be a specific focus on restricting the professional activities of physical therapists as a result of this legislation. For example, the Sponsor and Author's office indicate in written materials submitted to the Committee, "There have been reports of physical therapists performing these manipulations, and even when reported to the Physical Therapy Board they are not being reprimanded." However, the Physical Therapy Board reports to the Committee that it has no record of such complaints. The Sponsor also reports there have been "hundreds of complaints" received from chiropractors that have been forwarded to the Physical Therapy Board. However, the Sponsor is unable to provide any data to substantiate these complaints. Moreover, when the Committee checked with other licensing boards under the DCA, including the Board of Chiropractic Examiners, the boards reported little to no complaints from consumers or disciplinary action taken against a licensee relating to the issue of manipulation or SB 381 Page 10 adjustment . If there are in fact consumers who complain to their chiropractors about prior treatment from non-chiropractors, it is plausible that these patients may not fully understand the difference between the adjustment and manipulation of hard tissues authorized for chiropractors and the mobilization and manipulation of joints authorized for physical therapists to perform. This appears to be a long-standing disagreement as evidenced by the opinions dating back to 1976. Arguments from both sides seem to be based on anecdotal evidence and discrepancies about semantics. As noted in the 1980 DCA opinion, "We primarily view this controversy not as a matter of legal interpretation, but an inter-professional squabble, often referred to as a 'turf battle.'" Is making the proposed changes in statute to define joint manipulation and adjustment the appropriate avenue to take in order to clarify this scope battle ? As noted in the 1976 Attorney General opinion, "The definition adopted by the Board of Chiropractic Examiners in section 302, Title 16, California Administrative Code, reveals that physical therapy and chiropractic each involve the use of physical agent used by the other . We do not believe that this common use of agents presents a major problem because a chiropractor is prohibited by section 2630 from practicing physical therapy as such and a physical therapist is prohibited by section 15 of the Chiropractic Act from practicing chiropractic." As such, it appears that the intent of the manipulations is what matters. The intent of chiropractic manipulation of hard tissues, such as the spine, is to cure disease. The intent of physical therapy mobilization and manipulation is to provide physical or corrective rehabilitation to reduce pain. There obviously exists serious contention between the two professions which has led to reactive stances regarding this legislation. Perhaps the most judicious way to proceed is to concede that both professions are concerned with consumer protection, thus the specific activities of each profession need to be clarified. Specifically, both chiropractors and physical therapists are trained during their educational programs to perform Grade 1-5 exercises, which has led to considerable confusion about which profession is allowed to perform joint manipulation and joint adjustments, specifically since Grade 5 is considered a manipulation. The Committee may wish to consider whether it should direct the Board of Chiropractic Examiners and the Physical Therapy Board to collaborate and review the Grade 1-5 exercises to clarify, according to each profession's scope of practice, if it is in fact SB 381 Page 11 appropriate for both professions to teach these exercises. If the two Boards are unable to reach a conclusion, a legal opinion may help to clarify this issue. SUPPORT AND OPPOSITION: Support: California Chiropractic Association (Sponsor) Los Angeles College of Chiropractic 65 letters from licensed chiropractors 21 letters from individuals Oppose Unless Amended: California Naturopathic Doctors Association Opposition: Independent Physical Therapists of California Mount St. Mary's College 104 letters from licensed physical therapists Over 300 letters from individuals Consultant:Le Ondra Clark, Ph.D.
Last weekend I loaded the wife and kids into the car and made the long trip to the sprawling metropolis of Fort Covington, NY to spend Easter with family. While the kids watched Despicable Me (again) I listened to one of my favorite podcasts, This American Life. I highly recommend you take a listen to this episode which was dedicated to the disability system in the US. If you are not into podcasts then you can read about the topic here.
This episode focused on Hale County Alabama where 1 in 4 adults are on disability. However, this problem is not isolated to one county in one state. States like West Virginia, Arkansas, Alabama and Kentucky all have over an 8% disability rate for 16-64 year olds.
The US pays disability benefits to over 14 million people each month and these numbers continue to grow. Not surprising the fastest growing sector of disability is from musculoskeletal disorders (33.8%, up from 8.3% in 1961). I am sure like me, many other physical therapists have seen firsthand how messed up the system is.
What was most interesting to me about the episode was the impact that politics, social ideals and economics had on the disability system. For instance, the unemployment rate makes headlines all the time, but you never hear about the disability rate. So it is a political advantage to move unemployed workers to disability (poof, the unemployment rate goes down). Also, states have to pick up the bill for welfare but the federal government pays for disability. As a result, states will hire consultants to contact people on welfare and attempt to get them qualified for disability.
The episode further expands on this misalignment of incentives. Once on disability you are “punished” (disability benefits taken away) if you get better and/or get a job. As a result, very few people ever get off disability once approved. This got me thinking about the neuromatrix and pain. Imagine a patient with low back pain whose only source of income is a disability check and they have no job prospects. Getting better poses a huge threat and staying disabled and in pain may be the safer option. Maybe we need a questionnaire which measures the fear of getting better?
The last thing any physical therapist (or any health care practitioner) wants to do is diagnose a patient with a musculoskeletal problem when they actually have something nasty like a tumor. To avoid this potentially costly error we take a thorough history and detailed exam, keeping a close eye out for red flags. For patients with spinal pain there are 4 red flags (used to rule out spinal tumors) which are commonly cited and endorsed by the American Pain Society .
2)Being older than 50
3)Failure to improve after 1 month
4) A history of cancer
If a patient has one or more these red flags (there are others as well) they are considered to be at higher risk for having cancer and further testing should be considered. If red flags are not present, imaging such as x-rays and MRIs are often not indicated. But how useful are these red flags? A recent Cochrane review on the subject helps us answer that question.
Before we look at the details of the study it is important to remember what makes a good screening tool. First the tool needs to increase the probability that a condition is present. Second there needs to be few false negatives (high sensitivity).
In this review, the authors identified 8 studies which examined 15 red flags from the history. The sensitivity of the individual tests ranged from .5-.77. One study combined several red flags (age >50, history of cancer, weight loss and failure to improve with conservative treatment) and found the combination to have a sensitivity of 100%. The majority of the historical components examined did not significantly increase the post test probability of having cancer. The only exceptions were unexplained weight loss (increased from .3% to 1.2%) and previous history of cancer (increased from .3% to 4.6%).
5 physical exam tests were also identified and they had very low sensitivity and did not increase the post test probability.
The authors conclude that:
“Commonly suggested “red flags” for malignancy in clinical practice guidelines are: age > 50 years, no improvement in symptoms after one month, insidious onset, a previous history of cancer, no relief with bed rest, unexplained weight loss, fever, thoracic pain, or being systemically unwell ( Koes 2010 ). These “red flags” are usually elicited through the initial assessment (history taking and physical examination), to decide which patients should be referred for imaging or specialist consultation. The limited evidence available suggests that only one “red flag” when used in isolation, a previous history of cancer, meaningfully increases the likelihood of cancer. “Red flags” such as insidious onset, age > 50, and failure to improve after one month have high false positive rates suggesting that uncritical use of these “red flags” as a trigger to order further investigations will lead to unnecessary investigations that are themselves harmful, through unnecessary radiation and the consequences of these investigations themselves producing false-positive results. While the lack of evidence to support or refute the use of “red flags” is recognized, a more pragmatic solution is to consider the possibility of spinal malignancy (in light of its low prevalence in primary care) when a combination of recommended “red flags” are found to be positive.”
So it looks like other than a history of cancer, red flags are not all that helpful for determining when someone with spinal pain has an elevated risk of cancer. Hopefully, future studies will identify better screening tools.
So I want to present a new type of post called “Clinical Cases”. This type of post will show a video and then ask the viewers of this site to not only give their impressions on the anatomy and physiology involved in the injury but also the societal impact of the video, psychological variables that may impact or hinder recovery, personal and clinical “feelings” when viewing the video, potential rehabilitation, etc. Let’s learn how to utilize a “biopsychosocial” model in understanding injury and recovery.
So here is video #1 showing an injury sustained by Kevin Ware from this weekend’s Louisville/Duke game . Please note, this is not an easy video to watch. Let’s begin a discussion below:
Not all that long ago, arthroscopic surgery was routinely used to treat patients with knee OA. This practice was first called into question by a study published in 2002. In this study subjects received arthroscopic debridement, arthroscopic lavage or a placebo surgery in which the scope was inserted but nothing was done. There were no differences in pain or function between the three groups. Another trial compared the effectiveness of arthroscopic debridement to non-operative care. Again, there was no advantage to having the surgery. A study of 90 patients by Herrlin et al looked at partial meniscectomy in patients with OA and found no advantage over physical therapy at 6 months and 5 years.
A recent RCT performed by Katz et al (METEOR trial) looked to confirm these results with a larger multi-centered study. 351 subjects from 7 institutions were randomized into a surgical group or a physical therapy group. The surgical group had a partial meniscectomy and the physical therapy group “was designed to address inflammation, range of motion, concentric and eccentric muscle strength, muscle-length restrictions, aerobic conditioning (e.g., with the use of a bicycle, elliptical machine, or treadmill), functional mobility, and proprioception and balance” and was administered in three stages. Overall the physical therapy protocol seemed reasonable and did include manual therapy. The description of the protocol (which can be found here) did not give specifics on the manual therapy (which joints and which techniques) and did not give detailed information on the intensity of the exercise. Outcomes were measured (6 and 12 months) using the physical function scale of the WOMAC, KOOS and the SF-36.
The authors found no significant difference between the groups at 6 and 12 months. There was a 30%(6 months) and 35% (12 months) cross over from conservative to the surgical group. The authors did an intent-to-treat analysis to try and deal with this cross over.
Overall this is a good study and it confirms that physical therapy is a viable option for symptomatic patients with OA and meniscus tears. Hopefully this data will help to reduce the over 465,000 partial meniscectomies performed in the US each year.
It appears that the all-in-powerful Oz is being sued after a New Jersey man suffered third degree burns after following a recommendation he saw on the show. The man claims to have slept with “heated rice-filled socks” which were recommended by Oz in a show filmed in 2012. Unfortunately, the man is diabetic and suffers from neuropathy and could not feel his feet burning. Ouch.
As Physical Therapist’s, we must always educate our consumers on the safe use of modalities, and to always consult a medical professional before trying something they heard on this (or any other) show…