Does Anything Change In Healthcare? Well…
If you don’t subscribe the the New York Times Well Blog, written by Tara Parker-Pope, you may wish to. It is very thoughtful and I enjoy reading the author’s insights into a wide variety of health issues. A recent post looked at a 1980 letter written by public relations man, Larry Ragan, who ultimately died from Lou Gehrig’s disease in 1995. In reading Mr. Ragan’s letter, it becomes clear that many of his issues still exist today.
I also enjoyed the post entitled, "A New Twist on Ankle Pain," which begins to tell the tale of current evidence regarding ankle sprains. I do wish the expert went a bit further explaining the importance of early weight bearing in gaining control of the joint following a sprain.
Happy reading!
ERIC
Insurance Report Cards
Recently the American Medical Association (AMA) issued a report card on the nation’s health insurance providers. The report indicated that 14% of physicians’ total revenue was spent to collect their claims. Not paying at the contracted rate was a big problem, with United Healthcare leading the way.
"Physicians are spending 14 percent of their total revenue to simply
obtain what they’ve earned," said Dr. William Dolan, an AMA board
member.
I wonder if physical therapists created the same report, would that 14% number be much higher simply because they "earn" much less than physicians. If it takes 2 office staff to submit and collect claims, and they are paid similarly in physical therapist and physician offices, and the PT bills $100 per patient, but the physician bills $200 per patient…well?
If that case is true, then physical therapists should be under more pressure to upgrade to more efficient record and claims systems, in addition to the everlasting battle to gain more leverage in negotiations with insurance providers.
I would love to see the APTA report card on insurance! Perhaps, in conjunction with next year’s AMA report.
Why is Standing Up So Difficult?
I’m always amazed at how millions of individuals use similar movement strategies during normal human development. No one invents a new way to stand up or walk or crawl, as our brains seem to instinctively know the most efficient way to move our bodies around. But, it seems we may be wired to learn how to stand properly only one time in our lives!
Well, that may be taking this a little too far, but a recent research study out of the University of Delaware found that in patients with Total Knee Athroplasty (TKA), learning to stand normally is certainly not intuitive. It is a research study which has personal implications for me, though I’ve never had a knee replacement.
Investigators wondered why patients with knee arthroplasty continued to demonstrate reduced scores on functional movement tests despite reduced pain and normalized strength. To try to answer the question, the research team analyzed a sit-to-stand task, measuring joint angles, ground reaction forces and other variables of the motion. The subject group compared patients with TKA to age-matched controls up to 1 year after the procedure.
The surprising result was that even as the quadriceps muscle strength normalized, patients continued to use substituted patterns of movement. When rising from sitting to standing, patients with TKA relied on less quadriceps muscle function and more hip extension muscle activity. They achieved this reduced quad requirement by beginning the transfer with a greater amount of hip flexion compared to controls.
The significance of this is that physical therapists must be aware that, even in the face of normalized muscle strength, patients after TKA may need to be specifically trained in the transfer in order to perform it correctly. I wonder why the body doesn’t use the quad in the pre-injury manner on it’s own? Are we only wired once? Is there some inhibition of the quads that persists for a good reason? Is it related to TKA, or is this phenomenon present after all knee surgery?
Personally, I find I use my hip extensors most of the time in my very injured knee. I notice this while climbing stairs and, especially, while cycling on my road bike where the smallest movement of the seat completely saps my power.
By the way, this study has been getting nice pick-up by the press, even earning a feature in the LA Times.
Farquhar, S.J., Reisman, D.S., Snyder-Mackler, L. (2008). Persistence of Altered Movement Patterns During a Sit-to-Stand Task 1 Year Following Unilateral Total Knee Arthroplasty. Physical Therapy DOI: 10.2522/ptj.20070045
Where Did the APTA Go?
The entire APTA website has been down for more than 30 minutes! Yikes. How do I know what The Bottom Line is if I can’t log in?
Here’s a call to have login at the PT Journal live at the PT Journal website. I hate the 5 step process requried to log in to the PT Journal site. And why does the APTA not automatically direct me back to my intended content at PTJ? It makes me tell it again where I was headed with the "Click here to continue" or "Click to go the the home page" option. Obviously the website knows what I wanted, just give it to me!
AMA: No Bananas at the Doctor's Office!
I file this position statement by the AMA under things that “don’t make no sense,” to quote my favorite film of all time.
The position states the AMA is opposed to the operation of retail medical clinics in stores that also sell tobacco products. This quote can be found at the WSJ Blog from the above link:
“In no way is this resolution to get back at them,” William A.
Dolan, an orthopedic surgeon on the AMA’s board of trustees, told the
Health Blog. “It’s ridiculous that a health deliverer should be
dispensing cigarettes.“This would be akin to me spreading banana peels all around my
office area, and having people break things,” he continued. “My shop is
right there, and they come into my office and we fix their broken
bones.”
Why draw the line at tobacco? If that’s the rationale, shouldn’t the AMA also oppose the operation of retail clinics in stores that sell ANY product which could cause you harm? No clinics in stores that sell: knives, fatty food, glasses (they could break!), non-supportive footwear, toys you could fall off of….and so on.
The real issue here is the AMA’s refusal to acknowledge the fundamentally different environment of the retail clinic. While they state no opposition to the concept, a position like this seems a bit passive-aggressive. Retail clinics are a threat to the traditional entrepreneurial independence of physicians, so it’s not surprising to see a position like this.
I guess I need a new doctor now. My phsyician’s office is located next to a convenience store that sells cigarettes and those 20 year old hot dogs on the rollers.
I could get hurt there!
Healthcare is Bad Debt
I’m really enjoying the things I learn from Mike Leavitt’s blog. He, of course, is the U.S. Secretary of Health and Human Services. Mr. Leavitt connects Medicare spending to our overall national financial health:
"I would simply ask this question. If you were considering between an
investment in two organizations and one spent four percent on health
care with no future liability and the other spent 16 percent and had
trillions of dollars of unfunded obligations, which one would you be
most interested in?"
He tells us about Singapore, which spends only 4% of its GDP on healthcare. They live longer.
ERIC
Tiger Tore Himself Up!
I watched the US Open with millions of other viewers in awe of Tiger Woods. I also watched with concern, as his grimaced in pain after almost every swing and his gait was guarded. I wondered to myself how many things could be wrong that were not a serious injury that could potentially be causing his pain. The answer: not many!
And so today we learn Tiger tore his ACL last year and very recently was diagnosed with stress fractures which occurred during his recovery from an arthroscopic procedure in April. The ACL injury is usual, though his ability to play and win without his ACL might be another piece of evidence in the "ACL is over-rated" camp, of which I firmly belong to. The stress fracture injury is a bit concerning, however. I wonder what brought on this injury, which commonly occurs during overuse and strenuous training when the body is loaded too quickly without proper opportunity to recover.
Was Tiger rushed back too quickly by his training staff? Does Tiger get a little too rough in workouts? The ACL occurred during a training run, after all! Are Tiger’s bones a bit thin?
These are poignant questions that Tiger will now have time to think about as he misses the rest of the season.
Quote of the Day..well Yesterday
“Evidence suggests a disturbing gap between the quality of health
services that can be provided in principle and the quality of health
services that actually are provided in practice,” he said.
“Inconsistent use of best practices by doctors and hospitals is also
surprisingly widespread.”Ben Bernanke speaking to the Senate committee hearing on health reform.
Did he talk to a physical therapist before he made this quote? If so, he might have used the term “black hole” to make his point.
A group of students from my university are out on their first clinical rotation presently. The feedback they have been giving me about their experiences supports this point. It seems there is a common thread of knowledge among their clinical instructors, but the implementation of current evidence into best practice is all over the place.
ERIC
Get your Fox
It’s download day. Get your new Firefox web browser.
Pondering Push-ups: Risk vs. Benefit?
There is a 100 Push-up Challenge taking place over at the Get Fit Slowly blog community. The participants of the challenge are using a protocol to slowly build their push-up fitness. Push-ups are a difficult exercise, and many people have trouble doing them. The military uses the push-up as a global strength measure due to its ability to predict success in military tasks. But, push-ups can place the shoulders at risk, and may even rough up your back. It’s worth asking a couple questions: Are the fitness gains made doing push-ups worth these risks and, is there anything that can be done to improve the success of those undertaking the push-up challenge ?
What are you strengthening, really?
While it is intuitive that push-ups strengthen your arms, they do much more than
that! Push-ups are often used in late stages of rehabilitation for the work they do strengthening the chest and shoulders, specifically the scapular stabilizing muscles. Push-ups get a large amount of muscle activity in the upper trapezius muscle and the serratus anterior muscle. Additionally, and most importantly, push-ups work your body’s core muscles around the spine. As you do a push-up, gravity wants to make your back sag. Keeping a nice, neutral spine requires a lot of abdominal muscle control, which can help to reduce low back pain. This study suggests that a suspended push-up, where your hands are placed on a mobile surface like rings, provoke even more abdominal control, but also increase the load through the joints in your spine making this version of the push-up only good for healthy backs and strong cores. A strong core, of course, is important for preventing low back pain.
Are push-ups a danger to the shoulders?
In short, YES! Our arms are made for pushing, but in very specific positions. As you get to the bottom of a push-up, the shoulder moves more towards extension. When your arms are spread wide, this movement puts the shoulder in a precarious position. The worst case is a risk of shoulder dislocation. A less violent, yet more common occurrence is that the delicate tendons and joint capsule of the shoulder is over-stressed in this position, causing inflammation and pain. You can minimize the risk to your shoulders by going slow, stopping when your upper arms parallel with your body (don’t let your elbows go past your torso, as in the picture above), and keeping your arms somewhat close to your body, but your hands neutral or turned outwards (turned in stresses your elbow). If you keep good alignment and listen to your body over a dictated “preferred” form, push-ups can be good for your shoulders.
What to do on off days?
Since the 100 Push-up protocol calls for push-ups 3 days a week, that leaves 4 days to do something else. While your muscles need time to recover, especially after a challenging task of push-ups, doing some simple cross-training can speed up both recovery and performance. I would recommend aerobic exercise always, but also doing some non-arm-based core training on off-days. Example: crunches, swiss ball workouts, or hip and leg exercises like a leg press. Keeping your body moving on recovery days is the concept behind “active recovery” which is the preferred method of rest when training.
Warning Signs?
Doing too many push-ups too quickly can get you into trouble. The main spot of concern is the shoulders, of course. It is important to differentiate muscle soreness from injury-related pain. Injury pain is usually more focused in one spot and more intense. Muscle soreness goes away after a day or so, but injury pain returns when the activity is performed again or does not go away. If you’re doing the 100 Push-up Challenge and you feel some pain, please take a week off. Yes, not just a day, a whole week! In my clinical experience, it is much better to be conservative with inflamed shoulder structures than to challenge them. It could be that the small, but honest break will enable you to keep pace overall. Not taking that break can get you into some chronic pain trouble and doom your chances altogether.
Good luck!
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