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Tuesday, February 7, 2012

The "Top 11" Mistakes Physical Therapists Make... In my opinion...

I will probably ruffle some feathers with this blog- but that is my exact intent...  You may agree with some and you may disagree with some.  Please feel free to open up a discussion with me, that's the point.

I'm taking a page from the book by Jon Goodman of the Personal Training Development Center who recently finished the Free E-Book Titled "101 Personal Trainer Mistakes-- and the solutions to each".

I have been cruising around the web reading blogs, articles, websites, face book pages and everything else possible and I have noticed one common trend.  I am seeing the Fitness world really pushing hard to "better themselves" and learn from each other.  By learning from each others mistakes (and our own) we will only become better at what we do.  I came up with the idea to list what I think the 11 most common mistakes Physical Therapist's make on a daily basis and how to resolve them.  Here we go from 11 to 1!

11.  Inconsistent Re-Evaluations...
   Re-evaluations every 30 days or 10-12 visits is essential to developing proper Physical Therapy routines for patients.  If we are doing a good job, the patient should be progressing consistently and we need to see where their "new baselines are.  In all actuality, we should be reassessing every visit the person comes in for.  Everything manual technique, every movement should be used as a way to evaluate and determine progress.

10. No reasoning for developing certain exercises in a patients program...
   When I have students I tell them one simple thing:  I do not care what exactly you do with your patient (to a certain extent) but have a REASON for what you are doing.  Physical Therapy is NOT cookbook so create a program for the patient sitting in front of you!

9. Have the blinders on to other professions...
   I believe in chiropractic care, I believe in accupuncture, I believe in strength and conditioning, I believe in anything that works.  PT's have a tendency sometimes to only believe in what they do.  If you do not have a Strength and Conditioning background, don't pretend to be a strength coach.  Working together with other professions will only make you better as a practitioner and it will only help your patients get better faster and more effectively!

8. PT's tend to call themselves "Mulligan" Therapists, "Mckenzie" Therapists, "Maitland", etc...  Using tools and not the Tool box...
   This bothers me a a lot.  Be your OWN therapist.  Yes we must learn from others but there are pros and cons to each tool we use.  A GREAT therapist knows how to use the tools to work with each specific patient.  A GREAT therapist also never stops learning and never stops putting another tool into their box.

7. Utilization of Modalities for time killers or because it can be billed for...
  Do I even need to explain this one.  If you know me; you know I hate utilizing modalities such as E-Stim and Ultrasound.  If I need to explain this one to you then you probably fall into a lot of these categories i'm discussing.  There is a time and place for Electrical Stim but US; i'll battle anyone on this. Steel cage death match anyone?

6. A lack of understanding on how to market and build relationships...
   This baffles me?  PT's build relationships with patients everyday but for some reason have a hard time talking to physicians or other health care providers.  Have confidence in your knowledge and your skills.  Chances are they will respect you more if you have confidence and can be clear and concise.

5. Not having the "cojones" to either question a possible improper diagnosis or make their own diagnosis...
   If you think something wasn diagnosed wrong- make sure you approach the appropriate person.  Be ready to back your belief with solid data, but if you feel strongly, do not hold back.  But make sure you are respectful.  PT's (in most states) are allowed direct access and that means we are an entry point into the healthcare system.  Making a proper diagnosis from the start, needless to say, is fairly important.  Now the fun part begins-  you have made the diagnosis, but now you get to figure out WHY!

4. Are just content with being "good" and not "great"...
   Do something great, be something great and don't settle for just good.  Constantly learn, absorb, be mentored, mentor and teach others.  This will set you apart from the pack.  If you want to "just be good", you will never get ahead and you are not doing right by your patients.  Strive to be the best and nothing less.

3. Not listening to the Patient sitting right in front of you...
   The history is the single most important part of patient care.  Take a proper history, listen to patient and you will gather more information than you could ever imagine.  The history will lead your evaluation and will set you up for success.  Patients also crave this.  So give them what they want!

2. Not educating patients on the "why"...
  This really can be 1B.  Just giving someone an exercise is not good enough...  Just doing a mobilization is not good enough...  Just doing post-op rehab is not good enough...  You need to give the why component to the patient.  Explaining why someone is not allowed to do X after a Cuff Repair or why open chain knee extension is the Single. Worst. Exercise. Ever.  Just telling someone is not enough; you must educate them on the why.  If you do this simple task, they will trust you more, listen to you more and get better faster.  Isn't that what we want?

And #1....  Drum Roll please..........

1.  Go straight to the site of pain...  To take a phrase from a friend and colleague, Perry Nickelston: "Stop Chasing Pain"!...
   Man has he this nailed on the head.  Simply speaking just because someone has knee pain, doesn't mean the problem is coming from the knee.  By understanding human movement and how the body functions you can pick out and find the Non-Painful Movement Dysfunction that's causing the Painful Dysfunction.  It's as simple as that.  Systematically assess human movement and assess the patient- I promise you will find things that will blow you away and will blow your patient away.  In other words:  Treat the Problem and not the symptoms.  You also must be able to explain to the patient why a sprained ankle 3 months ago is the reason for their neck pain.  You have to get it first before the patient gets it.  If you can answer this question, then you are on the right path.  "Why would a rigid great toe with decreased extension on the lead leg of a pitcher lead to medial elbow pain in the throwing arm?"

Saturday, January 21, 2012

A Rant on what Physical Therapy REALLY is...

So, why am I writing this post?  I'm writing it because I want to help get more information out to the world about what Physical Therapy REALLY is.  There are thoughts, beliefs, ideas and misconceptions about what we do as clinicians and where are value lies.  Now for the purposes of this post- I am talking about Outpatient Orthopedic Physical Therapy and not other settings.


Let's start this off with some history behind why i'm writing this with some commonly asked questions:

Question: Why are you not using that magic gel stuff with the Ultrasound machine...
Answer:  I personally have not used Ultrasound in 5 years.  I do not see enough clinical evidence that proves to me it's effectiveness.  I would much rather spend an extra 5 minutes using my hands to manipulate tissue, facilitate movements, etc. 

Question:  Did you have to go to school for this...
Answer:  (I try not to get annoyed when asked this)  Yes, I have my clinical doctorate in Physical Therapy and as well had extensive clinical externships.  PT's go through 7+ years of school routinely and we are Board Certified.

Question: Can you put that stimulation thing with some heat on me to get warmed up and make things feel better...
Answer:  Lets get on the bike (or arm bike) to get warmed up and doing things that are movement based.  While yes, the Electric Stimulation feels good while it's on, it is not fixing your issue; it is just masking your pain.  Let's figure out WHY you have pain and solve that issue.

Question:  Why are you working on my neck and mid back when my pain is in my hand...
Answer:  I'm fixing the source of the problem.  You have "X" problems with mobility in a different area which causes compensation and causes pain where you have it...

Question:  My doctor gave me a shot of cortisone and I now feel better- why do I have to continue PT? OR My doctor gave me a shot of cortisone and I feel great. I wish PT would have helped more...
Answer:  Well, you are continuing PT because the biomechanical problems are still present and we need to fix that so the pain does not come back.  The cortisone took care of the inflammation, now we are fixing the root cause.  OR...  Physical Therapy did help, we fixed the mechanical issues first, you got some cortisone to reduce inflammation and now we can fix some of the higher level movement patterns and you should not have this issue re-surface (as long as the patient listens to instructions)

Those are just some of the questions I get asked quite regularly and while it bothers me, i do realize that there is a common misconception out there in regards to what our profession really is.  Here is my opinion on what a Physical Therapist is:

1- PT's are Anatomy and Biomechanical specialists that focus on movement disorders.  We assess, analyze and treat movement disorders that will help someone reduce pain and return to function.

2- PT's are trained clinicians that can diagnose orthopedic conditions and differentially figure out WHY the injury happened in the first place.  Example- You had a Rotator Cuff repair.  We do the rehab, get you better and figure out WHY it happeend in the first place.

3- PT's understand the body's ability heal, tissue response to variable factors and we get how the body compensates for an injury.  Example- An ankle sprain can cause neck problems simply due to the way gait changes.

4- We are Post-Operative Rehabilitation specialists-  We take the patient through SAFE and effective rehab programs after surgery to improve function without causing harm to the repair tissue.  We dictate to the patient what they can and cannot do and what will happen if they do not listen.  We see the patient multiple times a week and educate constantly.

5- We are relationship driven.  We develope relationships with patients, doctors, trainers, chiropractors, case managers, insurance companies, families, etc.  We make these relationships and gain trust, which in turn will improve outcomes.

6- We work as part of a team!  Teamwork is critical to patient care.  I think that point explains itself.

You can agree with what I am writing or you can disagree but one thing i promise you is that if you are a patient with "injury X" and you go to Physical Therapy where they see too many patients, Electric Stim and Ultrasound everyone and do not individualize your care, you are setting yourself up for failure.

I had a close friend of mine who is a well known Trainer and Performance Specialist say to me, "Because of you and (another PT) I now have a much better understanding of what PT really is.  Before you two, I honestly did not know and had a huge misconception"

Please do not get me wrong- There are thousands and thousands of GREAT PT's out there across the world.  The problem is that there are still lots out there that do not get "get it".  The more we educate clincians and the more we educate the general population, the better it will get.  That is my mission- To educate on what Physical Therapy REALLY is and to make a difference in the lives of others.

Hippocrates and Galenus are believed to have been the first practitioners of physical therapy as they created and advocated for manual techniques, exercise and aqua therapy to treat people in 460 B.C.  They GOT IT.  They treated people with their hands and with their knowledge on movement and the human body.  Now we look at people like Gray Cook, Gary Gray, Tim Tyler, Terry Malone, Christopher Power, Shirlie Sahrmann, Mike Voight etc...  They all GET IT.  They are at the forefront of taking Physical Therapy to the next level and educating people across the globe.

I encourage patients to ask their PT's questions such as: Why am I doing this particular exercise?  Why are you working on that area?  What is the reason for my having this issue in the first place?  If the clinician cannot give you a good concise answer, you are probably in the wrong place.  There should be an answer to all of those questions and it should make sense.

And that concludes my rant on what Physical Therapy REALLY is.  Is there more I can say, yes, but you get the jist.  This is how i function on a daily basis with any patient who walks through my door-  Evaluate, assess, educate and treat the person that is right there in front of you.  Decide what needs to be done based on the information right in front of your face.  Treat them with respect, have fun and when all is said and done, you have gained their trust for life and probably made a new friend.  Isn't that what it's all about?  Helping people and making friends?

Monday, January 16, 2012

Flexor Hallicus Longus and Plantar Fasciitis...

Do you have plantar fasciitis?  Do you have a patient or a client who has plantar fasciitis?  Does the fasciitis keep coming back time after time?  If you answered yes to any of these questions you will find this post extremely helpful.

Ok, so you have properly diagnosed that patient X has Plantar Fasciitis (PF for the purpose of this post).  Winner Winner chicken dinner!  What does this diagnosis tell you other than their plantar fascia is inflammed?  Not much...  We need to figure out WHY they have developed the PF in the first place.

Here are some thoughts/suggestions/ideas.  The only one below that you must do first, is #1 (in my opinion)

Step 1- Look at their gait and watch them MOVE.  You WILL find some faulty movement patterns that are leading to the increased stress on the planar surface of the foot...

Step 2- Look at their Gastroc/Solues Complex for facilitated muscles and restricted fascia (This should not be rocket science)

Step 3- Look at the distal tib-fib joint.  If this is restricted and leading to decreased dorsiflexion, something has to compensate and usually the PF will become irritated

Step 4- Flexor Hallicus Longus!  This is a major key to treating PF.  With PF, the FHL will almost always become facilitated and we cannot cure the PF without releasing the FHL.  Rememembet that the FHL Originates at the Posterior surface of the distal 2/3 of the fibula and as well the interosseous membrane and associated fascia.  FHL inserts at the base of the distal phalanx on the plantar surface of the great toe.  Bascially the tendon of the FHL travels directly along side of the plantar fascia, which can and will directly alter the mechanics of the PF.  Don't forget to treat the FHL both where it travels posterior to the medial malleolus AND where it travels parallel to the PF.

Step 5- Go look at the knee and go look at the hip.  Take a look at their glutes first...  Do we have a weakness of gluteus medius causing a trendelunberg gait?  Is this gait abnormality causing extra stress on the PF?  Bingo, yes it is...  Do we have a restricted iliopsoas?  Is this restreicted iliopsoas?  A restricted iliopsoas migh now cause the hip to slightly internally rotate which will change the mechanics of the lower extremity and possibly increase pronation of the foot. (And thats just scratching the surface)

Step 5- Based on your movement pattern assessments- treat and fix the dysfunctional movement patterns.

Treat the mobility issues manually with your tool box and make sure once you have fixed the mobility issues you fix the stability issues.  Use the KISS principle (Keep It Simple Stupid).  Make sure you start simple and dont progress until they are ready.  Fix the core, fix the foundation and then move to the more complicated patterns.  And dont forget to treat in ALL planes of motion:  Frontal, Sagittal and Transverse Planes.

And that's my two cents on Plantar Fasciitis...  Remember, figure out WHY it's there in the first place.  If you just treat the foot, the issue will return. Promised.

Sunday, January 15, 2012

Welcome!

Welcome to Game On Physical Therapy:  When function meets medicine...

My goal with this blog is to keep you up to date with the wide wonderful world of medicine and relating it back to human function.  Movement and function are 2 of the keys we need that opens doors to a healthy, happy and successful lifesyle.

My specialty is Sports Medicine rehabilitation and specifically Post-Operative Rehab of the Shoulder and Elbow.  I'll be discussing with you common shoulder pathologies and why they happen in the first place.  You will learn how an Ankle sprain can cause shoulder impingement and you will also learn why I tight hip flexor can cause elbow injuries in a thrower.

I hope you all enjoy!