Critical observations of health, science, and the physical therapy profession.
#CSM2013 is here! PT Think Tank and it’s contributors are all in attendance. We plan to provide highlights, quick summaries of sessions, and other insights right here on PT Think Tank as well as through the conference hashtag #CSM2013. If you are tweeting do not forget about the other hashtags curated and discussed in the #Physicaltherapy Hash Tag Project 2.0 . Not attending? Follow the hashtags at home and join the conversation.
Well, physical therapy didn’t exactly have a sex tape this week, but over the past several days, two notably large media outlets have featured PT in ways we might not, at first glance, like to be defined. The most prominent of these was physical therapist, Peggy Brill, who appeared on the Dr. Oz show to tout Ultrasound, Tiger Balm patches, and Bumpy Balls as cutting edge treatments for back pain.
The second piece may have been slightly smaller in reach, but not if you’re a regular internet news surfer. An article that originated on the website, Greatist.com, made its way to media juggernaut, The Huffington Post. The article, entitled, “The 8 Best Physical Therapy Methods Explained,” featured “Greatist Experts Dr. Mike Reinold and Dr. Eugene Babenko.” The troubling part about these spots, which drew national attention, is that of the 11 treatments extolled by the PT’s, only 2 were not weakly supported passive modalities. When you take a step back and look at the brand message being delivered, it says ‘Physical Therapy consists of ultrasound, electric stimulation, lasers, traction, heat, ice, smelly patches, something that resembles children’s toys, and oh, exercise and something called manual therapy. Yes, I cringe.
Now, before you hire the lynch mobs to go find these blasphemous physical therapists who soured the public’s view of the profession, pause for a moment and understand how the media works. PT’s do not direct and produce media development. Often, by the time the expert is contacted, the direction of a particular spot is already formed. I will say the Brill Dr. Oz video is difficult to defend, but if you look closer at the Greatist.com article, you’ll see that Mike Reinold did try his best to steer the article.
Statements like, “Ultrasound has also been shown to increase ligament-healing speed in our furry counterparts (read: rats), though more studies are needed to show whether the same holds true for us,” and “Note: Heat is just one tool to help the therapist be more effective, Reinold says, it shouldn’t be the main focus of a treatment plan,” clearly show how Dr. Reinold was trying to steer the article and minimize the message of passive modalities. He even tweeted later on that the author did a great job of taking his feedback on the article. I know Mike well and he’s not a slayer of physical therapy. He’s an advocate, and a powerful one at that, with a large audience who follows his rehab, sports medicine, and performance blog, MikeReinold.com. Still, the average internet reader and skimmer probably saw, Best PT = Ice, Heat, Ultrasound, Traction, etc. Yes, the article started with Manual Therapy being listed, but I argue that most readers wouldn’t recall that in their skimming compared to the more easily imaged words familiar to them, like heat and ice.
I can relate to this idea of physical therapy by mainstream media. I was interviewed recently for an article being prepared for a national publication. I spent most of the time in the interview trying to convince the writer that their preconceived notions of physical therapy weren’t actually physical therapy. I was moderately, but not fully successful. At a certain point, I had to draw the line or risk the writer moving on to a different “expert” who may have been more passive than I. And that’s the reality of media development. We should accept that the public has a very modality-based view of us and think of strategies to fix this.
Physical Therapist philosophizer, Allan Besselink, responded to the Greatist article, expressing not only his distaste for yet another passive treatment article, but also his idea of the 4 best physical therapy treatments for patient-centered care. He writes,
Here are the four best physical therapy methods for patient-centered care:
1. Mechanical assessment: The best treatment will be a natural progression from a good mechanical assessment based on sound clinical reasoning strategies.
2. Patient education: The patient needs to understand the solutions to their problem, the self care strategies involved, and the self-monitoring and progression of these strategies.
3. Exercise: Patient- and condition-specific exercise programs are critical self care strategies to promote optimal repair and remodeling, along with effective reduction of mechanical derangement if present. Exercise should be evidence-based and supported by the sport sciences research.
4. Mentorship and guidance: Physical therapists have the knowledge base and capacity to act as health mentors, providing instruction, progression, and guidance as necessary.
Of course, none of these sound quite so fancy or high-tech as laser or ultrasound. But they all depend on the consumer’s active involvement in their care. Isn’t that the message we really want to send to consumers?
Allan’s list is excellent, though I would change out the first item for something more recognizable to the patients. The Doctors of Physical Therapy blog developed a similar list. Perhaps my reworked list might look like this:
Eric Robertson’s List of the 5 Best Physical Therapy Treatments for Patient-Centered Care: (stealing some parts directly from Alan)
1. Mentorship and Guidance: Physical therapists have the knowledge base and capacity to act as health mentors, providing instruction, progression, and guidance as necessary. Inherent in this is the fact that physical therapy treatment is continually distilled with excellent patient education about their condition and road to health.
2. Exercise: Exercise is the super power of the human physiology. Patient- and condition-specific exercise programs are critical self care strategies to promote optimal repair and remodeling of all your body’s systems. Exercise should be evidence-based and supported by the sport sciences research.
3. Pain Reduction: Through an integrated strategy that can include hands-on manual treatment, targeted coping strategies, and even the judicious use of passive modalities, physical therapists can have a great impact on acute and chronic pain, either helping patients to overcome the cause of that pain or giving them tools to minimize and cope with their pain.
4. Movement Education: Physical therapists have a unique roll as functional motor control experts. Whether the task is rolling over for the first time as an infant, regaining balance after a stroke, or finding the precise control to play football again after an ACL injury, physical therapists can rise to the challenge. Physical therapists understand how your body moves and can connect the dots between neural control, musculoskeletal strength, and the reality of each individual’s form to maximize human function.
5. Health Optimization: Rarely do paitents or clients of physical therapy make it through an encounter without gaining some benefit to their health apart from the condition or problem that got them there in the first place. It might be improved posture, it might be working out the tight hip that caused the low back pain in the first place, it might be the improved cardiovascular benefit of exercise, it might be a better understanding of how to manage their diabetes, or it might be reduced fear about re-injuring yourself. Physical therapists do much more than just fix body parts. They fix you!
Here’s what we need to remember. Physical Therapy is lucky enough to be a profession that does get mentioned on national press. Inherent in these two spots is something very strong and very important. It’s the idea that ‘Physical Therapists Fix You’. Even if the scholars of our profession squirm when the national media misses the mark on evidence-based treatments, the idea that physical therapists can take care of you is still very present, and very powerful. That is our true brand. And, I can live with that.
As everyone is aware, Superstorm Sandy has wrecked things. Especially, my home state of New Jersey. Many of my friends and family are still without power. My cousin was particularly hard hit as his home in Ortley Beach, NJ was completely devastated. He’s the “Joe” featured in this video and pictured above. Authorities tell him he will not be able to return to his home for 7 months at the earliest. Devastation.
Please click on either of the two links and donate funds to help this stricken land.
American Red Cross Disaster Relief Fund
NJ Hurricane Sandy Relief Fund
I’m sure my family and friends will be thankful for your generosity.
ERIC
In a recent article in the NY Times entitle, “The Year of the MOOC,” writer Laura Pappano describes an exciting, ongoing disruption in education. MOOCs, or Massive Open Online Courses, are quickly becoming the next big thing. I’ve taken or am taking several of these and I very much enjoy the learning process. The ability to engorge your mind with such high-quality content is unmatched. However, don’t think this is simply sitting back and getting fed information. These courses, usually mirrors of the on-campus versions of the courses, can be a lot of work!
There are obvious implications for healthcare within this framework. In fact, the University of Texas System recently joined up as a main partner with EdX, a collaborative including Harvard, University of California Berkley, and MIT. In their press release on the matter, the UT office spoke directly to the idea of including health-based offerings on the EdX platform.
The UT System brings a large and diverse student body to the edX family. Its six health institutions offer a unique opportunity to provide groundbreaking health and medical courses via edX in the near future. The UT System also brings special expertise in analytics – assessing student learning, online course design and creating interactive learning environments.
Within the next year, expect to see MOOCs being offered with options to pay for credits. Within the next few years, expect to see a wholly different educational environment that what we have today. University education is set to undergo a rapid evolution. Here’s to hoping this evolution occurs consistent with the traditionally high standards that have always existed, and here’s to hoping physical therapists can find a way to educate more than just future PT’s using such tools. It’s a clear opportunity for worldwide advocacy.
I’m teaching a freshman seminar course this year at Texas State. It’s about introducing students to the university as well as the college learning environment and culture. I was prepping them for some interview and presentation assignments and stumbled across a fine TED Talk by Amy Cuddy about the importance of body language.
The information in this is fascinating. Basically, you can see significant, measurable changes in hormones simply by maintaining a posture for as little as two minutes. It doesn’t seem to matter if you actually feel powerful or weak, but if you hold the power poses, you increase testosterone and decrease cortisol. It also seems that subjects are better able to cope with stress and have superior results in job interviews following this 2-minute posture hold.
If the simple act of assuming a posture can alter the brain, I wonder if having patients in chronic pain can see a similar benefit. Power poses before therapy might just help take that edge off and allow more pain-free motion during a therapy session. Of course, this is just me postulating, but I wonder… Testosterone might not have an obvious connection to pain, but cortisol and resultant stress levels certainly could. Perhaps testosterone could somehow enhance self-efficacy, which is important for function in the face of chronic pain. Visit sites like indacloud to explore a wide variety of cbd products that may help alleviate pain from various health conditions and injuries.
In this stunningly beautiful, award-winning video work from The Astray, the message is about passion. Relax for a few moments and soak this masterpiece in. Let’s gather some friends and เล่น UFABET tonight for some fun.
I never set out to be anything in particular, only to live creatively, and push the scope of my experience through adventure and passion.
Passion is part of what drives the people who make change. It’s part of what makes someone work deep into the evening to make it right. It’s the people pouring out ideas in the #SolvePT movement. It’s the leadership of the profession, regardless of how effective you think they are.
For a long time I had no passion for this profession or my career. Moving from job to job, I had little fulfillment. With a little luck and a little self-exploration, I was able to discover which aspects of physical therapy resonated with me. Fortunate. My passion is now strong. This job has become my profession. This blog is an expression of that passion. What is your passion?
Live Creatively. With Passion. Expand Your Experience.
Earlier this week, I stumbled across this filing with the U.S. Patent and Trademark Office. It is a notice of Trademark infringement alleged by the American Osteopathic Association (AOA) and its component boards against James Dunning, concerning the use of the term, Osteopractor™, which has been commented on before at this blog.
In the filing, the AOA states:
Applicant’s mark so resembles Opposer’s previously used and
registered marks as set forth above as to be likely, when applied
to the services set forth in Applicant’s application, to cause
confusion, mistake, or deception or to comply that Applicant was
certified or approved by Opposer within the meaning of Section
2(d) of the Trademark Act.
There is, of course, a retort from the accused stating that they disagree. This will be interesting to watch as this debate unfolds.
On a somewhat related note, I find the architecture of the U.S. Patent and Trademark Office to be quite nice.
[list][/list]Sometimes, it’s pure and simple logic that prevails as the best solution to something. This was the case in an important new study published ahead of print in Spine. You may have seen the presser released by APTA, AAOMPT on the matter. They’re exuberant, and they should be. Well, mostly.
The study, published by Drs. Julie Fritz, John Childs, Rob Wainner, and Tim Flynn, examined a payor database and looked at over 32,000 data sets of patients with low back pain with the purpose of describing physical therapy utilization in primary care settings. Further, they looked at both associated healthcare costs and the question of whether the physical therapy care being provided was either adherent with practice guidelines for an active treatment or non-adherent. Treatments were classified as non-adherent when they included things like ultrasound that are not proven interventions for patients with low back pain. While not a perfect practice, the researchers used billing codes as their determination factor for treatment adherence.
The findings of this study are fascinating to me. Albeit, many public health studies that look at low back pain and care patterns and/or costs are fascinating to me, so I’ll let you be the judge.
The key findings of the study were:
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As you can see by the graph above, significant savings were realized by early referral to physical therapy and by adherent physical therapy care. Logic sure does shine forth here. If you’re going to go somewhere, well you might as well just get there. Significantly, the finding in this study is important because it runs counter to the suggestions by many LBP practice guidelines that suggest primary care physicians delay referral to other services as many patients are likely to improve anyway. Overall trends to reduce the medicalization of LBP are important, but this study reflects a trend whereby physicians are referring about half of patients to physical therapy within 14 days anyway. It turns out, this may end up being an evidence-supported practice.
Not all was rosy, however. Here are some other findings that were important:
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This study is full of many other gems. It’s gated at Spine, so apologies for not including a full text link. The good new: Spine is a huge journal and this will be seen. As with many studies, this leaves more questions to ask. Such as, what factors make the patients who are referred early have lower subsequent utilization. The authors hypothesize it may have to do with the concept of self-efficacy. I like it.
I like it so much, in fact, that I’m involed in a related study with some of the authors to examine a similar question in a Department of Defense database. I’m eager to see what we find.
This study was jointly funded by grants from the Orthopaedic and Private Practice sections of the APTA, AAOMPT, and a faculty research grant from Texas State University.
Alan Besselink, blogger and Austinite extraordinaire has written a thoughtful post entitled, “APTA’s Vision 2020: My 12 Year Report Card.” In the post, Alan breaks down the components of Vision 2020 and provides his summary of the progress toward each.
To review, here’s the Vision 2020 statement from the APTA:
“By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health.”
I’m sure certain parts of this resonate more with different folks. For Alan, the issue of Direct Access takes center stage. I agree with his critique of the APTA PR machine, which labels 40 something states as having some form of direct access to physical therapists…while in actuality, many of those states are not very gate-keeper free at all. Alan points out that the state we both practice in, Texas, is listed as a Direct Access state by APTA. I consider that false.
Here are Alan’s grades for each section:
Now, I’m not sure I agree with Alan on all of these grades (specifically the EBP and DPT grades), but he makes a good argument for each of his choices in his post. My question to you is, what do you think about the progress we’ve made on Vision 2020. As Alan points out, “As they say, if you do what you’ve done, you will get what you’ve got. Sadly, what we’ve got isn’t much different than what we had 12 years ago.” This may be a good opportunity to take stock and make some changes in strategy before we get too close to 2020 to change!
[icon style=”notice”]I’ll summarize the results of this poll in another post prior to the APTA Annual Conference.[/icon]
Recently, the open-access journal, Cancer, included a special issue: Supplement: A Prospective Surveillance Model for Rehabilitation for Women With Breast Cancer. This model has been described by researcher, Nicole Stout, as a “proactive approach to periodically examining patients and providing ongoing assessment during and after disease treatment, often in the absence of impairment, in an effort to enable early detection of and intervention for physical impairments known to be associated with cancer treatment(1).” In other words, checking early and often so that issues can be dealt with at a mangeable stage and not in a catastrophic end-stage presentation. Theoretically, this model of approach can mitigate many of the known poor related outcomes for patients following cancer treatment.
The model of prospective surveillance has been developed over the last decade at the National Naval Medical Center in Bethesda-now part of the Walter Reed National Military Medical Center. It’s the standard of care for all patients there and serves as a great base for research into the clinical effectiveness of this approach. While bottom-line cost savings numbers aren’t apparent yet, this seems a likely outcome, as overall, patients consume less care when issues are dealt with in early stages when their prognosis is still strong. Regardless, it’s a cool phrase!
The prospective surveillance model attempts to cover many aspects of cancer treatment, including awareness of known side-effects to the sometimes persistent upper extremity pain and dysfunction that so many women share following treatment for breast cancer. Describing and quantifying the séquelle of post-treatment effects that are common following treatment that can be ameliorated through rehabilitation are part in parcel in studying this model, and are dealt with as well in the supplemental Cancer issue. Check it out and get smart!
This issue hits close to home for me. My mother is a breast cancer survivor. As she recovered, I was well aware of the musculoskeletal dysfunction in her upper extremity, yet was confounded at the lack of attention that received from her care providers. Research into this area is a critical, emerging field of physical therapy and one that makes me proud. There are also new neuropathic pain treatments that can help with this.
As an aside, Nicole Stout is a member of the APTA Board of Directors (Scroll to Bottom). She is in candidate status this year and I’m sure would appreciate any support one could be in the position to be in as elections approach in June. She does important work.
1. Stout NL. Cancer prevention in physical therapist practice. Phys Ther. 2009; 89( 11): 1119-1122.