#CSM2011 Acute Care Lecture: Our Foundation and Our Future?

#CSM2013 has arrived! Pre-conference courses are in full swing and the regular section programming begins tomorrow morning. Acute care practice received press online and discussion here on PT Think Tank. Now, I am going to review an inspirational lecture from 2 years ago at #CSM2011 that I truly enjoyed.

Jim Dunleavy PT, MS gave the inaugural Acute Care Section Lecture at #CSM2011 entitled “Acute Care: Our Foundation and Our Future.” Jim has been instrumental in the Acute Care section as well as served as president of the New York Physical Therapy Association.

Here are some quick facts you may not know about the Acute Care Section:

  • Formed in 1992
  • First section with platform presentations
  • First to share special interest groups across sections
  • Goal of establishing an acute care physical therapy speciality certification
  • APTA’s 2011 Most Outstanding Section award
  • Twitter @AcuteCarePT (ond of the most active sections)
  • Fantastic website with excellent resources

 

Jim discussed the history of our profession in the United States. The physical therapy profession grew out of serving societal need, providing necessary service not otherwise available. Jim urged us to not loose site of what society and patients need, not merely what we desire to accomplish professionally. A focus on need, service, and commitment.

Now, I must say Jim has VISION. Throughout his lecture he kept emphasizing the “courage and will to change.” He even poised the question how could direct access physical therapy be practiced within the hospital? Interational therapists, notably some in Australia, practice in a direct access environment even within intensive care units.

Jim stressed pursuing measurable financial, personal, and patient outcome effects of acute care provided by physical therapists. He presented the necessity for openness to new business relationships with the facilities at which physical therapists are currently employed. Changes in healthcare, payment and hospital care delivery require physical therapist practice to evolve. Can an acute care physical therapist structure their practice like a hospital physician?

As I discussed in so, you think you can walk? Jim maintains that a function only approach may cost a facility more money. It is imperative physical therapists research and present their impact on costs to the patient, hospital, and health care system in addition to patient outcomes (pain, function, morbidity). Across settings, a function only approach results in far too narrow and limiting scope of analysis for our practice. A great example of the profound effect we can have on medical outcomes and complications, regardless of function, was illustrated in a recent PTJ manuscript investigating an early mobility program in a trauma and burn intensive care unit.

No adverse events were reported related to the EMP [early mobility program]. After adjusting for age and injury severity, there was a decrease in airway, pulmonary, and vascular complications (including pneumonia and DVT) post-EMP. Ventilator days, TBICU and hospital lengths of stay were not significantly decreased.

So, regardless of the functional implications of early mobility and a lack of effect on ventilator days and hospital length of stay, there a strong argument for the presence of a physical therapist and early mobility in a TBICU exists. If this investigation focused soley on function, a vital, important outcome of movement would have been overlooked.

But, the Acute Care section needs help and recognition from the other sections. Further, it needs young, motivated individuals to sustain and execute it’s vision and goals. Despite impressive and innovative acute care practice expansion over the years including more complex, acute patient populations and environments ranging from emergency departments to intensive care units, the Acute Care section has struggled for meaningful recognition and collaboration from professional colleagues…

So, what’s next?

Research illustrates the importance, effectiveness, and outcomes when a physical therapist is involved in patient care. Future investigations should focus on specifics of interventions including frequency, duration, intensity, and content which is most efficacious and effective for specific populations. But, global inquiry on the impact of physical therapists on patient, hospital, and healthcare outcomes should not be abandoned. Some of the more profound research is not just what physical therapists can do to improve function and quality of life, but on reducing the risk of adverse medical outcomes and morbidity. ALL students should have some type of acute care rotation or experience prior to graduation. If we truly want to assume our role as direct access providers of choice all students must obtain didactic knowledge and clinical exposure to acute medical conditions.

Dan Malone, PT, PhD, CCS and recently elected president of the cardiopulmonary section states in his editorial The New Demands of Acute Care: Are We Ready?

The articles cited here should inspire us—acute care practitioners, therapy managers, and educators—to examine and evaluate how to provide services as well as how to facilitate the integration of the specialized knowledge, skills, and behaviors that will bring success in acute care. We face many challenges ahead—an aging population; changes in work processes and care delivery; recruitment and retention of high-quality staff; and the imperative to define the value of physical therapy to our many stakeholders, including patients, referral sources, and third-party payers. Are we ready?

Physical therapists in acute care (and beyond) need to step up to the challenge. We need to focus on changing the process and concept of our practice. We need to improve our understanding of pain and musculoskeletal conditions. We need to treat patients within the hospital who have pain complaints. We need to assist in pain management, pain education, and pain understanding for out patients, our colleagues, and other professionals. We need to continue to educate our outpatient colleagues on the physical therapists role in managing medical conditions. We also need to learn from and collaborate with them.

This years Acute Care Lecture is on Wednesday from 6:30PM to 7:30PM in the Hilton Bayfront Indigo GH rooms. Sharon Gorman PT, DPTSc, GCS will discus Leveraging Technology to Advance Acute Care Practice. Even if you do not practice in acute care, please stop by. Interested in attending some Acute Care Section Programming? Here is the #CSM2013 schedule.

#PhysicalTherapy Hashtag Project 2.0

With #CSM2013 only days away, #physicaltherapist twitter chat relating to the conference will continue to increase. Quotes, links, pictures, and thoughts relating to #CMS2013 will spawn far ranging discussion. Individuals will participate remotely from all over the world. I anticipate the traffic on the #CSM2013 stream to be massive given the increase in physical therapists, students, and other disciplines engaging twitter professionally.

In #PhysicalTherapy Hashtag Project, I discussed hashtags in physical therapy specifically and healthcare in general. I also outlined some proposed hashtags for  the PT tweetsphere. These were meant to categorize links, discussion, and comments regarding specific practice areas and topics including sports, pain, acute care, business, advocacy, and research science. A nice discussion evolved both in the comments section, and on twitter inspiring me to create a follow up post based on the conversation.

The Healthcare Hashtag Project on Symplur continues to curate information relevant to various aspects of healthcare and various professionals within healthcare. Of course, much of the information is also important for public health and patients. Interestingly, the #DPTstudent and #solvePT tweetchats rank 5th and 7th respectively in trending tweetchats. #Rehab generally is 15th on the list of trending hashtags. Impressive! The four main categories of organization are hashtags, tweet chats, conferences, and diseases. I envision this project growing in both scope and specificity to connect various professions (and patients!) while simultaneously allowing for more focused categorization within professions. As introduced in the Physical Therapy Hashtag post, specificity of hashtags for the physical therapist profession adds value to the twitter community. A great feature is a schedule of healthcare related tweet chats.

A while back, PT Think Tank’s Eric Robertson introduced the idea of a new PT hashtag #LivePT to capture statements and sentiments that were more appropriately branded outside the #solvePT tag and chat. Below is the revised list of hash tags. Please review and comment….

Practice Areas

  • #AcutePT
  • #CardioPulmPT
  • #GeriatricPT
  • #ManualPT
  • #NeuroPT
  • #OMPT
  • #OrthoPT
  • #PainPT
  • #PediPT
  • #PelvicMafia
  • #SportsPT
  • #WellnessPT

Other Topics

  • #bizPT
  • #brandPT
  • #cashPT
  • #PTadvoc
  • #PTscience
  • #PTtech
  • #therapycap

Students and Education

  • #PTedu
  • #DPTstudent

Global #physicaltherapy Hashtags

  • #LivePT
  • #PTfirst
  • #PThero
  • #SolvePT

Other Hashtags

  • #HCSM
  • #meded
  • #mHealth
  • #SocialOrtho
  • #SportsSafey

Tweet Chats

 

Is the list too long? Too short? What hashtags do you utilize and follow? Any tweet chats you participate in or follow? Remember to utilize both the #CSM2013 hashtag and topic specific hashtags for your Combined Section Meetings tweets! See you in San Diego. Tweet with you if not!

 

#AcutePT helps ICU save $818,000 per year!

In a recent post So, you think you can walk? I outlined some of the evidence, rationale, logic, and decision making involved in acute care physical therapist practice. I discussed the important of conceptualizing and studying physical therapists impact “beyond function.”

An article from UPI.com entitled Providing Physical Therapy in ICU Helpful highlights exactly this concept. The study discussed will be published around March in Critical Care Medicine. An e-published ahead of print version is already available: ICU Physical Rehabilitation Programs: Financial Modeling of Cost Savings. The benefits of technology allow us to begin preliminary discussion and analysis!

The authors modeled cost savings utilizing best-case and most conservative estimates of length of stay reductions, upfront costs, and other factors based on  existing published data and their specific quality improvement project. The quality improvement project undertaken at Johns Hopkins University within the medical ICU included full time, dedicated physical therapists and occupational therapists in the medical ICU. The vision:

A multidisciplinary team focused on reducing heavy sedation and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines.

In total, the early rehabilitation program cost the hospital approximately $358,00 more per year than the previous standard of care. So, what did the results say? Within 1 year, ICU length of stay decreased by an average of 23% while medical ICU admissions increased by over 20%. An $818,000 per year net savings after accounting for start up costs (approximately $358,000) was observed. Conclusions:

A financial model, based on actual experience and published data, projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals. Even under the most conservative assumptions, the projected net cost of implementing such a program is modest relative to the substantial improvements in patient outcomes demonstrated by ICU early rehabilitation programs.

The “actual experience” investigation is actually published in Archives of Physical Medicine and Rehabilitation: Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. The study lead, Dr. Dale Needham, MD, PhD, passionately advocates for the importance and necessity of physical therapists and early mobility within ICU’s for individuals with critical illness. Independently, the results of that quality improvement study are also profound:

Results: Compared with before the quality improvement project, benzodiazepine use decreased markedly (proportion of MICU days that patients received benzodiazepines [50% vs 25%, P=.002]), with lower median daily sedative doses (47 vs 15 mg midazolam equivalents [P=.09] and 71 vs 24 mg morphine equivalents [P=.01]). Patients had improved sedation and delirium status (MICU days alert [30% vs 67%, P<.001] and not delirious [21% vs 53%, P=.003]). There were a greater median number of rehabilitation treatments per patient (1 vs 7, P<.001) with a higher level of functional mobility (treatments involving sitting or greater mobility, 56% vs 78%, P=.03). Hospital administrative data demonstrated that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4-3.8) and 3.1 (0.3-5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year.

Conclusions: Using a quality improvement process, intensive care unit delirium, physical rehabilitation, and functional mobility were markedly improved and associated with decreased length of stay.

  • Early mobility in acute care. It’s important.
  • The physical therapist in acute care. A vital part of the care team.
  • Looking beyond function to conceptualize and understand the impact of the physical therapist? Necessary.

So, you think you can walk? #AcutePT

All you do is walk people! Are you going to walk Mrs. Smith? Are you getting Mr. Johnson up? You don’t have to think in acute care!

In my opinion, the role of the physical therapist in acute care hospitals has some of the most profound & robust reasoning and logic. In addition, clinical research evidence continues to illustrate the positive benefit of physical therapists within acute hospitals for individuals who have had total joint replacements to the most critically ill individuals in intensive care units. The Physical Therapy Journal special issue on Rehabilitation for People with Critical Illness inspired me to discuss acute care practice in more depth. Despite the complex, fast paced environment and short lengths of stay, physical therapists continue demonstrate value in regards to patient outcomes, hospital throughput and flow, and risk reduction. The acute care environment is bursting with opportunity for physical therapists to enact meaningful change through innovative practice models and health care changing research.

Yet, the above are common statements and questions the acute care physical therapist must routinely face. Unfortunately, the skills, knowledge, role, and contribution of the acute physical therapist is misunderstood not just by other healthcare professionals within and outside the hospital environment. Equally as important, is the misunderstanding of physical therapist colleagues who practice in other settings.

In the editorial Acute Care Physical Therapist Practice: It’s Come a Long Way physical therapy journal editor Dr. Rebecca Craik, PT, PhD, FAPTA comments:

“Should Physical Therapists Practice in Acute Care Settings?” That was the 2007 topic for the Rothstein Debate, an annual event held at APTA’s conference and exhibition and established to honor PTJ’s esteemed Emeritus Editor in Chief Jules M. Rothstein (1945–2005).

 Dianne Jewell, PT, PhD, FAPTA, was moderator. Anthony Delitto, PT, PhD, FAPTA, and Charles Magistro, PT, FAPTA, argued for and against the need for physical therapists in the acute care setting. On one side, the physical therapist was characterized as a sophisticated decision maker with a breadth of knowledge that spanned medicine and physiology; on the other side, the physical therapist was characterized as just another clinical staffer who “dragged” patients down the hall.

The session was filled to capacity with approximately 300 people; the tension was palpable, the debaters articulate—but tempers were kept in check. The debate was declared a draw. I still recall my surprise that day at learning about the paucity of research on acute care practice:

1. The clinical decision-making process touted as complex by the “pro” team had not been described in the literature.

2. Responsive outcome measures had not been agreed upon.

3. Clinical trials had not been conducted to compare different interventions in that setting.

4. Cost-effectiveness had not been examined.

Today, in my opinion, I feel asking whether physical therapists belong in acute care shows a gross misunderstanding for the history and future of the physical therapy profession generally and the role of the acute care practioner specifically. Where is the recognition and assessment of the logic, rationale, and research behind acute care practice? My hope is that this debate topic was purposefully chosen to expose physical therapists to the acute care practice environment. Dr. Craik contends it inspired action. Acute care research and investigations since that debate have grown tremendously in both number and quality.

What are the physical therapist’s roles in acute care?

The obvious role of the physical therapist is to examine and evaluate a patient within the International Classification of Functioning, Disability, and Health (ICF Framework) to determine current and future need for rehabilitation, appropriate discharge location, equipment needs, and current functional level. Specific impairments of body structures and function, activity limitations, and participation limitations can be identified. Physical therapists can then also prescribe mobility and movement recommendations which I like to term “movement medicine.” This conceptualization of acute care practice, while accurate, is overly simplistic. For many, this is where their understanding and conceptualization of #acutePT ends.  In fact, it only represents a minute fraction of the effect and role of PT.

Beyond Function…

The profound effect that physical therapists can have in the acute care environment extends far beyond function and mobility. When analyzing the acute care practice environment from the outside many often ask if specific physical therapy interventions are effective from a functional, patient outcomes standpoint. While valid, this narrow scope does not fully encompass acute care practice.

The role and effect of the physical therapist’s presence, input, and treatment (generally and intervention content specifically) needs to be analyzed from multiple perspectives. Various metrics need to be assessed. Outcomes from multiple levels of the care and delivery process from the individual patient to the specific unit to the hospital to the entirety of the healthcare system need to be analyzed. This includes not only function and functional improvement, but current and future costs of an episode of care. No doubt, patient performance and function including future functional status and time to accomplishment of functional milestones are vitally important. But, length of stay, readmission rate, proper/safe discharge location, and reduction of medical complications are all important outcomes to patients, hospitals, and the healthcare system.

Physical therapist’s presence, guidance, and treatment can actually reduce the risk of adverse medical events including pneumonia, blood clots, readmissions, and longer lengths of stay. They may have an impact on hospital costs, future medical costs, overall healthcare costs and morbidity. These are important outcomes metrics. Taking a function only approach to acute care physical therapist practice and research may be detrimental. For example, a study may show that the functional outcome of a patient population treated by a physical therapist resulted in minimal improvements in function at hospital discharge. But, what if the same study illustrated that the treatment drastically lowered the incidence of pneumonia. Is that an outcome of interest to patients, physicians, hospitals, and health care administrators? A retrospective study illustrated physical therapists make accurate and appropriate discharge recommendations. More interestingly, when actual discharge location did not match the therapist recommendation the odds of readmission were 2.9 times higher than when the actual discharge matched therapist recommendation.

Physical therapists act not only as treating clinicians, but valued consultants (or a consulting service) in the acute care hospital. In a qualitative study of acute care practice the authors discuss acute care physical therapist practice in the evolving healthcare and hospital environment

According to the Centers for Disease Control and Prevention’s National Center for Health Statistics, the number of hospital days of care for patients of all ages was 226 million in 1970 compared with only 166 million in 2006. Similarly, the average length of stay was 7.8 days in 1970 and 4.8 days in 2006. Today’s hospital environment is one where patients are admitted for procedures, invasive medical management, and surgical interventions while longer-term healing, recovery, and rehabilitation occur elsewhere.

As a result, questions have been raised regarding the relevance of physical therapist intervention and management, commonly associated with the more lengthy rehabilitation phase of care, being delivered in such a fast-paced setting. The responses of the physical therapists interviewed in the study by Masley and colleagues suggest something else is occurring. The themes of this article and previous studies regarding the role of the physical therapist seem to demonstrate that physical therapists have evolved to becoming valued professional consultants who provide a unique, essential perspective, rendering them integral contributors to the acute care team. Today’s physical therapists specialize in evaluating and managing the patient’s functional mobility needs and, within that scope, serve as both consultants and effective transitional care providers.

Communication and Advocacy

Inter-professional communication is an ongoing necessity within the acute care hospital. Physical therapists are routinely interfacing with nurses, physicians, case managers, social workers, and other hospital staff. Acute care physical therapists are positioned to find and fight for allies outside the physical therapy profession. Emergency medicine and critical care physicians are recognizing the skills, expertise, and contribution of physical therapists. From coast to coast, they are advocating for physical therapists within and outside hospital walls resulting in development of innovative clinical programs and lines of research. Physical therapists are routinely a part of trans-disciplinary programs to improve patient care and outcomes. Through their physical location within a hospital setting, acute care physical therapists can leverage knowledge, skills, and expertise to promote and advocate for the entire profession of physical therapy.

Where’s the evidence?!?!

Recently, on twitter, a #DPTstudent tweeted that acute care had the least amount of supporting research. One of the reasons for this perception, I believe, is that much of the evidence supporting physical therapist practice in acute care is published in non-physical therapy specific journals such as Critical Care Medicine, Chest, and the Archives of Physical Medicine & Rehab. For example, Critical Care Medicine published an entire supplemental issue on Intensive Care Unit-Acquired Weakness (ICU-AW). But, the Journal of Acute Care Physical Therapy and Cardiopulmonary Physical Therapy Journal are still fantastic resources (by jennifer). As I outline in the Leveraging Technology Series post Selection of Content, we must read outside of the physical therapy specific literature. So far, I have discussed some of the rationale, which is vital, but what has research illustrated?

Total Joint Replacement
A study investigated the effect of immediate postoperative physical therapy on length of stay for total joint arthroplasty patients illustrating that “Isolated PT intervention on POD 0 shortened hospital LOS, regardless of the intervention performed.” A study published way back in 1993 illustrated that receiving weekend treatment by a physical therapist correlated with decreased length of stay following joint arthroplasty.

Emergency Department
I have written before about the emergence of physical therapists in the emergency department. Preliminary data illustrates potentially improved patient satisfaction with care and shorter wait times when physical therapists are present in the ED. In addition, physicians practicing in emergency medicine have recognized the expertise and contribution of physical therapists in a variety of conditions including painful problems, musculoskeletal conditions, dizziness, and overall mobility/safety/discharge determination. An article in PTJ discussed the development of this novice practice venue.

Intensive Care Units
Intensive Care Units cater to patients with the most serious injuries and illnesses, most of which are life-threatening and need constant, close monitoring and support from specialist equipment and medication in order to maintain normal bodily functions.”

Early mobility and physical therapy has been shown to be not only safe, but feasible in the individuals who require mechanical ventilation. A randomized control trial investigating early physical therapy and occupational therapy in critically ill mechanically ventilated patients concluded that not only was early physical therapy treatment safe and well tolerated early on in a critical illness course, but resulted in better short term functional outcomes and less delirium. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project  demonstrated with “hospital administrative data…that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4-3.8) and 3.1 (0.3-5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year” And earlier this year, a systematic review on early mobility in the intensive care unit was published.

Response Dependent Progression

Back to some of the original questions. Well, so what? All you are doing is helping people get up and walk around. Can’t a nurse assistant do that? In a study of mobilization level in a surgical intensive care unit it was found that physical therapists mobilize their patients to a higher level than nurses.  And, sometimes sitting ain’t easy. What appears simple procedurally often involves complex knowledge and decision making. A gentle manual technique may require a complex reasoning process and constant assessment of patient response. Similarly, in acute care the decision to sit up, stand, transfer, or ambulate requires the integration of physical therapy specific principles with knowledge of medical conditions, medical management, pharmacology, and pathophysiology. Mobility and therapy progression (within and between session) is based upon the principle of response dependent progression which necessitates integrating the previous knowledge with the patient’s current presentation/functional status while constantly monitoring physiologic status (vital signs), patient performance, and patient feedback (fatigue, shortness of breath, and other symptoms). The acute care physical therapist must assess and integrate complex information from various sources. Much of this information is dynamic in nature requiring constant integration and re-assessment…

So, you think you can walk?

New vision & role for the physical therapist in athlete management #sportsPT

The following post was written by Paul Mitalski. Paul is not a physical therapist, but has vision for the where the profession of physical therapy can go in the realm of sports and athletics. The introduction was written by Matt Sremba, PT, DPT. Matt is a physical therapist. He is passionate about the profession of physical therapy and critically thinking about what we are doing, why we are doing it, and how we can do it better. Matt introduced me to Paul, and the three of us have discussed specifically the physical therapists role in athletics. What are your thoughts?

Introduction

The evolution of the physical therapy profession is something that has always intrigued me. It is continually looking for new models of growth, practice, and education as seen in the recent progression towards the year long clinical model, the Innovation Summit by the APTA, and of course many discussions by passionate PTs on twitter and blogs like this to name a few. While spending the day at Dr. Christopher Powers’ Movement Performance Institute, I had the chance to meet with Paul Mitalski.

Since that time, Paul and I have discussed many areas of Physical Therapy and I believe he brings an interesting angle to these topics as he is not a PT, however has worked closely with them for many years.  We look forward to discussing his innovative model and vision for the role of physical therapists in the management of athletes which can be wagered on 홈카지노.

Matt Sremba PT, DPT
@MattSremba

Background

Before I present a snippet of my vision of the future of performance training and wellness (PTW) and the role I believe physical therapists should embrace, I will briefly describe how I got here. In short, I am the CEO of Conatus Athletics and I am not a physical therapist.  I am a computer programmer/software engineer/consultant by trade and mathematician. I led the development of three unique entities; the first and only complete mathematical model of the kinematics/kinetics of basketball, the first general methodology for performance training based on engineering principles, and a complete hierarchical “System” to implement the previously mentioned methodology. The last entity, the “System”, will be the primary focus of this blog post and I will discuss  the unique role of a Physical Therapist. My “System” is now a new business venture. My company, Conatus Athletics, is an education company and a training company. I lease space at the Movement Performance Institute in Los Angeles CA. and currently train professional athletes, however, our priority is developing and delivering  curricula based on science, engineering, and our system. My training “System” wasn’t intended to be a business nor was it created with the input of the sports performance world or fitness industry. I developed it in the late 1990s to prevent injuries in basketball and it is based upon mathematics, science, engineering, with refinement and guidance from physical therapists.

The Conatus Athletics System was designed to be a complete systematic process for managing all aspects of an athletes training and rehabilitation with clearly defined roles and responsibilities for all individuals. The role of the Physical Therapist in the Conatus Athletics System is unique. Here are some of the components, which help define the role of our therapists in our “System”.

COMPONENT 1. Therapists manage and oversee ALL therapy and training as well as related care extenders

We believe in a hierarchical model in which a MD and PT are peers and collaborate at the top of extender clinicians made up of PT’s, strength coaches, ATC’s, interns and residents to oversee and treat athletes. The MD and the PT both act as attendings as in a hospital setting, and must oversee all other clinicians. PT’s must contribute to the performance training program and must be present for all training including court, field, weight room, etc. This role is necessary due to our belief that athletes are NEVER “healthy” and always have musculoskeletal issues and require real time feedback during performance training. PT’s oversee the training regimen but do not execute it. Extenders are used for that role. The role of the Therapist in observing training regimens is to diagnose potential problems or future injuries and monitor return to activity.

COMPONENT 2. Therapists “Own” Musculoskeletal Problems

Physical Therapists are in charge of all musculoskeletal Problems and must establish treatment plans while altering training to allow continued performance training. We expect true collaboration between exercise physiologists, MDs, and strength coaches, and engineers. Although we believe in performance improvement, the health of the athlete is the highest priority. Therefore our conclusion is the Physical Therapist must “own” the training regimen.  This component also defines relationship/collaboration with Physicians in the training environment. In short, the therapists own the diagnosis of Musculoskeletal Disorders. MD and therapist must consistently communicate because some pathology requires both skill sets. The MD is not trained to “prescribe” a treatment plan (rehab) or manage the performance training. At the same time PTs should not try to be MDs and prescribe medications, etc. either. PT’s focus on mechanical problems.

Therapist Roles

1. Final approval of all Performance Training
2. “Veto” power over individual units in training regimen
3. Adjust individual units (exercises), add and replace units (exercises)
4. Defend his/her decisions to other professionals with rational explanations
5. Insure  team members are also to be able to defend the decisions related to training

Constant mentoring and explanations from the therapist is required…Team members WILL question the decisions made by the therapist. The culture is one of skepticism and constructive criticism. The therapist must take ownership and responsibility for management.

“Owning” a problem or issue is a part of Leadership training (google it). I have yet to meet non military trained therapist who understand this leadership topic. I suspect there are many natural leaders among the therapist ranks and I look forward to recruiting them into my happy company : ) I still feel this is a missing aspect of therapy curriculum. It is non negotiable in my System.

I would like to summarize.  I concluded that physical therapists should manage and lead performance training.  I am completely dismayed that physical therapists do not seem to want this role.   My system requires therapists to lead, manage, collaborate with other professionals (MD, Scientists, Engineers), defend their decisions, accept criticism, and  collaborate with other therapists for diagnosis and treatment. At the same time I hear therapists tell me they want these responsibilities, they resist embracing them and the sometimes difficult steps necessary to raising the standards in their profession.

Are there physical therapists out there who want this role?
Are physical therapists ready for this role?
Are the physical therapy curricula preparing students for this role?
Are you interested in the challenging steps necessary to make this system become the standard?

Paul Mitalski
Paul is the CEO of Conatus Athletics.  He has a B.S. in Mathematics, a M.S. in Computer Science, and is currently pursuing a M.S. in Engineering with a concentration in Biomedical Engineering.  He worked as a consultant for over 10 years and now is an entrepreneur focused on promoting Mathematics, Science, and Engineering in performance training and therapy.

Matt Sremba PT, DPT
Matt is a graduate of University of Colorado Doctor of Physical Therapy program in 2009. His clinical experience is in orthopedics/private practice and in the neuro rehabilitation hospital setting. His current interests include sports, orthopaedics, and manual therapy. He currently practices in Orange, CA where he is also trying to surf some waves.

#PhysicalTherapy Hashtag Project

#Hashtags are a robust means of tracking or tagging information on Twitter. They help you manage the fire hose-like nature of the constant stream of information on Twitter. Conferences, tweet-chats, and general topics of discussion all benefit from the use of hashtags. Combined Sections Meeting (CSM) of the American Physical Therapy Association, the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT), and the Private Practice Section of the APTA all have hashtags surrounding their conferences. The conference acronym is usually followed by the year. For example, #CSM2013#AAOMPT13 (No AAOMPT conference this year because of IFOMPT Conference), and #PPS2012. Functionally, hashtags  group tweets by keywords. For those not familiar check out Twitter’s help page what are hashtags? or the wikipedia page hashtag.

Personally, I have leveraged hashtags to follow and contribute to discussion surrounding conferences (CSM and AAOMPT for example). I  unfortunately was not able to attend #AAOMPT11 or #IFOMPT12. But I did learn, discuss, and contribute via the conference hashtags. The # creates potential for discussion and collaboration on a topic, course, conference, or issue. Unable to attend a conference or event? Participate virtually! Busy during the time of a tweet chat? No problem, you can search the hashtag later to read, respond, and continue the conversation. Wondering what individuals are saying on a particular topic? Search that hashtag. Storify even lets you create and save conversations or stories based on certain parameters.

Outside the PT Sphere

@HealtSocMed claims #HCSM (Healthcare Communications and Social Media) forumlated in January of 2009 was the first global healthcare tweet chat. Other non physical therapy specific hashtags or tweet chats include #SocialOrtho#SportsSafety, #mHealth, and #MedEd.

Physical Therapy Hashtags

Established physical therapy hashtags include #physicaltherapy, #physicaltherapist, and #physioPT. Kendra Gagnon PT, PhD (@KendraPedPT) who has guest blogged here on PTTT, utilizes hashtags in entry level DPT education. Her students tweeted #WhyIchosePT to communicate their reasons for pursuing the profession of physical therapy. Her class used #PTprof throughout the semester. On her blog, Kendra discusses social media communication as a part of the curriculum in a Professional Interactions course.

In some cases hashtags are utilized both as a tweetchat and to track discussion on a particular topic. #SolvePT is an example with weekly tweet chats on Tuesdays from 9-10PM Eastern Standard Time as well as ongoing discussion related to issues pertinent to the physical therapy profession. @SnippetPhysTher (Selena Horner, PT, GCS) discusses the emergence of the hashtag and the tweet chat. The #SolvePT hashtag continues to be an interesting conversation regarding physical therapy.

Call to Action

I propose a #physicaltherapy hashtag project. As a physical therapy community lets discuss specific hashtags for practice areas, topics, and ideas. I recently began using #AcutePT to tag some tweets containing evidence and rationale for the physical therapist’s vital role in the acute care environment. The Healthcare Hashtag Project has curated content and hashtags relating to health care topics, specific tweet-chats, conferences, and even diseases!

Below are my proposed hashtags for the physical therapy profession in addition to what we currently utilize. What did I miss? Should we change the wording? Let’s get started…

Practice Areas: #AcutePT #CardioPulmPT #GeriatricPT #ManualTherapy #NeuroPT #OrthoPT #PainPT #PedsPT #SportsPT #WomensPT

#PTscience for research, evidence based practice, and critical thinking relating to physical therapy.

#PTAdvoc for physical therapy advocacy and legislative issues.

#bizPT for business and private practice topics.

#PTtech for information relating to technology and the physical therapist.

#DPTEd for topics relating to physical therapy education and educators, including clinical education.

Hashtags for education and student topics could include #PTedu or #PTschool. Rumor has it that #DPTstudent will emerge as a hash tag topic and potential chat spear headed some of the student leaders in social media. You know @MattDeBole is at the center of that! Also check out @LaurenSPT as well.

And last, but certainly not least, #PTHero for inspiration and greatness within our vital profession.

@Dr_Ridge_DPT

 

Direct Access #SB924 & California #PhysicalTherapists

In the past, I have written about how the anti-POPTS (physician owned physical therapy services) movement in California  utilized technology and social media to educate the masses regarding referral for profit. Vist the Stop POPTS YouTube Channel  and stopPOPTS.org for more information.

Recently, a direct access to physical therapy services bill (Senate Bill-924) emerged in the California legislature. Great news!! Well, not so fast. Watch this short 16 second video in which the Assembly Appropriations Committee announces the amendments…

SB924 direct access to physical therapy services. Do pass as amended to require a diagnosis after initial 30 day period in order to continue to treatment. To amend consumer disclosure language and other technical amendments.

Read the entire text of SB-924: Physical therapists: direct access to services: professional corporations. For more legislative information you can visit Official California Legislative Information Webpage. The wording from the actual bill:

The bill would prohibit a physical therapist from treating a patient beyond 30 business days or 12 visits, whichever occurs first, unless the physical therapist receives a specified authorization from a person with a physician and surgeon’s certificate or from a person with a podiatric medicine certificate and acting within his or her scope of practice. The bill would require a physical therapist, prior to the initiation of treatment services, to provide a patient with a specified notice concerning the limitations on the direct treatment services.

Did I mention that this bill would also legalize physician owned physical therapy services?

This bill would add licensed physical therapists and licensed occupational therapists to the list of healing arts practitioners who may be shareholders, officers, directors, or professional employees of those corporations. The bill would also provide that specified healing arts licensees may be shareholders, officers, directors, or professional employees of a physical therapy corporation.

If you live in California, tell the following that back room deals are not OK. Utilize this letter template to write legislators and the governor. Patients deserve better. Seniors deserve better. Their consituents deserve better. California deseveres better. The national deserves better.

Minority Floor Leader Connie Conway @AssemblyConway Phone: (916) 319-2034 Fax: (916) 319-2134
Caucus Chair Jerry Hill P: (916) 319-2019 F: (916) 319-2119
Assistant Majority Whip Rober Hernandez @Roger_Hernandez P: (916) 319-2057 F: (916) 319-2157
Majority Whip Toni Atkins @toniatkins P: (916) 319-2076 F: (916) 319-2176
Asstistant Assembly Floor Leader Mike Allen P: (916) 319-2007 Fax: (916) 319-2107
Floor Leader Charles Calderon P: (916) 319-2058 F: (916) 319-2158
Speaker pro Tempore Fiona Ma @fionama P: (916) 319-2012 F: (916) 319-2112
President pro Tempore Darrell Steinberg P: (916) 651-4006 F: (916) 323-2263
Assemblyman Felipe Fuentes P: (916) 319-2039 F: (916) 319-2139
Assemblyman Mike Gatto @mikegatto P: (916) 319-2043 F: (916) 319-2143
And last, but certainly not least, Speaker of the California State Assembly John A Perez @SpeakerPerez P: (916) 319-2046 F: (916) 319-2146

Follow the #SB924 hastag as well as the following physical therapists on twitter: @ChrisReed1 @Jerry_DurhamPT and @RobertSnowDPT. California based physical therapy program University of the Pacific (moderated by Todd Davenport) @PacificDPTweet and @PittPT Pittsburg Physical Therapy student @MattDeBole. Tweet at @APTAadvocacy and The California Physical Therapy Association @CPTAtweets.

Who else may be interested?

Resources

Letter to CA Legislators Template (Google Document)
Pitt Physical Therapy Student Site: The Monday Memo

Senate Bill 924
SB-924: Physical therapists: direct access to services: professional corporations
Bill Text with Strike Through Amendments (PDF)

Stop POPTS
When a Bad Bill gets WORSE
Back Room Dealings by Mary Hayashi & John Perez

Senate Bill 924 Amended by Democrats, would legalize physician kick backs…

 

Term & Title Protection for the #PhysicalTherapist & #PhysicalTherapy

APTA Term Protection Ad

The American Physical Therapy Association recently constructed a Term and Title Resource Center regarding the use of the terms physical therapy and physiotherapy as well as the titles physical therapist, physiotherapist, PT, DPT, and MPT.

They have even constructed a 1 page advertisement, that I think is actually rather clever. The APTA announces

The full-page color advertisement will run in future editions of State Legislatures magazine, the monthly publication of the National Conference of State Legislatures which is provided to state legislators, legislative staff, and other state policy makers in all US jurisdictions.

I commend the APTA for their efforts and resources, which are no doubt, an important step. And, there have been some victories. Virginia successfully enacted term protection for physical therapy and title protection for physical therapists.

Unfortunately, physical therapists are currently losing this battle on both the legislative (lack of term protection laws), but just as importantly, the judicial level. In 2010, the Washington State Supreme Court issued an impactful ruling that dealt specifically with physician owned physical therapy services (POPTS). But, the ruling also has significant ramifications for the use of the term physical therapy.  Details about the ruling can be found in an APTA released statement. The Kentucky Supreme Court issued a similar opinion.

The Washington State Supreme Court Opinion states:

Physical therapy is one aspect of the practice of medicine. The practice of medicine is defined by RCW 18.71.011(1) as ‘[o]ffer[ing] or undertak[ing] to diagnose, cure, advise, or prescribe for any human disease, ailment, injury, infirmity, deformity, pain or other condition, physical or mental, real or imaginary, by any means or instrumentality.’ This broad definition readily encompasses all the acts constituting the statutory definition of the practice of physical therapy.

Ouch. But, it gets worse. The Washington State Medical Association exclaimed “Big Win in Supreme Court!!!” following the ruling. They continue:

The decision represents a victory for physicians and medical practices, not only because it is now clear they can employ physical therapists, but because an adverse ruling could have outlawed their employment of other licensed health care professionals (such as nurses).

Double ouch. The ruling as well as the medical community’s reaction clearly illustrate that legislators, the judicial system, and physicians do not view physical therapy as a unique profession nor physical therapists as skilled, collaborative, unique members of the healthcare team. It appears physical therapy continues to be viewed as a prescribed or provided modality with physical therapists as mere technicians or employees under the physician umbrella.

We either need to more aggressive with our formal national, state, and local legislative lobbying and education (including legislators,  patients, colleagues, etc), or we we need to seek and secure allies within the medical and healthcare community, including but not limited to physicians. I vote for both.

What are you doing to #SolvePT? What should we do at the grassroots level?

Resources

Term and Title Resources via the American Physical Therapy Association
Term Protection Advertisement/Handout
Physician Owned Physical Therapy Services (POPTS) and Referral for Profit via AAOMPT Student Special Interest Group Blog
APTA Statement on WA Supreme Court Decision
WA Supreme Court Decision and Statement
Virginia Term Protection
Kentucky Court Ruling Information[/list]

The Evolution of Learning, Knowing, & Finding in the Digital Age

photo of classroom by Max Wolfe

Knowledge, information, and intellect are fuzzy concepts. Knowledge may involve the ability to recall specific pieces of information. But, does knowing lead to intellect? The more information the better? And, what information is needed for intellect? Interesting questions, but definitely beyond my philosophical capabilities. Without a doubt these concepts have evolved in the digital age. An interesting piece entitled Connectivism: A Learning Theory for the Digital Age  is worth a read.

In the past, there was an advantage (likely even an incentive) to “knowing” information, because “finding” information was slow, cumbersome, and time consuming. Think about performing a literature review prior to the internet. It was likely harder (both effort and time wise) to find facts, ideas, and concepts. Potentially, this may have lead to slower, more deliberate processing in the form of in-depth analysis and more critical thinking with reflection, analysis, and connecting to ensure strong knowledge recall.

With the advent of new technologies, and the ever increasing speed and ease of information transfer, the paradigm may have flipped. With the proliferation of the internet and search tools, finding information continued to become easier and faster (this does not address or speak to accuracy, validity, or utility of course). Taking the time to truly know, relate, and connect content was effectively de-incentivized as finding it became convenient beyond belief. Even Einstein was quoted as saying “It’s not what you know, it’s knowing where to find it.” For some information and procedures, this is absolutely true. Atul Gawande addressed this very concept in the book  The Checklist Manifesto (which is fantastic! check out this video summary).

But, do the manifestations of this paradigm shift have the potential to be devastating for students and learners, including clinicians, of all types? The incentive for laziness is present. Google search, “the abstract says…”, “so & so tweeted this.” One must consciously recognize the potential traps, and work hard to critically appraise, connect, reflect, and relate to information.

The same is true of evidence based practice. “Well, this article conclusion states X is good for Y.” “The systematic review recommends X for Y.” Now, I am not advocating against evidence based practice, just pointing out a potentially devastating short cut or pit fall. Without a conscious and attentive adherence to prior plausibility, principles of science, and critical thinking, we are all likely to fall victim to “citing the evidence” in this regard. Now, this really is a different topic, for a different time…

With the advent of Web 2.0 and social media technology information is pushed directly to you. For better or for worse, masters of technology and social media with large followings or broad connections have the power to proliferate ideas to large numbers of people, many of whom did not even seek this information. The term “viral” captures this concept accurately, as ideas or internet memes exhibit virus like tendencies. But, even small time social media users can have significant impact if the information they push is deemed useful by those that encounter it, and thus, pushed onward. And, viral growth is born.

The evolution of this technology may prove to be profoundly beneficial if utilized appropriately. People will encounter information in the form of Facebook status updates, tweet thoughts, blog posts, research articles, and news they did not even seek. Technology and social media including blogs, can be leveraged to not only encounter new information (most of which is not purposefully sought after), but to engage, connect, critique and more deeply understand. Both the author and the reader can benefit, as social media now allows the reader, or consumer, to engage via comments and replies. Learners armed with the power of new technology and the cognitive skills to appropriately use it can make a major impact.

In the future, I foresee the potential of these new technologies and paradigms fundamentally changing not just education, but the face of formal science and publishing. Jason Silvernail and I have discussed this before when discussing if industry standards were serving researchers, clinicians, and science. Building on that topic, Diane Jacobs at SomaSimple, recently posted a link to blog post Why Academic Papers are a Horrible Discussion Forum. These insights set the stage for how new technology and social media can be tools of meaningful change in the future of learning, knowing, finding, discussing, and learning.

This anonymous quote summarizes it best

Education means developing the mind, not stuffing the memory

Unfortunately, our education system at all levels seems on the cusp of  failing in this regard. Some of these technology tools, if not utilized appropriate, may have the potential to exacerbate the problem. But, as we have witnessed, technology has the potential to make big changes, for the better.

Osteopractor™

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