NCPTA

North Carolina Physical Therapy Association

Review of APTA’s new vision statement

This is a guest blog written by Paul Weiss, PT, Dip MDT.  Thanks Paul and I look forward to some discussion to follow.

The APTA’s New Vision Statement

In their 2013 meeting, the House of Delegates of the American Physical Therapy Association (APTA) adopted a new vision statement. It is:

“Transforming Society by Optimizing Movement to Improve the Human Experience”

I, for one, am not always a big fan of such platitudes. However, this one resonates with me. I’m writing to tell you why.

This is what we do. Let’s look at it by breaking the statement down into three key phrases.

“Transforming Society…” Physical therapists work with individual people. How can working with an individual transform a society?

The changes we make in the life of a single person have ripple effects.

Take for example the injured worker who is no longer disabled and can return to their job. By empowering that person to remain gainfully employed, that person’s family benefits. The employer benefits. The insurance company benefits.

On a larger scale, physical therapists decrease the overall cost of health care. Here are two examples.

We decrease the need for more expensive treatments. Many common injuries that are thought to require expensive imaging and surgery can be successfully managed by physical therapy.

We decrease the risk for falling in the elderly population. Falls in the elderly often lead to serious and potentially fatal injuries. In fact, most elderly people that I see for low back pain also have poor balance, a risk factor for falls. In many cases I find that improving upon their balance leads to a decrease in back pain.

“…by Optimizing Movement…”  Most people who present to my practice do so because they are in pain. Pain and movement are inextricably linked. I often hear statements like: “It hurts to turn my head to look over my shoulder”, and “It hurts to bend to tie my shoe”. I find success not by trying to fix someone’s pain, but rather by helping them to move better. When someone becomes capable of turning their head or bending to touch their toes, invariably they find that the pain they once had is better. I often sum this up as “move better, feel better”.

“…to Improve the Human Experience.”  When someone moves better and returns to their normal role in society, they don’t just feel better physically. They feel better emotionally. Physical therapists alleviate the fear of pain with movement, fears of falling, and fears of reinjury. Being in pain can be depressing. By getting someone to move better, pain can be lessened and moods can be improved!

I applaud the House of Delegates for adopting this vision statement for our profession. It represents what we do. And I take great pride in what we do.

Paul Weiss, PT, Dip MDT owns and operates Cedar Hill Physical Therapy. While within the town limits of Summerfield, NC his office has a Greensboro mailing address. Paul is married to Angela Cook, and has two dogs. Sadie is a Flat-Coated Retriever, and Cooper is a hound dog mix. As his practice is based in his home, his family helps him by welcoming patients.

Visit us at www.cedarhillpt.com

Paul is also an avid nature photographer. You can view his photographs at:

www.facebook.com/PaulWeissNaturePhotography

Graded Motor Imagery

I had the opportunity to attend the International Federation of Orthopedic Manual Therapy’s (IFOMPT) 2012 conference the other week.  It was an excellent conference well attended by over 1500 physical therapists (and physiotherapists) from around the world.  The topics were vast and there were many breakouts addressing orthopedic and manipulative physical therapy.

One of the speakers I had the privilege of listening to and speaking with is David Butler about neuroplasticity and graded motor imagery (GMI) to treat those with pain complaints.  This month I would like to introduce the topic of GMI to those not familiar or who just have a touch of what is this mirror box thing.  Please go to the Neuro Orthopaedic Institute for more specific explanation or for course information.  You can also access more information on GMI at http://bodyinmind.org/ as well as links to more articles.

First off GMI is a process of treatment and not just a series of techniques.  The concepts behind GMI relate to neuroplasticity and per Butler the term broadly means that the rehabilitation is focused on graded synaptic exercise.

So let us look at the GMI process.  For the purpose of this blog post I will skip the pain neuroscience and discussion of the neuromatrix paradigm developed by Ronald Melzack.  This is important background information which I plan on addressing at a later time.  I will start with a definition of pain from the IASP: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.  Moseley has another definition which includes the neuromatrix: Pain is a multiple system output activated by an individual specific pain neurosignature; the neurosignature s activated whenever the brain concludes that the body tissues are in danger and action is required

GMI is broadly divided into 3 components to be integrated (as appropriate) and graded exposure based on response into an overall rehabilitation program, it is not a stand alone treatment.  The 3 components are:

1)    Laterality Reconstruction

2)    Explicit motor imagery

3)    Mirror therapy

Let us discuss further.  So what is laterality?  Essentially it is the ability to determine left from right.  There is research that shows persons with CRPS take longer to identify the affected side when shown pictures of the body part.  This has been shown to improve with training.  It is not known exactly why this occurs, but there is suspect of neuroplastic changes due to pain and avoiding the painful part.  You can assess your own laterality by going to the NOI site and using their Recognise site (there is a free 5 time trial).  There are also applications for tablets which allow you to test, record, and train laterality.

The second phase is explicit motor imagery, which is essentially a cognitive process of imagined posturing or moving your own body part without actually moving it.  Have you ever had the patient who says “it hurts to think about moving” or have you ever felt a true physical discomfort watching someone do something that appears quite painful.  Watch any room full of men react after someone gets hit below the belt.  How many cringe and flex at the hips.  They can feel a sense of pain even though there is no tissue damage to the individual.  This second part expands upon laterality and uses imagined movements to start training the brain that these positions are not threatening to the individual.  Thus trying to minimize the output response of pain.  Moseley looked at imagined motion and found increased swelling and pain from imagined movements in the CRPS population.

Thirdly we advance into the mirror box therapy.  Here we place the involved extremity behind a mirror.  With our “well” extremity we start moving, with the involved at ease.  Activity gradually progresses to more complex motions and then to the hand behind the mirror starting to move.  If you are not familiar with any mirror work try it yourself.  Watch your hand in the mirror (the reflection) move, while keeping your hidden hand still.  Spend a few minutes and see what you start to feel.  Do you gain “ownership” of the reflected hand?  Follow this link to see the rubber hand illusion in effect.  You can also learn more about use of a mirror box in amputees based off the work of V.S. Ramachandran.

Now there is a process with GMI and it is not a therapy intended to treat or fix everything.  It is a treatment process we can utilize.  I have included a few references imbedded in the text above (as many to full text as I can get) which go further into this process and show the early positive effects of incorporating GMI into practice.  Much of the early research deals with CRPS and painful phantom limb, however there is still some work being done looking at persisting pain complains in the extremities, and there are some pending trials looking at facial pain.  It is still too early to put all our eggs in this basket, but it appears promising from a pain sciences perspective.

So I pose a few questions to you.  Have you heard of GMI?  Have you used GMI or any of the subcomponents of it?  Is the concept of treating the brain and trying to alter neuroplastic changes new to you or seem unreasonable?  Please let me know what you think and why.  Look forward to discussing this more with you.

Mike Hoy, PT, DPT

Olympic Spirit

Olympic fever has hit many of us.  I have been spending my evenings and weekends watching athletes at the top of their sport compete in this international event.  As I spend my time watching these amazing athletes one thing really stands out to me…Kinesio tape.

It seems everyone is getting taped these days.  Shoulders, backs, knees, and abdominals are all taped, to name a few regions.  Oh the pretty colors and the way they get taped up, it looks so artistic.

So does the tape do anything?  I took the Kinesio tape class back in 2004 and I do use it in clinic.   There is much for anecdotes, but we know that anecdotes do not make up research, and the plural of anecdote is not data.  I have been reading articles on the internet and there seems to be some question as to if it works or how it works.  So what does the research say?

This month in the Journal of Orthopaedic and Sports Physical Therapy Link to abstract  (how timely) there is an article comparing Kinesio tape application vs. cervical thrust manipulation for patients with mechanical neck pain.  This was a relatively large trial of 80 patients comparing only the 2 interventions provided.  So what were the results…

“Patients with mechanical neck pain who received cervical thrust manipulation or Kinesio Taping exhibited similar reductions in neck pain intensity and disability and similar changes in active cervical range of motion, except for rotation” and “Changes in cervical range of motion were small and not clinically meaningful”. 

This is just a sample from the article, please read full text for more in-depth results as well as strengths and weaknesses of the study.   This was an outcomes oriented study and in no way is able to determine the mechanism of action of the treatments.  Overall seems that there may be some benefit to the tape in this patient population.  If anything the abstract for the article sells.

So I would like to ask a few questions for discussion.

1)    Do you use any form of “kinesiology” taping?

2)    By what mechanisms do you think the tape helps the patient?  Is the color special?  Can you actually support a structure? Placebo? Some other mechanism?

3)    Do you have any research that you utilize to support your use of Kinesio tape?  If so please provide a link to the article.  Do you have any discussion in regards to the JOSPT article?

I look forward to your input and discussion.  And I would like to give a big congratulations to all of our athletes representing us in London.

Mike Hoy, PT, DPT

Early Access to Physical Therapy

Physical therapists play an important role in the management of low back pain.  The usual path to physical therapy can be a bit twisted with delays along the way.  Typically the patient may have multiple physician visits, medication, radiographic diagnostics, and interventional procedures.  Physical therapy may be referred to at any time during this process.  So my question is, “when is the best time to refer to (or access) physical therapy”?

Recently Fritz et. al. (pubmed link) have published new findings on this.  It is still in a publish before print format in the journal Spine.  What did they find?  Well it may be no surprise to physical therapists that treat low back pain, but they concluded “Early physical therapy following a new primary care consultation was associated with reduced risk of subsequent healthcare compared with delayed physical therapy”.  This was a study of over 32,000 patients.  Early physical therapy was categorized as less than 14 days.  Early physical therapy resulted in lower costs for the care of low back pain including decreased need for multiple physician visits, advanced imaging, injections, and surgery as compared to delayed access to a physical therapist.

I am talking costs here, but the lower costs are related to patient improvements and functional gains.

These findings seem to follow the 2006 Virginia-Mason Medical Center (link) study with Aetna and Starbucks.   They found that early referral to physical therapy (see image) for low back pain resulted in earlier return to work and lower costs.  In their study time they found that patients with a back injury could be seen in about a day.  Only 6% of patients needed to take time off of work.

This article in USA today (link) looked at Intel’s plan of getting patients into PT within 48 hours.  So what happened?  Well treatment time went from an average of 52 days to 19 days, costs of care dropped 10-30%, and there was higher satisfaction and quicker return to work.

It seems that access to what we do can help greatly.  As physical therapists we are educated in screening for red flags and are trained to refer out when the condition is beyond our scope of practice or required further diagnosis.  In North Carolina we do have direct access to provide patient care.  So how good are we at getting patients this early access?  How soon do you see your low back patients?  Do you get this information to your referral sources?

I would like to hear what you think.  

Mike Hoy, PT, DPT

Mentoring in Physical Therapy

‘‘People seldom improve when they have no model but themselves to copy.’’

                                      Goldwin Smith, 19th Century educator and historian.

I would like to open this blog the topic of mentoring.  I hope that this blog can be a way for physical therapists to interact and learn from each other.  I happen to be in a manual therapy fellowship program.  Requirements of fellowship (and residency) programs include one on one mentoring and training.

Recently I have been involved in my mentoring hours.  I have to express gratitude for those who are opening up their clinics and their minds to me.  Even with my 17 years of experience as a licensed physical therapist I am amazed at what I can learn by interacting with my peers and engaging in this type of relationship.

So what is mentoring?  Mentoring is most often defined as a professional relationship in which an experienced person (the mentor) assists another (the mentee) in developing specific skills and knowledge that will enhance the less-experienced person’s professional and personal growth.  Teaching and coaching are not mentoring, but mentors can teach and coach. 

As physical therapists and physical therapist assistants we have all taken weekend courses.  How do we truly integrate this information and be sure that what we are using is in fact the most appropriate way?

I would like to hear what you have to say on the topic.  Have you been mentored? and how was your experience?  Is it worthwhile to be mentored?  Is it worthwhile to be a mentor?  Can you be mentored by a person who has been a therapist many years less than you?  I hope someday we can have a strong mentoring program through the NCPTA to advance our practice and provide the best care to our patients.

Looking forward to what you have to say.

Mike Hoy, PT, DPT

 

Godges JJ.  Mentorship in Physical Therapy Practice. Orthop Sports Phys Ther, Vol 34, No 1.  January 2004

http://www.apta.org/CareerManagement/Mentoring/

http://www.management-mentors.com/resources/corporate-mentoring-programs-faqs/#Q1

Welcome

We would like to welcome you to the new blog site for the NCPTA.  We are under a little construcion now, but check back soon. 

In the meantime enjoy this video:

There are no scraps of men

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