TelePT: Inform Thyself

Sunset over a sheltered Bay Area

Day 65,000 of Shelter in Place (a.k.a 8),

There has been a heck of a lot of info flying around the airwaves as PT’s rapidly prepare themselves to be full on telehealth providers. I wanted to link to some resources:

 

 

It’s a Strange, New World!

View of San Francisco Bay

Well it’s been a bit. And what a bit it’s been!

I’m presently completing day one of “shelter at home” courtesy of COVID-19. As I am a regular worker from home, some parts of my day has not changed. Others, have changed greatly, and, really, who knows what is to come. I translate all this to: it’s a fine time to start writing again. Thus, new theme, new look, new images, and new thoughts for everyone!

Things on my mind:

Stay tuned. I need to go fixed m “Y” button on m three week old MacBookPro which makes me ver angr .

#dumbcoronavirus #DCV

Priceless Protections: Pre-Existing Conditions Can Happen to You!

Well, here we are again, on the cusp of another GOP vote on health reform, and about to lose federal protection for pre-existing health conditions. Troublingly, there has been this discourse floating around that places blame on said person with a pre-existing condition. As if, by making correct decisions, you can avoid having a need for health care, therefore, you should not have to pay for someone else’s care who made bad choices. This logic largely ignore rates of obesity and heart disease correlations to states where representatives (and constituents?) seem to think this way. Well, it’s wrong. Health, or the lack of it, is not a reflection of morality, or worth. Sometimes, and I know this personally, it happens in a split second.

To illustrate this point, I’d like to share the story of a very dear friend of mine, Courtney Kelsch Ward and her family. Courtney posted this on her Facebook shortly after Jimmy Kimmel’s tale from Monday night. She was gracious enough to share. I think it illustrates the stark odds (and costs) in front of us as a nation as Congress decides to abolish pre-existing condition protection.

The Story of Baby Robbie

On Monday night, Jimmy Kimmel gave a moving monologue in which he described the gut-wrenching experience of discovering his newborn son had a heart defect. Through tears, he explained the harrowing minutes when the doctors and nurses were examining his son in the neonatal intensive care unit, the ambulance transfer to a specialized hospital, and his son’s three-hour open-heart surgery. The story had a happy ending, thankfully, but Kimmel ended his talk with a plea for compassion and reason in healthcare reform.

Before 2014,” he said, “if you were born with congenital heart disease like my son was, there was a good chance you’d never be able to get health insurance because you had a preexisting condition. You were born with a preexisting condition. And if your parents didn’t have medical insurance, you might not live long enough to even get denied because of a preexisting condition. If your baby is going to die, and it doesn’t have to, it shouldn’t matter how much money you make. I think that’s something that, whether you’re a Republican or a Democrat or something else, we all agree on that, right?

As it turns out, we don’t all agree on that. On Tuesday afternoon, former Illinois Representative Joe Walsh tweeted,

Sorry Jimmy Kimmel: your sad story doesn’t obligate me or anybody else to pay for somebody else’s health care.

Many others echoed this sentiment. An overwhelming number of people seem to actually believe that a baby deserves to die if his parents can’t afford to save him.

Over the last nine months, I’ve had a lot of conversations with a lot of people about the state of our healthcare system, and I’ve found one assumption lies at the heart of many of these arguments—that sick people have done something wrong to deserve their fate. A few days before Kimmel’s monologue went viral, Alabama Representative Mo Brooks said that increasing costs for people with preexisting conditions will help to reduce “the cost to those people who lead good lives, they’re healthy, they’ve done the things to keep their bodies healthy.” These are the people, he said, “who have done things the right way,” the implication being that sick people are those who have done things the wrong way. Back in January, Pennsylvania Senator Pat Toomey compared people with preexisting conditions to burned down houses. This belief is common. Not everyone says it as explicitly as these legislators, but deep down, many people hold this view—that good, hard-working, responsible people don’t end up in these situations.

I’m here to tell you, that’s simply not true.

My husband, Mike, and I approached starting a family the same we approach everything else—thoughtfully, with long discussions about logistics and preparation. We worked and reworked our budget and moved to the suburbs so we could get more space for our money. We bought books on how to have a healthy pregnancy and baby. I scheduled a mostly pointless pre-conception appointment with my doctor and took prenatal vitamins for the recommended three months prior to trying to conceive. When we finally got that positive pregnancy test, Mike wouldn’t let me lift a finger around the house. I stopped drinking wine, of course, and coffee. I even gave up my nightly cup of chamomile tea because I couldn’t find a clear answer about whether herbal tea is safe during pregnancy. I avoided unpasteurized cheeses and deli meats. I agonized over what to have for lunch every day, as even egg salad was questionable, according to the internet, as was really any cold meat. One time I asked the people at Panera to heat up the chicken on my Caesar salad, just in case. I suffered through chronic headaches because most painkillers are considered unsafe during pregnancy. My doctor said Tylenol was ok, but I avoided it anyway because a few studies have linked it to ADHD. I even started using different skincare products because salicylic acid is considered possibly unsafe. The amounts absorbed when washing your face are minuscule, but over and over again, I asked: why take the chance?

All of this is to say: there’s doing things the right way and then there’s going way over the top, and we were certainly in the latter category.

And yet, on July 25th, after just 22 weeks and 5 days of pregnancy, I went into labor. My doctors worked hard to stop the contractions and hold off my son’s birth, but four days later, on July 29th, my son was born at just 23 weeks and 2 days gestation. Some neonatal guidelines do not suggest intensive life saving efforts at this age. At 1 lb 5 oz and 11 inches long, Robbie was about the length of my forearm. His foot was half the size of my husband’s thumb. With severely underdeveloped lungs, he was unable to breathe on his own. A good outcome was certainly not a given. He was immediately intubated and remained on a ventilator for the first 78 days of his life. He spent over 4 months in the NICU, fighting to survive. There were many days when the doctors were not sure that he would make it. To this day, nine months after his birth, we consider it a miracle that our son is home with us.

We still don’t know why it happened. It wasn’t because of anything I did or anything I ate. It may have been because of something in my biological makeup, something that predisposes me to preterm labor. But maybe not. During my pregnancy, I had a single umbilical artery and slightly low levels of a hormone called papp-a. Both of these things increase the likelihood of preterm labor, but by such a small percentage that neither my OB nor the perinatal doctors were particularly worried. Neither of these factors were caused by anything I did, and the doctors said they varied not just from woman to woman, but from pregnancy to pregnancy. My OB herself told me she’d had low papp-a in her first pregnancy and completely normal levels in her second. The message from my doctors at the time was very much Do Not Panic. All of our other tests had come back good, so there was no need for alarm, they said. They planned to watch me a little more closely in the third trimester, but that was it. A second trimester delivery was not on anyone’s radar.

Since Robbie was born, we have asked why I went into preterm labor, why our son was born four months early, and we have received the same answer from every medical professional: sometimes these things just happen.
The cost of my week-long stay in the hospital was roughly $50,000. The cost of Robbie’s stay in the NICU was $1.7 million. This number does not include the costs since he has been home, the countless doctor appointments, the seven medications he was prescribed at discharge, four months of home nursing, three $3,500 shots to help protect him from RSV during cold season, or the oxygen tanks currently sitting in my living room. No, that $1.7 million was just the cost of his 129 days in the NICU. It’s the cost of keeping my baby alive.

If our health insurance company had been allowed to set an annual limit to the amount they will pay for one person, Robbie probably would have hit that limit in 2016. If they were allowed to set a lifetime limit, he’d probably hit that too before long. Can you imagine looking at a nine-month-old baby and telling his parents he’d used up all of his healthcare coverage for his lifetime? We have been incredibly lucky in that Robbie is doing great and has made wonderful progress since coming home, but his prematurity puts him at a higher risk for a host of health issues, and Mike and I spend every day waiting for the other shoe to drop. The reality is, some day in the future, Robbie may very well be one of those people with preexisting conditions everyone is arguing about.

There are a lot of factors to consider regarding the economics of healthcare, and we have to continue having this complex debate. But we won’t be able to solve this issue as long as we think of sickness as something that happens to bad people who are lazy and irresponsible. When you pay for health insurance, you are not just paying for someone else’s healthcare. You are paying for the possibility that you, too, may need that care someday. Your education, your hard work, your moral superiority—none of these things can protect you from a health emergency or a chronic illness. You can do everything right and still end up in a hospital bed, or standing in a neonatal intensive care unit watching your child struggle to survive. It can happen to anyone. We could have been the spokespeople for “Doing Pregnancy Right,” and it happened to us. It can happen to you, too.

 

Dr. Manual Therapy, Or How I Came to Stop Worrying and Love the Placebo

With a central theme based on cinema, and a message potentially confused as a doomsday device for manual therapy, Dr. Joel Bialosky’s (along with Drs. Bishop and Penza) latest commentary in JOSPT, “Placebo Mechanisms of Manual Therapy, A Sheep in Wolf’s Clothing?” certainly deserves a Dr. Strangelove derivative title. But, is it really doomsday for manual therapy?

The fascinating thing about this must-read paper is the re-framing of placebo as a negative, non-specific sequitur of bad outcomes, to one of a specific, powerful, and necessary aspect of many interventions. To me, this is perhaps the key to how there can be so many different schools of manual therapy, and passionate adherence to each, and despite vastly different application, the apparent effectiveness of each. It’s as if we are all using different codes to access the same central computer, only to perform the same essential task.

The authors of this commentary leave us with a warning:

“Manual therapists, having invested large amounts of time perfecting their craft, may be troubled by the prospect of placebo as a primary mechanism.” Bialosky, Bishop, and Penza

I too, would like to issue a warning:

“The anti-manual crowd of therapists should also be careful to not mis-interpret the data around placebos by mistakenly believing this science is justification to not perform manual therapy.” Robertson

In a perfect world, the two groups would equally understand that specific active mechanisms of analgesia through physical therapy remain elusive despite the overall effectiveness of said treatment. Indeed, if we could work to understand the critical factors needed that result in a positive outcome for patients, perhaps we would be more effective at applying them, and less judgmental of people using a different coding set to access the “computer.”

Yet I wonder, what would happen to those practitioners stripped of their passion to defend their specific approach? Maybe that is the real doomsday device!

 

Chronic Whiplash: Is it really a Medical Mystery?

neckpain copy

A small while ago, the well-known and widely read periodical, The Atlantic, published a piece entitled, Chronic Whiplash is a Medical Mystery. In the article, the author, Julie Beck, poses the thematic question, “Being jostled in a car accident should only cause a few weeks of pain—so why do some people suffer longer?” Well, that is a good question, isn’t it?

Over the past decade, tremendous advances in the science related to Whiplash and Whiplash Associated Disorders (WAD, as it were) have been achieved. Recently, this science took a giant step forward with the publication of Part I of a two-part special series dedicated to whiplash in the Journal of Orthopaedic and Sports Physical Therapy (October 2016 issue). This issue featured guest editors, Drs. Jim Elliott, Dave Walton, and Michelle Sterling and an editorial by Gwen Jull. Heavy hitters for sure. When it comes to accidents and injuries even if it is the ones that the injures in a truck accident on the highway there are lawyers to protect and get justice.

So, it’s not surprising that some of these researchers took notice of Beck’s article in The Atlantic. It’s also not surprising that to these researchers, whiplash might not be the mystery it may seem to others. And so, without further ado, PTThinkTank.com is proud to publish a response piece to Beck’s article, entitled, “Chronic Whiplash: Is it really a Medical Mystery?” Well, that is a good question too, now isn’t it?

Enjoy the essay from Jim Elliott, Peter McMenamin, and Dave Walton. Thank you, sirs, for the contribution.

Chronic Whiplash: Is it really a Medical Mystery?

Decoding the Brain: Will Future Physical Therapists Manipulate Hippocampi Instead of Spines?

Interneurons
Image courtesy NIHCD via Flickr

National Geographic Channel is featuring a slick new program:

Breakthrough: Decoding the Brain” on Sunday, November 15, at 9 pm ET on National Geographic Channel. 

As part of this show’s launch, they’re posing the following question for commentary:

“What if scientists were able to implant or erase memories? For some, like those suffering from PTSD this could be life-changing, or do you think this is scientific innovation gone too far?”

This question is right up our alley!

The Brain and Chronic Pain

The recent meeting of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) in Louisville, KY was a bit unique. Unique, because in contrast to years and years of this conference unsurprisingly featuring scientists purporting the evidence for using manual therapy techniques like spinal manipulation for patients with musculoskeletal pain, this year the conference featured speakers who didn’t use their hands. The conference keynote was delivered by Dr. Peter O’Sullivan, (his cool blog is here) who spoke about his work related to Congnitive Functional Therapy for patients with chronic pain. Other talks revolved around pain science, big data, and a general change in the tenor was noticeable.

Manual therapists have long struggled with patients who have chronic symptoms, as short term gains are quickly realized, but long terms gains are extremely difficult to achieve. So, what prompted the AAOMPT, a scientific academy founded around manual therapy techniques, education, and science, to feature a pallet of speakers speaking about techniques that didn’t involve hands or cavitating  joints? Well, friends, science is always a moving target, and it’s broad, and sometimes you need to look outside your cerebral solar system to learn new things. This is one of those times for physical therapists!

But, perhaps we don’t need to travel too far! This new traditional neuroscience science is now showing up in manual therapy journals like…well, Manual Therapy! In a recent article, entitled, “Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories,” Nijs et al address the concept of movement-related pain memories and exercise for patients with chronic pain. They suggest that clinicians should preempt exercise therapy by first priming the brain via neuroscience education, and then utilizing movements to help the body ‘forget’ those memories associated with those movements and pain. Sounds just like Peter O’Sullivan’s CFT doesn’t it? This work builds on work by neuroscientists who are exploring the role of the hippocampus in generating pain-related memories. This is a wide open field, and the potential of learning how to impact pain related memories is truly astonishing!

Manipulating Hippocampi?

While the concept of having memories erased seems on the surface frightening… (I wouldn’t want to forget that cool downhill bike ride down Mount Snow even though it hurt!)… it does seem that breaking links between pain experiences and memories is one of the keys to managing chronic musculoskeletal pain conditions. Just how we do that best remains to be seen! Will future physical therapists have a cadre of tools that not only allows for mechanical inputs to alter central nervous system activity (spinal manipulation), but also precise strategies to target pain memories and more directly impact cognitive reasoning about pain? I sure hope so!

I’m excited for the new Breakthrough series on NatGeo. It just seems like one of those times when all sorts of science is converging on something…on the true potential of that “3lb mass in our heads!”

 

 

Doctor is Just a Title: How to really experience your #DPTstudent education

The collective here at PTTT appreciate the insights, contributions, and struggles of the #DPTstudent. And thus, we present a new guest post by a current 3rd year #DPTstudent @GabeStreisfeld. Gabe is an eager, motivated student who connected with both Kyle and Eric at #APTAcsm. His insights are both thoughtful and valuable. We also owe him for attending our talks. So, enjoy the read…
——

Don’t worry, I am not about to argue why or why not the doctor of physical therapy is important, or whether or not we should market it. You can find that argument plenty of other places on the internet. Instead, I’d like to discuss the DPT education process from my perspective as a 3rd year doctor physical therapy student, and why I believe some students miss out on a huge aspect of it.

First let’s pave the way with google’s top answer to “definition of education”:

1) The process of receiving or giving systematic instruction, especially at school or university
2) an enlightening experience

Furthermore, when googling “definition of formal education”:

Formal education is classroom-based, provided by trained teachers. Informal education happens outside the classroom, in after-school programs, community-based organizations, museums, libraries, or at home.

I would argue that formal education is closely related to Google’s first definition. It is the hours spent in class. It is the hours spent memorizing the origin, insertion, and innervation of every muscle of the body. It’s the practicals, competencies, OSCEs (objective structured clinical examinations), and paper tests. The logistics that pave the path between students and those 3 powerful letters: DPT. Formal education can absolutely harbor definition two; enlightening experiences. Although, I sense the busywork and exam-related stress can sometimes interfere with the more contemplative, reflective, and self-directed experiences that many would consider enlightening. Formal education is only one side of the coin, and although I cannot dispute its importance, my observation is most students focus too heavily on the formal only to neglect the potential power of the informal.

Informal education is where definition two takes the forefront. It is seeking those enlightening experiences outside of class. Getting involved with PT organizations at the school, community, and national level; pro bono and volunteer experiences; the conferences; lively social media debates, and self-driven PubMed searches. It is even the critical blogs and podcasts that continuously question and reframe. Informal education is not merely the knowledge gained, but the actual process of seeking that information. It is a unique, learned skill. Informal education allows the student to add her personal interests, inquiries, and discoveries to the DPT. It is where the student can evolve herself , nearly without restraint, to a higher level of critical thinking. You know the saying “it’s not the destination, it’s the journey.” However, why is some of the knowledge, skill, and insight gained outside the classroom unable, or unlikely, to occur in the formal education environment?

Obviously, informal education differs from formal education. There is no set end product. No exams for which to study, or degree to be obtained. This allows the student to focus on the process, present experience, and self paced exploration which can ultimately lead to that sense of enlightenment and profound self- discovery. I have observed formal education struggle to extract such concepts, because the end products of grades, degrees, and expectations often cloud the student’s view of the present experience. And, the narrow focus can also hinder a sense of the bigger picture.

However, investing in informal education pays dividends. It provides motivating power, allows intrinsic self-guidance, and hopefully facilitates the evaluation skills necessary to add perspective to a seemingly endless list of assignments and tests. This facilitates the ability to fully appreciate the intended processes and outcomes of formal education. It is imperative that students and professors alike recognize this connectedness between the informal and formal, because if nurtured properly, it will contribute to the experience and meaning of achieving a doctor of physical therapy degree.

The opportunities that lie within the realm of informal education are equally as important to the DPT program as the concrete curriculum. The doctorate is 3 years of classes, assignments, and exams; but it is also 3 years of potential time. Time to explore the profession we will all be entering; to view the profession, beautiful and ugly, from the inside before actually practicing. Time to map out and dip our feet into the numerous career pathways before embarking on our own professional journeys. 3 full YEARS of time to hone not only our professional skill set and knowledge base, but lay the foundation upon which we build our future careers.

Personally, I feel that informal education has contributed significantly to my personal and professional development during the pursuit of my DPT. It is where my professionalism thrives, and my critical thinking is tested and molded; where my thought processes and assumptions have been challenged. Informal education has only one rule: that you are motivated enough to direct yourself toward improvement. None of your professors can fully guide you in this experience, although they may attempt to initiate a spark through various structured experiences like reflection assignments, discussion boards, research assignments, and compiled portfolios. But, these are still well within the construct of the formalized education process. Potential barriers to informal education include time, resources, and support.

However, the vastness of this informal domain allows for a variety of successful approaches; you just have to be willing to explore the possibilities. It does not need to happen every day, or even every month. It requires no schedule. As long as you remain pro-active, inquisitive, and open minded, informal education will find its way to you, even if you don’t recognize it. This self-directed discovery, the auto-didacticism, prepares us to remain ever a student even after formal education has commenced. This is where I truly believe the title doctorate gains substance, otherwise what is it besides grades on a transcript?

Due to the self-directed nature of informal education, I cannot tell you where to explore. I personally find my informal education at national and state level conferences; by reading blogs, both scholarly and opinionated; following and entering twitter debates; listening to PT related podcasts; collecting, organizing, and disseminating research on topics that I find interesting; engaging classmates in philosophical PT discussions. Even writing a blog post. It does not matter how you conduct your informal curriculum because it is that: informal. The only advice I can give on making the most out of your 3 year doctorate education is the following:

Do not limit yourself to formal education.
Do not think everything you have to learn about being a physical therapist will be taught in school. It won’t.
Learn how to question what is being taught to you, and how to seek your own answers to those questions.
Learn how to ask the right questions.

The profession has much to offer students who demonstrate interest, so take advantage. Informal education is what will make the difference in your education. It will help solidify the foundation of your career. It will give you the bigger picture of our profession, the one we, as DPT students, will soon be entering.

Finally, if you have been, or are planning on, spending your 3 years of PT school just getting through classes “B’s get degrees” style, by all means, you will obtain a DPT. But, then again, doctor is just a title. Remember, the piece of paper you receive on graduation day signifies merely the beginning of your journey, not the end.
——-
Gabe Streisfeld is a 3rd year DPT student attending Thomas Jefferson University in Philadelphia, PA. He is a life-long student of human movement both professionally through his physical therapy education and personally via a variety of physical pursuits including (but not limited to) powerlifting, hiking, parkour, and bouldering.

He’s always been intrigued by human movement and its capabilities. He believes in not overcomplicating the elegant and evolutionary simplicity of the human movement system. We are beings with the ability to adapt and grow in the presence of a stimulus. He yearns to use his knowledge and views on the human movement system to help others understand their capabilities and improve their physical function.

Follow him on twitter @GabeStreisfeld

Our Gratitude

Image Courtesy https://www.flickr.com/photos/wwworks/
Image Courtesy https://www.flickr.com/photos/wwworks/

As many of you know, our beloved PT Think Tank was hacked two weeks ago. The hack consisted of copious amounts of comments being posted, and some code inserted into the database that returned pharmaceutical ads when any page on our blog was queried on Google. It was annoying, expensive, and a real bummer that we would be victims of random trolling.

We never thought spammers could cost real cash on a free blog site! Boy did we learn!!

We are all fixed, thanks in no small part to the very excellent skills of one Aaron Brazell. However, talent like that does not come inexpensively, and so we quickly realized help was in order. And to that notion, you, our readers, came through wonderfully!

The purpose of this post is to publicly thank all who donated to our GoFundMe campaign and express our deep gratitude. To date we have raised over $1200 to repair our site and recover from the hack. THANK YOU!

Without further ado, we present to you the “Benefactors of PT Think Tank,” after all, without you we would not exist. In no particular order:

  • Eric Robertson
  • Jason Silvernail
  • Tim Noteboom
  • Kyle Ridgeway
  • Kathleen Nestor
  • Karen Litzy
  • Mike Bade
  • Mike Pascoe
  • Matt Moretta
  • Chris Bise
  • Lauren Kealy
  • Mark Powers
  • Janice Ying
  • Jonathan Walton
  • Kory Zimney
  • Sam DePaul
  • Naomi Cook
  • Tyler Shultz
  • Mary Derrick
  • John Marrujo
  • Nick Parton
  • Amy Pakula
  • John Synder
  • Eileen Li
  • Mary Hartenstein
  • Lorien Appman
  • Wesley Miller
  • Aaron LeBauer
  • Chris Hinze
  • Sturdy McKee
  • Cody Peterson
  • Joel Anderson
  • Several who wish to remain anonymous, but who still rock!

This was touching, and inspiring. The authors of this site are indebted to you.

Please don’t hesitate to say hi and introduce yourself one day if you happen to be some of the folks we don’t know. We’ll be glad to shake your hand in person.

We’re going to leave the campaign open for another week and then close it and move on. With your collective help, we certainly made lemonade from these lemons!

Keep Your Hands

Image Courtesy: https://www.flickr.com/photos/xlordashx/
Image Courtesy: https://www.flickr.com/photos/xlordashx/

A Hand Raised in Concern

At the 2014 APTA Combined Sections Meeting in Las Vegas, during the Orthopaedic Section membership meeting, Dr. Catherine Patla stood up and expressed a notion to the Section’s Board of Directors. She was concerned physical therapists were giving away their hands (she also expressed a similar concern to the AAOMPT Executive at AAOMPT 2014). After over a year of consideration and contemplation, I have to agree. We are in the midst of a silent crisis of physical therapy scope of practice!

Motivated by Dr. Patla’s observations and concerns, I began keeping unofficial (and admittedly unscientific score) of students in my musculoskeletal programs and how their clinicals handled, well, the hand. Conservatively, about 50% of the students reports that they were expressly forbidden by clinic policy to treat hands, elbows, and to a lesser degree, shoulders. Concernedly, the distal upper extremity appears to be the land of the OT.

This is a complicated situation.

A Handsomely Negative Impact

From a profession-wide perspective, there’s not much that can easily be done to counteract clinic-level policies. Certainly, both Occupational Therapy and Physical Therapy are qualified to perform rehabilitation to distal upper extremity injuries. Furthermore, I think the ultimate care pathway, for many injuries common to the area, involves both professions. I’ve not actually met a member of either profession who thinks differently (or at least admitted as such), yet the policies exist.

This trend has potential long-term, and wide implications. From my perspective as Director of the Kaiser Hayward Physical Therapy Fellowship in Advanced Manual Therapy, this increases the challenge to train fellows, who by decree, must have experience treating and managing patients with distal upper extremity diagnoses. Outside of residency/fellowship training, new professionals may exist without ever getting to see a hand patient in some clinics/regions! Over time, the collective knowledge of physical therapists will be diluted and will atrophy. Soon no one will be left to TEACH the hand. At my previous University, it was common practice for the senior orthopaedic PT faculty to contract an OT to come in and teach the hand to DPT students. This was a constant and disappointing source of stress for me. What message does this send! We could literally be voluntarily cleaving off an important scope of our practice! The irony is, it’s the body region most important to how we treat! It’s decidedly more difficult to be a PT if you don’t have hands.

The Hand Rehabilitation Section

I don’t know any more than a couple people in the Hand Rehab Section of the APTA. Perhaps that’s my issue. Perhaps it’s because the Section itself is a bit of an anomaly. Of the 18 Sections within the APTA, it’s the only one designated by an anatomical focus. The other sections are delineated by practice areas like Orthopaedic or Neurologic, settings like Home Health, Acute Care, or Aquatics, or related professional activities like Research, Education, and Federal Advocacy. Arguably, the Women’s Health section is anatomically focused, but in fact it’s not, since Women’s Health is more broad than a pelvic floor and I think “The Vagina Section” would offer some terribly difficult search engine optimization challenges! I do not know the history of how the Hand was excised from the rest of the Orthopaedic Section and would love to learn.

All that criticism on name/organization aspects aside, you have to also argue that the Hand Section is doing the best it can with the membership audience it has (~472 members and 36 Facebook likes). It offered an outstanding selection of programming at this years CSM Meeting in Indianapolis. Everything from a high-profile lecture including ESPN’s Stephania Bell, to a comprehensive clinical reasoning model for TFCC management by Brenda Boucher and Pieter Kroon was offered. Notably, the Hand Rehab Section also offered two pre-conference courses and presented the results for projects for 3 different clinical practice guidelines: carpal tunnel, distal radius fractures, and lateral epicondyalgia. Yet, while all this is taking place, other PT’s seem more than happy to give up the hand and let someone else manage it. Let some other PROFESSION manage it.

Hands are for Holding

To me, this boils down to a grassroots effort, and is an issue of personal responsibility as a professional. You cannot in good conscious, let your clinic enforce and carry out a policy that prohibits, or through practice, eliminates the opportunity to treat any body region, especially the hand. We all know the outcry when outside professions claim a technique is only their purview, and attempts are made to remove that from our practice. Physical therapists rise up in a collaborative rage and claim it back. Yet, I see malaise and laziness, and an acceptance of insufficient knowledge as a behavior pattern among physical therapists in these clinics. That may seem harsh, but I can’t see it any other way.

My one caveat, and an important one at that, is that some hand injuries do require a very experienced hand specialist. Hand tendon surgical repairs quickly surpass entry-level practice. There is an insufficient numbers of physical therapists trained Certified Hand Therapists. In fact, I have only encountered one PT who holds the dual acclaim of Fellow of the Academy of Orthopaedic Manual Physical Therapists AND is a Certified Hand Therapist: the aforementioned, Dr. Boucher, who hails from Texas State University and teaches as part of the Manual Therapy Institute’s manual therapy fellowship program.

There are pathways, and opportunities that can happen, and I’ll outline my suggestions in just a moment, but this boils down to each and every physical therapy professional deciding to hold onto hands. It’s up to YOU!

Getting a Grip on this Problem

By all means, this is just a suggestion, but we need to start somewhere and why not now? Please comment, edit, innovate, or ACT on this:

  • Hand Rehab education should be led by physical therapists as often as possible in DPT programs.
  • Individual PT’s in clinics with hand-prohibitive policies should challenge these, and reach out to professional advocates like those in the Hand Rehab Section for assistance if needed.
  • Consideration of upper extremity policies in DPT Clinical Education should occur.
  • Joint clinical practice guidelines should be developed by OT’s and PT’s collaborating as authors.
  • Increased visibility and ultimately membership in the Hand Rehab Section. 36 Facebook likes is not going to cut it. 472 members is difficult to defend.
  • Development of post-professional pathways for Hand/Wrist/Elbow instruction including residencies, fellowships, and some stake in the Certified Hand Therapist credential.
  • Consideration of how the Hand Section can further collaborate with the Orthopaedic Section (absorbed by the Ortho Section?) and AAOMPT to further their collective mission.
  • Wide APTA support for these endeavors, including resources for training training, pathways for expertise, research, and advocacy.

Thanks for listening. Thanks for thinking. Thanks in advance for taking the challenge to not let this problem get any worse!