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Physical Therapy Metrics

With the widespread use of EMR, more and more data is being collected about the way we practice. A recent post on the Four Hour Work Week by Eric Ries, has me thinking about metrics, specifically PT metrics and how they relate to the care I provide, and the experience my patients have. Eric breaks business metrics down into two types: vanity metrics and action metrics. Vanity metrics is the data that “might make you feel good, but they don’t offer clear guidance for what to do.” On the other hand, action metrics help us make decisions and give us valuable information about our practice. Traditionally metrics in the PT world can generally be broken down into 3 categories: billing, productivity, and referral metrics. More specifically, lets explore how vanity and action metrics relate back to individual (not company wide) practice.

Vanity Metrics: Private practice owners might argue that “no data is bad data” when it comes to tracking patients and therapist performance in the clinic. However, some data points simply do not provide an accurate picture of individual therapist performance, and could be better suited when applied to company performance, or ignored altogether.

  • Visits per case/referral: In my opinion, this data set is the most inconclusive of all metrics commonly tracked to individual PTs in EMR programs. The general rule-of-thumb for most private practices is that the visits per referral number should be between 10-12. This depends on several factors: skill level of therapists; number of post-operative referrals, geographic location, patient population/SES, referral source, clinic reputation, and the list goes on and on. I have found this metric has no bearing on patient outcomes, or patient/physician satisfaction. If you can obtain the same outcomes in 6-8 visits versus 10-12, your patients will be happier, and your referral sources will be impressed. In return, you see a higher volume of new evaluations – which means more and more happy patients.
  • Incomplete metrics: Other metrics that are commonly applied to individual PTs are actually “incomplete,” or too variable to apply to individual performance. For example, scheduling related metrics, such as cancellation and no-show rates, are mostly out of the control of the therapist and do not reflect on the quality of care provided. Obviously, a good clinician that creates buy-in, demonstrates value, and has good outcomes will generally have a low cancel rate. But, cancellation rate does not always reflect productivity – a clinician with a cancellation rate of 4% does not mean they are more effective than a therapist with a cancellation rate of 10% – this variation could easily be due to scheduling, clinic hours, weather, traffic, or an entire host of other variables.

Action Metrics: Action metrics are the data that should be used to evaluate therapist performance and patient outcomes. These metrics help the decision making process, and can demonstrate value to your referral sources and the general public.

  • Plan of Care (POC) complete to Discharge: Perhaps the most under-tracked, but most important data point is patients who complete a POC to discharge. Generally this happens when appropriate care is provided (regardless of number of treatment sessions), goals are met, and functional limitations are eliminated. The therapist and the patient are on the same page, and the patient is happy with the care they receive. And happy patients produce more business – not only by word of mouth and leaving reviews online, but also by telling their physician about the quality of care they received. A high percentage in this metric indicates that the clinician provides quality care and communicates well with their patients.
  • Units/visit: Another metric that is highly variable depending on the patient population and insurance type, but useful nonetheless is units per visit. Tracking units/visit at the provider and company level is beneficial – this serves to make sure therapists are not under-billing; which is all too common in PT practice. It also allows therapists to make sure they are not over-billing, which may make you more susceptible to audits. This metric also allows for more accurate clinic budgeting and forecasting income.
  • FOMs: Tracking change by using functional outcome measures is critical to evaluating therapist performance and patient outcomes. Functional outcome measures should be used with every patient, every time. However, accuracy requires that valid measures are being used, and that measures are used with the correct patient population. Understanding MCID and MDC for each measure is also important. These metrics should also be used to support Functional Limitation Reporting. In addition, physicians and referral sources often use and understand these measures, easing the communication gap while marketing to potential referral sources.
  • New patients per therapist/requested therapist: Another under-tracked and under-utilized metric is new evaluations per therapist. Particularly, patients who request a therapist by name are often more satisfied with the care they receive and more likely to complete their recommended course of therapy. I find this number often correlates with patients who complete their POC to discharge, looping back into the cycle of happy patients and word of mouth referrals.

When extrapolated across a group of therapists in a company or clinic, action metrics provide a more meaningful picture of how valuable our services are. Individually, vanity metrics can be misleading and provide little value as to the value and productivity of a therapist.  Eric Reis encourages us to “measure what matters” – meaning that more data is not always better, and argues that the key to having actionable metrics is “having as few as possible.” It can be tempting with EMR to look at a seemingly endless set of metrics, but narrowing our focus on a few can provide better insight into therapist, clinic, and business performance. How do you use metrics in your clinic? Which ones are used to evaluate individual performance?

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Physical Therapy: Technology Update

This is my presentation given at Evidence In Motion's Manipalooza 2013 Symposium held in Aurora, CO.

http://manipalooza.com

I was traveling at the time but the organizers graciously allowed me to submit my talk as a recorded video. Therefore, you will be experiencing the talk just as the symposium participants did!

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How Do I Twitter Anyway? #DPTstudent

Twitter is an amazing place. I get smarter everyday by observing and connecting on the platform. However, I’m routinely astonished at the reluctance of the vast majority of the students I teach to engage. The #DPTstudent tweetchat has been a great conversation, but it’s only a droplet of the approximately 8000 of PT students currently in school.

One barrier to Twitter engagement is the requirement to spend time figuring it out. Twitter without filters and careful content curating is like trying to drink from a fire hose. It’s just not going to be a very comfortable event.

To that end, Mary Derrick (@Mary_PT2013), a Texas State DPT student who is mere weeks from graduating has crafted a handy and excellent user guide for those folks interested in playing along on the #DPTstudent chat. It’s also great for anyway who would like to figure this Twitter thing out! Enjoy!

(I suggest you expand this prezi to full screen size for optimal viewing.)

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Comments On: Building Community & Discourse Through Conversation

Often, intense dialogue emerges in the comments section of blog posts. In my opinion, the discussion enriches the original post. Comments add depth to the post, and benefit the reader. Further, it allows a post to remain dynamic over time as knowledge improves or reasoning changes. A guest post on @MikeReinoldBlog entitled Trigger Point Dry Needling for Lateral Epicondylitis resulted in over 220 comments. At one point, Mike even closed comments. Later, in a decision I respect and agree with, he re-opened the comments section. That post is rich in various content, lines of reasoning, and debates on various aspects of science, physical therapy research, pain, and mechanisms of manual therapy. A true resource. On PT Think Tank, our most commented on post  OsteopractorTM Not now, Not ever currently has 201 total comments. In  Comments Off on PT Podcast @ErikMeira states:

Do I not want the feedback? Do I not want to foster discussion? Not at all. The answer is simple: I don’t have the time to manage it. When I have allowed comments in the past I was bombarded with spam posts. This required constant attention to weed out the crap… The other problem is trolls. Most comments are either blind emphatic agreement or blind emphatic disagreement. Then you get into name calling and weird irrelevant attacks. No thanks. I’m not the only one who feels this way. Look here, here, and here for some much more thought out reasons for not allowing comments on blogs.

I agree that moderation can be difficult. Spammers and trolls are a constant, annoying problem. Spam widgets and spam reducing practices exist. See 7 Ways to Reduce Blog Spam for ideas. For those not familiar, @ErikMeira hosts two fantastic podcasts, PT Podcast (@PTPodcast)and PT Inquest. On his site, he published a fantastic 5 part Science Series.

Once a site decides to have comments open the author of a post has a couple of options:

1. Allow the commenting community to discuss
2. Address critiques or questions directly
3. A combination



For moderation, a policy statement can guide decisions to un-approve a comment(s) utilizing set standards as a reference. I uphold that heated discussion and debate eventually lead to progress, are extremely helpful to readers, act as real time peer review, and illustrate when people are being ridiculous. The more people comment, the more obvious their intellect, intent, and true value (or lack of) is displayed. Comments allow for multiple participants and viewpoints to present and discuss issues. Often, connections are made to other concepts not explicitly explored in the initial blog post. For a reader, following the discussion can engage analytical processes, allow them to follow arguments, and challenge ideas. There is value for the author in the for of feedback, questions, and a forum for further clarification. There is value for the commenting to engage with the author and each other in an archived discussion. There is also value to the reader. Personally, I have extracted tremendous intellectual challenge and benefit from reading through a blog post with a engaged comments section.

Although a fear of negative comments is present, allowing individuals to post dissenting views illustrates enriches the post. Even without any moderation the community of commentors can come to the rescue in the case of poor logic, bad reasoning, misinterpreted references, or just plain nastiness.Comments and the ensuing discussion give blogs their true power. In best case scenarios, they are an example of real time, open source peer review and academic-clinical discussion. We can discuss and collaborate around the world. SomaSimple is a prime example of an open forum. Many view SomaSimple negatively, but they have presented a moderators consensus on the Culture of SomaSimple and Information for Guests which includes the Disagreement Hierarchy. One of the resounding themes of the forum is “Here you are safe, by your ideas may not be!”

A prime case example of “comments on” is the contraversial post OsteopractorTM Not now, Not ever. To date, the post has garnered more than 200 comments. The dialogue was not terse and rather intense at times. Overall, I think the comments section benefits those who read and engage PT Think Tank. I attempted to respond to most comments  and critiques. The commenting community dialogued further. Eric Robertson moderated comments that were blatantly attacking individuals or grossly off topic. In total, less than 10 comments total were moderated (deleted or discarded). One comment by a single individual and all the rest by another. So, overall 2 users and less than 5% of all comments required moderation.

Comments? Comments, anyone? Anyone?

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Do you MOOC?

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.

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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.

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Can we use Twitter to #SolvePT

Recently, a new hash tag has emerged in the physical therapy twittersphere: #SolvePT. Selena, via the Evidence in Motion Blog, shared her thoughts in a post The Pulse of Physical Therapy. Dr. E of the Manual Therapist also briefly highlighted this new hash tag in a post.

#SolvePT

Initially, discussions focused on financial issues of physician owned physical therapy services (POPTS), student loans, payment, and educational costs. But, today involvement and content was rich with various contributors and topics. Physical Therapist Twitter regulars such as myself (@Dr_Ridge_DPT), Larry Benz (@PhysicalTherapy) and @SnippetPhysTher were present. @PTThinkTank even tweeted a few insights. Other tweeps included:

Topics discussed today were extremely broad and covered many areas of practice:
  • Education: Cost, Length, Effectiveness, Organization
  • Clinical Education: Models, Need for change, Payment
  • Financial: Debt vs. Income, Payment by Setting, Incentives, Payment Models. You may seek Professional Financial Solutions if you are struggling with your financial liabilities.
  • Best Practice: Defining, measuring, incentivizing, and teaching
  • Outcomes: Which ones? How to Measure?
  • Value: Cost Savings, How to measure, How to communicate
A very interesting question that I took from the discussion was: Who is the physical therapy consumer or customer? I made the point that physical therapy has many consumers at various levels of the care delivery process. An individual receiving care from a physical therapist is an obvious and direct consumer. But, other customers of our services include referral sources, other health care providers, payers, hospitals, entities we work for, the health care system, and society as a whole. Our care, but also our knowledge or advocacy, can directly or indirectly affect these various stake holders.

Web 2.0 principles allow us to crowd source and brainstorm with a much wider audience; geographically, practice setting, and expertise. This hashtag will allow for the recording and analysis of a wide range of view points and ideas. We can follow the evolution of topics over time. This stream and  medium could be leveraged by larger, more formal organizations (are you listening APTA?) for idea generation  to guide future task forces and initiatives. In fact, some of the issues, solutions, and thoughts for future direction are solid. #SolvePT is already evolving into a task force.

My Insights and Thoughts

There was a lot of focus on “best practices” in physical therapy. Defining, measuring, communicating, and then teaching best practices is extremely challenging. Todd Davenport of @PacificDPTweet, made the observation that “best practice” is a moving target given the evolution of research, science, and understanding. I agree. Further, who defines best practice? I think we must look beyond a specific patient and episode of care when defining, analyzing, and teaching best practice. In addition, we must look at multi-level outcomes. For example, for an outpatient perspective we can not just look at the patient specific outcome of that episode of care, the time/number of visits, and it’s cost. That is a too narrowly focused frame of reference. We should broaden our lens, and our potential for impact. We need to also need to consider (and target?) recurrence, future health care costs, risk reduction for other medical conditions, and overall health/fitness. Cardiopulmonary fitness is maybe the most dramatic modifiable factor to prevent disease, morbidity, and mortality.

I brought up the topic of physical therapists in hospital intensive care units. Johns Hopkins performed a quality improvement project where they staffed 1 physical therapist for a 16 bed medical ICU. Their estimation is that by decreasing ICU length of stay and increasing patient mobility/function the hospital, and thus the health care system, saved an estimated 5 million dollars over a 1 year period. The internal investigation lead to the hospital staffing 2.2 full time physical therapists solely in a 16 bed medical ICU. This is a dramatic change in practice focused not on productivity or reimbursement, but on VALUE, risk reduction, and other broader outcomes.

Unfortunately, in discussing best practice no attention was brought to the actual content of current PT programs. In my opinion, pain science/physiology, basic neuroscience, critical thinking, philosophy of science, cognitive biases, and metacognition are vastly lacking from our curriculums.

The teaching and study of pain should be integral in all PT education, both didactic and clinical. We have neuromuscular, musculoskeletal, cardiopulmonary, and or medicine tracks in our programs. Why do we not have a specific pain track? Or, at least a focus and integration of neuroscience and pain physiology into our other courses? Regardless of practice setting, the majority of our patients will have a primary or secondary complaint of pain. Joe Brence, who blogs at ForwardThinkingPT, started an online petition regarding this exact topic. I recommend you sign it HERE.

In order to be “evidence based” (or more accurately Science Based) we need extensive training in the philosophy of science and critical thinking including prior plausibility, research design, and article analyses. To assume that students entering PT programs received such instruction as undergraduates is, to put it nicely, a huge assumption. How are we to make appropriate clinical decisions if we do not understand our inherent cognitive traps and biases? How are we to correct them, if we can not even recognize them? The skill of appropriately analyzing a single article based on design, statistics, and results in the context of plausibility, basic science, and the state of other literature AND THEN applying that to everyday clinical practice is what being a master clinician-scientist is all about. And, that is what we need to strive for. The title of Tamara Little and Todd Davenport’s recent editorial in the Journal of Manual & Manipulative Therapy sums it up quite nicely: Should we be expert clinicians or scholars? The answer is yes.

How do we generate results from this passion and discussion?

  1. How do you think we should #solvePT?
  2. What are the most pressing issues in education, payment, practice, and our evolution?
  3. How can we focus some of the general issues and proposed ideas into specific and concrete action; solutions!?

#SolvePT has been thought provoking. Hopefully, it will continue to grow. I foresee big potential in this type of interaction.

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Leveraging Technology VI: Case Example: ACL Injury “Prevention”

Recently, I stumbled upon a website post via Twitter:

Original Tweet

 

I absolutely love the basis and intent of the tweet! Female athletes exhibit increased incidence of non-contact anterior cruciate ligament injuries, so we need to work to reduce their risk of injury through specific training, performance, and post-surgical rehabilitation programs. ACL injury, reconstructive surgery, co-morbidities, rehabilitation, return to sport, and prevention all are hot topics currently. Studies have investigated risk factors for ACL injury, sport specific rehabilitation and return to play, accelerated vs. standard rehabilitation timeframes, as well as predictors of osteoarthritis following reconstruction. Some investigations attempt to identify individuals who can cope without an ACL vs. those who require surgical intervention. And unfortunately, as ACL injuries occur in younger and younger athletes physical therapists must consider the proper management of ACL injuries in skeletally immature individuals. I posted about fear of re-injury and return to sport following ACL reconstruction.

The link in the tweet is a Santa Monica Sports Medicine Foundation website page that explains the Prevent Injury and Enhance Performance (PEP) Program. But, I had 2 discussion points:

  • The PEP may not be the best program
  • Prevention may not be the best wording



Based upon my understanding of the literature on the topic, Sportsmetrics seems a superior choice for both injury risk reduction and performance. Second, I do not think we can truly and absolutely prevent injuries. Injury is an inherent risk of sport. Even non-contact ACL injuries are not totally preventable. Now, injury risk reduction is possible and feasible. I believe that the using the term prevention is the wrong nomenclature. It conveys an inaccurate message. Every attempt is made to reduce the relative risk of injury. But, make no mistake, there is no way to totally abolish injury risk. Maybe I am being too fussy…

In a strike of happy coincidence I read the abstract of a systematic review from the journal Sports Health: A Multi-disciplinary Approach the day before through Google Reader. The title of the article is Anterior Cruciate Ligament Injury Prevention Training In Female Athletes: A Systematic Review of Injury Reduction and Results of Athletic Performance Tests. The review analyzed the results of other studies in an attempt to ascertain which training programs decreased ACL injury risk and in conjunction what measures of performance were improved. The conclusion:

Sportsmetrics produced significant increases in lower extremity and abdominal strength, vertical jump height, estimated maximal aerobic power, speed, and agility. Prevent Injury and Enhance Performance (PEP) significantly improved isokinetic knee flexion strength but did not improve vertical jump height, speed, or agility. The other 3 programs (Myklebust, the “11,” and Knee Ligament Injury Prevention) did not improve both ACL injury rates and athletic performance tests.

My initial response
And nomenclature thoughts
A little bit of info from the review
Responses
Other tweets

 

@PacificTigerDPT brought up some excellent points in our exchange. The importance of marketing to patients and clients to maximize accessing the most effective care was something I did not think about. I really enjoyed conversing, discussing, and learning via Twitter.

Now, I am bias, because my practice location utilizes the Sportsmetrics program. I am most comfortable and familiar with administering Sportsmetrics. But, given the data in the above systematic review, I think Sportsmetrics is overall a superior program. Obviously, you want your injury risk reduction program to reduce the risk of injury! That is priority number one. But, improving performance measures such as power, aerobic capacity, strength, and agility is always at the forefront of any training, recovering, or rehabilitating athlete’s mind. In this regard, the data seems to suggest that Sportsmetrics outperforms Prevent Injury and Enhance Performance (PEP) Program. I would argue the Enhance Performance part of the name should be taken out, given the data shows that it only improves isokinetic knee flexion strength, but no measures of athletic performance.

The interactions on this topic I had through twitter as well as this resulting blog post are a real illustration of how to leverage Twitter, tweet replies, RSS feeds, and blog posts to engage in the analysis of literature, discussion of clinical practice, and comparison of research. I think this is the future of professional discussion, and potentially continuing education.

I was able to engage information from a tweet with replies. I read a website post on the PEP and compared it to the abstract I had read through RSS and Google Reader. Then, replied to the tweet with some of my analyses and a link to the systematic review. Lastly, I expanded upon my thoughts and analysis through this blog post. As illustrated, current technological and social media tool are not mutually exclusively. They can be leveraged together to facilitate networking, discussion, and professional growth.

Leveraging Technology Series

  1. RSS and Web2.0
  2. Google Reader
  3. Selection of Reader Content
  4. Blog Reviews
  5. Engagement
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Leveraging Technology V: Beyond RSS to Engagement

This is the 5th in a series of posts investigating how to leverage technology:

  1. RSS and Web2.0
  2. Google Reader
  3. Selection of Content
  4. Blog Reviews

In the previous blog posts I have outlined how information is pushed directly to you via RSS feeds and Web 2.0. I explained how to access information from journals and blogs without searching the net. I even discussed which journals and blogs you may want to follow and why. But, to truly engage, retain, critique, and apply this information to our clinical practices and research we must move beyond just reading. We need to discuss and analyze and integrate….but…

How do we do this when we are sitting by ourselves on a computer? There are a variety of built in tools that we can utilize to accomplish this within Google Reader, in the comments sections of blogs, via Twitter and Facebook. Most of the technology presented in this post series can be linked and utilized simultaneously. All of this from you office, laptop, tablet, or smart phone. In this post, I have bolded words, phrases, or concepts that I think are important throughout this post. This includes the concept of “pushing” information, modifying a tweet, micro-blogging, and discussion via blog comments.

The exact topic of blogs and the discussions stemming from them was recently written about on the CasesBlog: Medical and Health Blog. In the post, Blogging is good for you – and for most people who read blogs it is stated:

The back-and-forth between bloggers resembles the informal chats, in university hallways and coffee rooms, that have always stimulated economic research, argues Paul Krugman, a Nobel-prize winning economist who blogs at the New York Times. But moving the conversation online means that far more people can take part.

The post links to an article from the Economist Website titled Economic Blogs: A less dismal debate. Interestingly, they assert that papers that are blogged about and/or authors who blog may be considered more respected:

Academic papers cited by bloggers are far more likely to be downloaded. Blogging economists are regarded more highly than non-bloggers with the same publishing record.

I wonder if in the future, features such as track back or blog presence will be utilized to calculate a journal’s impact factor or rate researchers and academics.

TWITTER, with it’s 140 character limit for tweets and profile descriptions, is truly a micro-blogging medium. Everyone who is on Twitter is a micro-blogger. It forces succinct communication. Twitter offers a variety of opportunities and ways to access and discuss information. Obviously, you can read the tweets and go to the links that others post. You can reply to tweets to initiate a dialogue. RE-TWEET is when you tweet someone else’s tweet with RT before their twitter handle (name).

Here I re-tweeted @BodyinMind’s link about research and blogging. The link is the article I mention earlier in the post.

Now, you can also tweet a MODIFIED TWEET (MT). Essentially, with an MT you are changing or editing the content or message of a tweet. Below is an original tweet about manual therapy from @DenverDPT regarding manual therapy effects from the 2011 AAOMPT Annual Conference:

Original Tweet
My modifications

I then modified the phrasing and content to deliver a similar, but more specific message based on my understanding of manual therapy. I preceded the tweet with MT to communicate that I had modified an original tweet by Denver Lancaster.

I view FACEBOOK as a personal mini-blog. Links, videos, and articles can be posted with ease. Similar to a blog, friends can comment and discuss. Through pages, individuals can connect on a specific topic, cause, or organization. For example, the American Academy of Orthopaedic Manual Physical Therapists has a Facebook Page: AAOMPT Facebook Page. Beyond networking and professional connection, Facebook is an also a means to access, read, and talk about information.

It is not necessary to have your own BLOG to utilize the medium to discuss and learn. You can utilize BLOG COMMENTS to write your insights and questions. If you disagree with a conclusion you can formulate a more thorough, researched response. Often, I find myself more intrigued and challenged by the discussion that happens in the comments section of a blog post. Especially if you do not publish your own blog, posting well researched and thoughtful comments is essentially blogging! You can have online discussion with links to other blogs, research articles, and online resources with the blog’s author and commentors. Professionals, researchers, and students from across the world can have in-depth, passionate debates at their convenience. Want to stay plugged into a debate? Many blogs offer the option to SUBSCRIBE TO COMMENTS via e-mail or RSS. You will automatically be alerted when a new comment is posted.

After dabbling in blog engagement, you may even desire to publish your own blog. This process is actually quite simple. There are many free resources including Blogger and WordPress. Blogger is Google’s free blog hosting service. A very professional looking blog can be started in an afternoon utilizing free templates and helpful layout designs. As I have mentioned previously, I am disappointed in the lack of blogs surrounding neurologic and acute care physical therapist practice. I remain hopeful that this segment will grow.

PUSHING is an interesting concept in the current social media landscape. All of us has experienced pushing whether we realize it or not. E-mail is a pushing service. Information is pushed to our in-box, and we push information to others. As discussed in previous posts, we utilize Google Reader to have information pushed directly to one location (our RSS Reader). Further, information chosen specifically by our Facebook friends and the tweeps we follow on Twitter is pushed automatically to our news feeds. Conversely, we can push information between our social media accounts through certain applications or linkages. For example, I have a twitter application that allows me to push any tweet to my Facebook account by putting the hashtag (#) FB at the end of my tweet > #fb.

Some pushing and linking features are automatically available. You can “like” an item on Google Reader and then make comments. Then, individuals who follow you on Google Reader can see your comments. Information can be pushed or shared directly from Google Reader to Facebook and Twitter (via the “Send To” button). A post can also be made directly to Google+. There is even a button to e-mail the link!

Most journals are now publishing content and articles online before the print version of the journal is available. E-PUB AHEAD OF PRINT simply means that article was electronically published online ahead of the print version. Journals, including Physical Therapy Journal, even have RSS feeds for E-Pub content. Now, people can blog, comment, Tweet, and Facebook about articles before the print version is published. By the time someone who subscribes to a print journal reads an article, it has probably arlready been shared, critiqued, analyzed, and discussed for weeks to MONTHS.

Interestingly, as widgets and applications evolve the line between various forms of social media and Web2.0 principles becomes more blurred. For example, Twitter feeds and tweets can be seamlessly integrated on the sidebar of a blog. Applications allow for the automatic pushing of tweets to Facebook profiles. And with tools such as HootSuite you can control both from one dashboard. Many Twitter applications allow the scheduling of Tweets into the future, so you do not overload followers with 1,249 tweets in 5.9 seconds. Facebook also allows users to create a badge, or snapshot, to have the sidebar of blogs.

Imagine networks of students, researchers, and clinicians connecting through Google Reader, Twitter, Facebook, and blogs to diseminate and discuss research, blog posts, newspaper articles, and legislation. Imagine the proliferation of professional networking, learning, and discussion. The potential exists for clinicians to collaborate remotely on patient care and research projects. If you have not already, check out PHYSIOPEDIA. Physio-pedia is the model for the future fusion of technology with education, learning, and research.

All of these tools have the ability to elevate our individual knowledge base, care delivery, and research. On a grand scale, it gives us the opportunity to improve professional growth and patient care for all regardless of geographical location. I imagine technology integration and colloboration as the basis for the future of “continuing education” and professional learning…

I envision a future where professionals from across the globe are accessing, disseminating, discussing, critiquing, and even performing research and clinical practice.

In the next post, I will illustrate these principles from a real life scenario. As a preview, I responded to a Tweet that linked to a performance and injury risk reduction program aimed at decreasing ACL injury rate AND improving performance. In that interaction, I utilized and pushed an article via Google Reader to Twitter. I was able to engage in a virtual conversation with a handful of individuals regarding the topic. After I present the interaction, I will discuss and analyze the encounter and research evidence surrounding the specific topic of ACL injury risk reduction and performance improvement.

Posted on

Leveraging Technology IV: Blogs

So, this series has had a long, long hiatus between posts for which I apologize!! Time to start the new year off right. This is another dense post with a ton of resources and links. I hope you enjoy. In the previous post, I presented which research journals publish the most and highest quality clinical trials of interventions. I also discussed what research journals we should consider following. The preceding posts in this series were:

  1. Web 2.0 and RSS
  2. Google Reader
  3. Selection of Content

But, research journals are not the only way for us to engage information relating to clinical practice and scientific research. Blogs are another great online resource. With the advent of Web2.0 principles physical therapists, students, and researchers from around the world can critique research, discuss science, and debate clinical practice through the blog format (And, the micro-blog format such as Twitter, but more on that in the next post!). Disagree with a bloggers interpretation of the evidence? Comment on the post! If utilized civilly and with proper logic blogs (and social media like Facebook and Twitter) are a great platform for learning, discussing, and reviewing. And, as I have mentioned in previous posts with RSS feeds the information is pushed directly to you. Then you decide what to skip, what to skim, what to read, what to push forward through Twitter or Facebook and what to comment on!

There are many blogs relating to physical therapy, rehabilitation, training, science, exercise science, training, and research. I stumble upon new ones all the time. Some of them are great, some are bad, and some are just ugly. Below I am going to review some of the blogs that I follow.

I love the interactive nature of the blog format. You can participate in high level discussions regarding research and clinical practice from anywhere in the world. This type of crowd sourcing has the potential to elevate our knowledge dissemination, discussion, and growth. In fact, the proliferation of blogging and micro-blogging will (I believe) fundamentally change not only how information is disseminated, but how we learn, discuss, and collaborate on clinical care and research.

For each blog, I have included the title/subtitle hyperlinked to the actual blog as well as the author(s) twitter handle with a hyperlink to their twitter profile. Please comment on your thoughts of these blogs.

What blogs do you follow? Let us know in the comments section! Speaking of, follow @PTThinkTank as well as all the authors, including the creator @EricRobertson and humble contributors @MPascoe and @Dr_Ridge_DPT


I have to start off with some student blogs. As a student this is how I became exposed to and involved with leveraging technology!

AAOMPT sSIG: Blog of the Student Special Interest Group of AAOMPT

The AAOMPT sSIG Blog is where I got my start blogging about such issues as the doctor of physical therapy degree, direct access, physician owned physical therapy services, and grass roots political advocacy. The blog provides information on the happenings of the student special interest group. If you are a student, or know a student, send them to the blog for more information on getting involved in the sSIG. It is a great group of motivated, high energy students. Unfortunately, the AAOMPT sSIG is not on twitter, but you can e-mail the students directly with comments, suggestions, and questions: ssigaaompt@gmail.com

Colorado Student Physical Therapy Advocacy: Act now to protect the future of your profession

Author: @COSPTAdvocacy

I may biased since these students are from my Alma Matter, but these students are truly organized and accomplished. Not only did they WIN the APTA’s Student Advocacy Challenge they are leveraging technology through Blogger, Twitter, and Facebook to create a sustainable and visible student movement.

Below are some of the blogs that I regularly read and definitely have in my RSS Feed. Most of them deal directly with physical therapist practice, and are authored by physical therapists. Others are authored by other professionals, but still very applicable to physical therapy. Enjoy!

Better Movement: Learn to Move with More Skill and Less Pain

Author: @ToddHargrove

Todd is a Seattle based Feldenkrais Method movement instructor who used to be a lawyer. He writes about a neurocentric approach to movement, training, and pain. In Both Sides Now, he discusses research investigating the training, or treating, one side of the body and the effect on the contralateral side.

Body In Mind: Research into the role of the brain in chronic pain

Authors: @bodyinmind @NeilOConnell

This is the blog of Lorimer Mosely and crew out of Australia. They provide research summaries and discussions regarding the mechanisms of pain and the treatment of chronic. Probably one of the most robost blogs on the net regarding pain physiology and current research. Why Things Hurt is an outstanding Tedx video by Lorimer Moseley on the neurophysiology of pain. They even discuss if Chronic Pain is a Disease.

Categories: Pain Science, Chronic Pain, Neuroscience, Physiology, Research

Leaps and Bounds: Perspectives from a physical therapist

Author: @ForwardMotionPT

Corey provides unique insight into physical therapist practice, and is obviously a very deep thinker. He has produced many videos illustrating the use of novel movements of various body regions. Here is a great post about The Movement Diet.

HealthSkills: Skills for health living for health professionals working in chronic pain management

Author: @adiemusfree

Healthskills is a blog for health providers who want to read about research related to self managing chronic pain. Topics include chronic behavior therapy, measuring outcomes, patient education, and many other topics. The author was originally trained as an occupational therapist. In this post, she discusses what to do when a patient is “inconsistent” with their pain behavior or presentation.

Categories: Pain, Chronic Pain, Cognitive Behavior, Clinical Treatment of Pain

The Manual Therapist: Promoting the highest level of physical therapy practice

Author: @The_OMPT

Dr. E posts very regular providing links to other blogs (including this one, thank you!), videos on techniques he uses, clinical cases, and clinical reasoning. He has a very expansive background being both a fellow of AAOMPT and MDT diplomat. See the post What is the Mechanism Behind Rapid Change? for a discussion we had regarding mechanisms of manual therapy. (Here is the comments section)

Mike Reinold: Rehab | Sports Medicine | Performance

Author: @mikereinoldblog

The most up to date information related to evaluation and treatment of athletes, specifically overhead athletes. Good citation of clinical research for evaluation and exercise treatment. Lots of links to different courses/products. Mike is the head of athletic training for the Boston Red Sox, and is well published on issues regarding the shoulder and injuries in throwers. In the post Rotator Cuff Fatigue Increases Superior Humeral Head Migration, Mike discusses the importance of not training the cuff to fatigue.

Categories: Athletes, Shoulder, Knee, Sports, Orthopaedics

Move It: The New Professional’s Collaboration Blog

A group of young physical therapists (<5 years experience) discuss clinical practice, clinical development, and issues regarding being a new professional. It has been a while between posts, but they have some excellent content. Check out A Generation with Challenges, Vision, and Debt.

Categories: Young Professionals, Professional Development, Legislative Advocacy, Professional Issues

My Physical Therapy Space: Evidence in Motion Blog

Authors: @EIMTeam

The blog of the Evidence of Motion crew. Great information regarding private practice, legislative issues, and research pertaining to orthopaedics. Discussions regarding the overuse of imaging and surgery, as well as the how physical therapists can provide value to society and healthcare. In a Blast from the Past, John Childs illustrates how some clinicians and researchers cling to old models of pain and treatment despite evidence to the contrary. Tim Flynn discusses how access to early, cheap care (physical therapists!) for low back pain is Not Rocket Science, and could have HUGE implications for our society. Larry Benz deconstructs poor logic about Physician Owned Physical Therapy Services (POPTS) that appeared in Advance Magazine.

Categories: Professional Issues, Private Practice, Orthopaedics, Research, Professional Development

The Sports Physiotherapist: Resource for physiotherapists (or physical therapists) with a passion for assessing, diagnosing, and rehabilitating the sports injuries of the world’s athletes

Author: @TheSportsPT

Extremely well cited articles discussing the evaluation, assessment, and treatment of athletes including surgical approaches and their implications on rehabilitation. Their blog and website is maybe the most comprehensive sports physical therapy resource on the net. In this post, they review the diagnostic accuracy of tests used to identify Acetabular Labral Tears of the Hip.

Categories: Sports, Athletes, Research, Examination

Physical Therapy Diagnosis: Make Decisions Like Doctors

Author: @timrichpt

Private practice owner in Florida discusses clinical decision making as well as leveraging decision support tools/software. Lots of discussion of Medicare flaws, clinical decision making, and issues in private practice. Tim recently authored a book detailing bullet proof decision making processes to improve documentation and efficiency in outpatient practices. Tim presents The Art and Science of Physical Therapy by analyzing the Oxford Debate from the American Physical Therapy Association’s Annual Conference in 2011

Categories: Private Practice, Legislative Issues, Clinical Decision Making, Outpatient

Save Yourself: Science powered advice about your stubborn aches, pains, and injuries

Author: @painfultweets

A massage therapist by training who turned to science focused blogging regarding painful problems. Skeptical analysis of pain, pain syndromes, and treatment techniques. Great information for patients and practitioners alike. Although I very much respect Paul’s work and critiques, there is a very apparent bias towards trigger points as a significant pain complaint and treatment target. Paul talks about MRI Overuse and how MRI is too sensitive of a diagnostic tool. He also does a nice job of summarizing some of the Science Surrounding Stretching.

Categories: Pain, Chronic Pain, Manual Therapy, Science

SomaSimple: The so simple body. A place for physical & manual therapy.

@SomaSimple Contributors: @jasonsilvernail @dfjpt @BarrettDorko @wrtrohio @JohnWarePT @ForwardMotionPT among others

You will not find a more thorough or logical analysis of manual therapy, physical therapy, and their relation to people with painful problems anywhere. The folks over there are true skeptics in their thought process, and challenge all. Be ready to be challenged, even if all you do is read the forums! This site is such a density of information and discussion you could read for months. Whether you troll or join in on the discussion it will deepen your analysis and understanding of pain, pain physiology, and clinical practice. Enough is Enough is a well written piece by Jason Silvernail talking about how we need to stop looking for the magical technique or tissue and focus on deeper models of understanding pain. In Crossing the Chasm, he absolutely shines in his ability to tie current clinical research to a deeper, neurophysiologic understanding of pain as he describes his process of evaluation and treatment utilizing sub-grouping in low back pain.

Categories: Pain, Neuroscience, Discussion Board, Manual Therapy

The blogs above are more specific to physical therapy principles. But, it also useful to engage information from other disciplines or sources. For example, decision making, principles of science, behavior, and psychology are all integral parts of physical therapy practice. These topics relate to how we treat patients, but maybe more importantly how we make decisions and analyze/integrate literature.

Science Based Medicine: Exploring issues and controversies in the relationship between science and medicine

I believe this is a must read blog for all health care professionals. It discusses the application of scientific principles to improve evidence based practice. These principles include prior plausibility, physiologic plausibility, and an increased focus on the integration of basic science into the understanding and practice of medicine. Although, much of it is not related directly to physical therapy, the lessons and principles discussed are applicable to research interpretation and clinical practice of all health care professions. In fact, physical therapists receive a mention in the post Subluxation Theory: A Belief System that Continues to Define the Practice of Chiropractic.

Check out these posts:

  1. About Science Based Medicine
  2. Announcing Science Based Medicine Blog
  3. Does Evidence Based Medicine Undervalue Basic Science and Overvalue Randomized Control Trials?
  4. Is it a Good Idea to test Highly Implausible Health Claims?

Eric Cressey: Performance and health on a whole new level

A personal trainer with a masters degrees in kinesiology with a highly successful persontal training facility targeted towards baseball players. Collaborates with Mike Reinold. Although targeted for personal trainers and fitness specialists, he provides amazing information on training athletes that is very applicable to physical therapists.

Very detailed information about the training of high level athletes especially baseball players. Eric exhibits in depth understanding of kinesiology, training, and anatomy specifically as it relates to baseball players and overhead athletes. Although, he does seem to have a poor understanding to mechanisms and effects of manual therapy and at times “plays doctor” in regards to client’s pain complaints. In How Much Rotator Cuff Work is Too Much? Eric discusses the implications of training the rotator cuff in throwing athletes both in season and during the off season. He highlights the fact that many throwers overuse their cuff musculature.

Categories: Sports Training, Baseball, Shoulder


  1. Do you read any of the blogs above? If so, what is your critique?
  2. Did we miss a good resource? Please comment and enlighten us!
  3. Do you have a blog? Comment with a link and a brief summary!

Unfortunately, there seems to be a lack of physical therapist focused blogs relating to in-patient acute care, neurologic physical therapy, and in-patient rehabilitation (hint, hint, any takers??). Most focus on outpatient, orthopaedics, sports, and private practice.

I hope you have enjoyed the leveraging technology series thus far! We have covered a ton of information as these posts are are very dense. The next post will discuss the use of social media tools including Twitter, Facebook, and Blog comments to move beyond RSS into active sharing, discussion, and engagement of information! Remember, we always value your feedback and comments.

@Dr_Ridge_DPT