So this happened today:
1mo ago, Reagan came to us w/ a Dx of CRPS and hadn’t put weight on her R foot in over a month.
Yesterday she made her cheerleading team.
Today, she graduated PT. I promised I would do a choreographed cheer with her.
So for your viewing pleasure 🙃😅
I’m tired of hearing about patients who come in to rehab with complaints of shoulder pain when they reach there arm overhead.
Then proceed to pull on bands below 90° flexion 3x/week for 8 weeks.
So here’s 6 of my favorite exercises to help improve OH strength:
My student has been struggling a bit w/ confidence in his exercise prescription/selection.
So I made him a very simplified flow chart.
And now I’m posting it on Twitter cause I think it’s important to remember to not get too “cute” with rehab and remember the basics 💪🏼
Forcing my student to leave clinical (against his insistence) an hour early so he can go watch his kids Trick or Treat.
Because there’s far more value in being there with his family than he could gain in that extra hour.
And that should be the norm. Not the exception.
About 2 years ago, I got COVID and utilized my quarantine time to try and develop an ACLR protocol thanks to everything I’ve learned here on Twitter.
I’ve continually updated it over the past 2yrs to the best of my ability.
Here’s where it stands now.
Science: People who are runners have better cartilage health than people who are sedentary.
Healthcare: You have pain in your knees when you run? Oh no! Never run again or you’ll continue to do irrevocable damage to your cartilage. Swim.
Public: Running is bad for knees.
Me:
Also, I think a huge compliment needs to be given to Ohio State’s Sports Med team for holding Marvin Harrison JR out of the game on an obvious possible concussion.
They made the unpopular choice. Even when he wanted to go back in.
That speaks volumes to their team 👍
Fencing vs Posturing:
Seeing as my timeline is full of rehab professionals, every time there is a head injury in a major athletic event, the discussion on fencing and/or posturing comes up.
These terms are two different things and are generally not interchangeable.
A thread:
Sometimes I feel like 90% of rehab is convincing people it’s ok to move. Whether it’s post surgical, acute, or chronic, the general public perception is that movement/use= damage.
I understand why the public has this opinion. I don’t understand why it’s still reinforced by HCPs.
You’ve stayed up last night reading all the latest rehab research…
You’ve found that when it comes to pain:
❌Modalities don’t work
❌Manual Therapy doesn’t work
❌Exercise doesn’t work
❌Pain-sci education doesn’t work
You greet your first patient of the day…
“I’m in pain”
Telling patients they “have to fail therapy before getting an MRI/Surgery” is setting them up for failure.
Tell them they are “trying the least invasive option that has shown to be just as effective for their condition”
Semantics matter. No more negative connotations.
Dear Any new Healthcare Professional,
This is exactly the right way to deal with an injury of this magnitude. Calm the player first then attend to the injury. You know his ankle is busted. Assessment without increased distress will ultimately result in a better outcome!
Working with a patient with a C5 SCI.
We’ve rebranded Fridays as “Fuck Around and Find Out Fridays”
Him: “Put me on that damn elliptical. You won’t!”
Me: “Alright, hope your arms are ready for a workout moving those chicken legs”
End Result:
Had two young patients today (11 & 12yo) that I decided to double book to try and make PT a little more fun for them since they both talked about struggling socially...
At the end, the one asked the other for their Snapchat and it was the most wholesome thing ever 🥺
I have a very simple rule for when patients ask if they should ice or heat.
It’s the same regardless of Dx or acuity.
It’s simply:
“Do what feels best. Especially if it keeps you moving”
We have bigger problems to deal with than debating superiority of thermal modalities.
Coming out of PT school, I thought I was going to be a “Sports PT”
I had got a job at a clinic at an Olympic training level facility, I had an Athletic Training Background, I would work for a few years and work on getting my SCS.
It seemed like I was set to follow that path…
It might be an unpopular viewpoint but:
I will gladly trade a large paycheck for smaller one if it means I get to have work-life balance, practice at the top of license, and have a deeply engrained sense of purpose in my community.
I’m not chasing dollars. I’m chasing meaning.
Working with a 28yo today who suffered a C5-6 SCI 3 months ago:
He gets married tomorrow.
You better believe we borrowed another patients wedding band and spent the whole hour making sure he could put a ring on my finger 😂
Me: “Given current evidence, what are the indications for using this machine?”
Student: “I honestly could not tell you…”
Me: “Driving up units and reimbursement at mill PT clinics”
#TheMoreYouKnow
There’s probably a lot of clinicians who need to hear this so I’m gonna say it:
-No treatment you apply will ever be 100% supported by evidence.
-Even the treatments w/ the best evidence won’t work for everyone.
&
-Doing your best for the patient in front of you matters most.
I think we need to start reframing rehab as:
What can you do? ➡️What do you want to do? ➡️How do we get you there?
As opposed to:
What can’t you do?➡️Why can’t you do it?➡️How do we fix you?
A subtle change that shifts focus to empowerment & resiliency from reliance & fear🤔
I have the belief that too many educational programs (AT & PT) focus so much on giving students “tools” (IATSM, DN, cupping, laser, etc) for their “toolboxes” that they neglect to give them a good “toolbox” (fundamentals of rehabilitation and S&C principles) to put them in. 🤔
8 months ago, Ryan suffered a C5 SCI.
3 months ago, he was told he has “reached his maximal potential” by a renowned Neuro hospital.
He was sent home with a power wheel chair and minimal guidance other than “change your insurance to Medicaid”
Today: He did this.
4 x 60 feet
You want to know why so many ATs get backlash for holding a kid out?
Because on the biggest stages, w/ the public watching, kids are allowed to RTP after something like this happens.
So when a parent says “he just has a little headache, he’s fine”
This is where it starts.
Had a patient last week with 2+ yr history of knee pain and end stage OA on xray.
Eval showed quad and glute weakness as 1° deficits.
Gave 3 exercises for HEP:
-SLR
-Clamshell
-Resisted Knee Extension
Guess what happened?
I think I’ve reached the point where I’ve stopped trying understand the complex biomechanics of the spine, the complex nuances of pain science, & the complex medical journey most LBP pts have been on.
New Approach: Keep moving & gradually load in a positively framed environment.
Friday Night Thread:
Plyometric training is something I didn’t realize was important in rehab when I graduated both PT & AT school.
Fortunately, I’ve had some excellent guidance over the past 10yrs on its importance in programming.
So here’s a basic rehab plyo progression:
Quick Friday Note:
If you’re treating athletes (or any patient) in the OP setting, whether it be AT or PT, you need to get objective measures to elevate your care.
It’s not the “best” measure of strength but “test, don’t guess” rings true!
For $40, you can surpass MMT scores.
Because my life as a PT is never normal…
I just did an evaluation on a 19yo who completely dislocated their SIJ in an MVA and is s/p ORIF.
And for the first time in my career, I’ve actually had a patient tell me their SIJ was “out of place” and it was in fact out of place 🤯🙃
In light of my new found knowledge of how the Psoas innervates the diaphragm…
I decided to do some breathing exercises this morning before clinic today.
Made sure to hit both Open and Closed Chain Psoas work so to really “unlock” my tidal volume.
Had 4 evals today.
All 4 had been previous pts over past 7yrs
Student: “How is it that you remember so much about each patient’s life? I feel like you spent more time talking about them & their families than what they were coming for.”
Me: “Why do you think they came back? 😉”
Gave myself a birthday present.
Paid my last student loan off.
Gonna brag for a second cause I’m real damn proud of my wife & I.
In < 6 yrs:
-$160k Student Loans
-2 vehicles ($40k)
-Wedding ($10k)
-Bought a house ($45k off principal)
$250k in debt paid off! Huge day for us!
I have a new student starting on Monday.
One of our patients has a significant Brachial Plexus Injury after shoulder dislocation.
I’m going to nonchalantly ask them to draw the brachial plexus and tell me where the lesion is.
My 2023 Theme for being a CI is violence 😂
My current PTA student is 1yr younger than me.
So far in life he’s served 2 overseas tours, received a Purple Heart (great story), lived in like 5 states, became as a tattoo artist, won a regional strongman competition, & homesteads.
Meanwhile, I’m like…I graduated PT school🙃
6 years ago, Bob lost his ability to walk due to a Spinal Cord Injury. Today, he took his first steps under (mostly) his own power. He’s been resilient in his PT and it’s moments like this that make my job so worth it!
#MakePTHappen
#DefeatTheChair
I will die on the hill that the biggest effect on prognosis is not the method of treatment you chose but how well you treat and engage the patient as a person.
The best treatment approach is unlikely to work if the rapport isn’t there.
It’s 8am and my student has allowed our 10yo patient to steal and hide my coffee mug as part of her “therapeutic activities…”
It’s a rather bold move with midterms coming in the next 2 weeks 🤨🤔
Healthcare costs have risen about 20% since 2015.
Things that have not increased in the last 5yrs:
-Provider reimbursement
-Patient access to care
Things that have increased in the past 5:
-Commercial insurance profits
-CMS employee salaries
Just so we ALL see the problem.
After multiple anatomy classes, 2 Healthcare degrees, and a decade of clinical practice….
I was today years old when I learned the diaphragm was innervated by the Psoas and not the Phrenic nerve 🤯
🙃
(What’s wild to me is how many HCPs just blindly believe this)
6 years ago today, I received my passing score on my NPTE.
Still haven’t used therapeutic ultrasound at 3.0MHz, 1.5W/cm^2 for 8 minutes to heat a tissue no more than 2.5x the size of the application device at a depth less than 2.5cm from the surface.
Useful knowledge though🙃
First day with a new PTA student.
Having a student makes me explain and rationalize every treatment and intervention.
It also makes me improve communication skills and clarity with them as colleagues and also with patients.
Having a student makes me a better clinician.
The Art of being an Evidenced Based Clinician
By: A random Physical Therapist in Ohio who specializes in nothing but reads too much and spends 40 hours a week treating everything Rural America has to offer.
Why it’s so hard to implement research into clinical care:
Insurance company denies requests for visits & asks for a re-eval/progress note
I write up a template knowing I’ll be seeing the patient next week and I just need to plug in measurements.
Front desk accidentally sends it in. Blank.
Insurance company: *approves 8 visits*
Youth sports have got to the point where there are almost no kids playing in local community Rec leagues.
Meaning parents are shelling out thousands of $$ so their community rec league kids can play against other community’s rec league kids w/ “Elite” slapped on the jersey.
In honor of
#WorldPTDay
:
(Cause my job is cool AF)
16mo ago: C5 Asia A SCI. (Literally internal decapitation)
13mo ago: Discharged in from neuro rehab hospital because of “plateauing”
*I haven’t seen any plateau in
@geoffyjohnson30
since I met him 13 months ago*
This week:
I had an 18yo patient today who told me that most of her knee issues were a result of her hips being “out of alignment” and she would “always have problems”
Which she was told by a PT.
While rehabbing an ACLR.
At age 15.
Words and framing matter.
This is my first tweet as a Dad.
Looking forward to embracing all the best aspects of Dad Culture: Dad Jokes, Dad Bod, BBQ, Light beer, and a significantly enhanced understanding of basic vehicle maintenance 🙂
Hot Take:
Most patients don’t care about your credentials.
Patients care about how they are treated.
I’ve seen patients trust PTAs over neurosurgeons, ATs over orthopedics, PTs over PCPs, & everything in between.
Want to improve value? You have to show more than a degree.
I had a pt ask me today
“What EXACTLY is causing my pain?”
5yrs ago, I probably would have answered w/ a complex biomechanical explanation
Today I answered w/:
“I’m not 100% sure. It’s probably a variety of things. But I have some ideas that might help you manage it better”
Students:
Sometimes, I Google the answer to the question I just asked you. Just to make sure I’m right.
Every now and then, I’m wrong.
It’s impossible to remember everything you’re taught. The important part is recognizing that it’s ok to forget things.
-Your CI/Preceptor
Don’t confuse Recovery for Rehab.
There’s a difference.
Recovery IS great. But sitting in a cryochamber or Normatec, bashing your muscles with a theragun, or foam rolling doesn’t really do much unless your engage in an ACTIVE rehab program.
Patient Education on this is 🔑
1. Theraband Wall Lift Offs
-Targets Low Trap
-Improves Thoracic Extension
-Not scary but harder than it looks
-Helps you pull hidden chocolate bars off the top shelf
I must have missed the lecture where the fencing response was a common symptom of a “stinger” 🤡
Absolute failure by MSU sports med staff to allow this player to return same day.
There has to be better accountability at the highest/most visible levels.
Dear High School Coaches:
Making “voluntary” practices (that aren’t really voluntary) during a time when schools are closed for a pandemic is, pardon my language, irresponsible as fuck.
Set an example. Or lose your job.
5 Things I Share w/ all my students:
1. My salary
2. Our general reimbursement rates as a small company
3. What larger companies/hospital systems get reimbursed
4. What I know people in those larger systems make.
5. Revenue v Salary
It’s always enlightening for them.
The amount of people asking to not be discharged because of how much they value the social interaction of coming to PT is becoming concerning.
The social health of this country is at an all time low.
I have a patient who came to us diagnosed with a C5 ASIA A SCI 6 months ago.
He was told he would spend the rest of his life in a power chair.
He was in a manual chair by December.
Today I watched him roll from his back to stomach and then sit up.
Watched.
I live in a world where I could literally make thousands of extra dollars by selling a flashy product with unsupported claims all in the name of “health”
The only thing stopping me is a strong moral opposition to grifting a vulnerable population.
I hate it here.
I am moderately convinced that in the early 1980s, these stairs were mass produced for every PT clinic/hospital in the country and then never purchased or produced again.
#sturdy
I have a proposal to orthopedic surgeons:
We (rehab professionals), will stop giving clams shells, press ups, and bridges to every single LBP patient
If…
You stop giving completely random, arbitrary 5lb lifting limits on people who had back surgery.
Deal🤝??
I can’t believe it’s 2023 and I have to say this but:
If you are an adult.
Working with a child.
And they have pain while doing an exercise:
Don’t tell them to push through it.
Don’t tell them they are weak.
Don’t tell them nothing is wrong.
Script: “L Hip pain”
Pt: “So, I got COVID in early 2022 & they kept pumping me full of prednisone & then I got really bad hip pain after I got out of the hospital & they found I developed AVN from it so they did a THA & I only had 2 weeks of HHPT & now I limp & I don’t want to!”
My student was off today.
Which meant I got to treat patients.
(And I was low key kind of excited)
First patient of the day:
“Oh, you’re actually gonna work today and not just walk around talking and practicing your golf swing…”
😂🙃
Hot Take:
We need to be much better at elevating the floor of our professions before we can consider expanding our scopes.
There is far too much low quality care out there to persuade the public we can do more if we haven’t ensured that what we are currently doing is adequate.
I am going to share my treatment approach to low back pain:
1. Identify what movement(s) hurt.
2. Stop doing that movement(s) into pain.
3. Start slowly reintroducing same movement while reiterating for them to avoid pain.
4. Load as tolerated.
*sprinkle pain modulation prn*
This is 100% completely anecdotal but Jefferson Curls (Kettlebell) have become a staple exercise with my LBP patients and they overwhelmingly respond positively both in session and longer term.
Pt: So should I use ice or heat?
Me: Which feels best?
Pt: Well isn’t one bad?
Me: Depends on what research you want to look at 🙃
Pt: 🤨
Me: Do what feels best for YOU.
Me: Now let’s talk about getting that thing moving.
#debatesettled
Sometimes I push on people’s backs for like 2 minutes & they get a lot of “cracks.”
Then they get up and do 55 minutes of heavy strengthening and mobility work & feel great.
And it costs me nothing.
Im waiting for the argument that convinces me that MT & TherEx can’t coexist.
Sometimes I wonder if healthcare providers realize how blessed they are that every day they wake up & go to work; they have the ability to change someone’s life for the better.
I think about this every time I feel defeated.
Always about perspective. Live a purpose driven life.
Hey
#medtiwtter
! Today
#Scientissimum
would like to show you another
#orthopedic
#surgery
case of removing intramedulary nail. In the previous post we showed how it is placed, in this post we are showing its removal.⚒️
Today, I had a pt (Transverse Myelitis) walk 10’under his own power for the first time in 4yrs.
I had another (17yo w/ Spina Bifida) hit a 150# Deadlift PR
I had a 3rd perform a 6” step up for the 1st time since their TKA
Everyone’s goals look different. Treatments should too.
A Guide to Therapeutic Activity:
Note: “Pt will demonstrate ability to pivot on L LE and shift weight to R LE evenly while performing complex motor planning of B UE and improving hand-eye coordination”
The activity:
The biggest thing I miss about being an Athletic Trainer is the ability to provide care to my athletes without worrying about insurance reimbursements. The impact you can have on a kid is far more valuable that any dollar sign attached to a CPT code.
I don’t usually do this but really been digging this exercise for a hip mobility/eccentric strength rehab lately.
3 angles (Abd, 45°, Ext) to work on hip flexors/adductors. Also like using it to work on core stability and abductor stability on stance leg (needs work here).
After watching 3 Bar Rescue marathons, I’ve decided I want to start a PT Rescue show where I go to outdated clinics and throw ultrasound machines to the ground, scream at unethical billing practices, and make sure there’s a squat rack for each treatment table.
Me: “What’s a SMART goal?”
Student: “Specific, Measurable, Attainable, Relevant, Time Based”
Me: “And why do we do them?”
Student: “To appease insurance companies.”
*My work here is done. Clinical passed*
Direct Access to PT is good.
Had a 20yo college student who had no health insurance come in today for shoulder pain (self pay).
He had talked to people, educated himself, and found that PT was probably the cheapest & most beneficial route to start.
The culture is changing.
One of the hardest clinical skills to master is the ability to recognize when is the right time to push back on a patient’s beliefs vs when to accept, acknowledge, & move on.
I’ve found that I will very rarely be able to convince someone their hips are not out of place on Day 1.
Another student.
Another “I was there to treat more patients rather than learn” story.
I’ve had 18 students over the past 7 years and the stories ARE. NOT. CHANGING.
If you want to be a leader in change, you have to have your own house in order first.
We. Are. Failing.
Beliefs I’ve held since graduation of AT & PT school that I no longer hold: (2012/2015)
-No OKC exercise p ACLR.
-NWB p Meniscus repair
-ACLR RTS 4-6mo
-NWB p Achilles Repair
- Knees can’t go over toes
-Concussions require complete rest
-Flexed spines squeeze your discs out
1/
MOI: Whiplash injury 1 month ago.
X-Ray: Mild to moderate changes at cervical spine
Patient: “My doctor walked in and said “You have the neck of a 55yo construction worker.””
We have a massive systemic issue in the framing of healthcare and how we speak to patients.
10 years post C5-6 SCI.
Today, you’re standing independently with an RGO.
It’s been a long process to get to this point.
Thanks for including me in your journey, Bob!
We’ve reached the point in the year where every 3:00 hour sees the clinic filled with like 5-6 high school athletes putting in some high level work and the one older patient who is quietly asking their therapist “I’m not gonna have to do that exercise am I?” 😅
Dear Insurance Companies:
Please focus more on denying this type of care and less on only giving me 4 visits to rehab an ACL repair.
No seriously, it’s ok to deny this stuff.
Signed,
The Actual Medical Community
In roughly one month, we are about to find out if our small, private practice company can branch out on its own and:
-Prioritize 1-1 care
-Pay fair wages/benefits
-Accept most insurances (including MCaid/ACA)
I’m a bundle of nervous energy to see if we can show it can be done!
Reviewing some recent medical bills:
(Anthem)
A unit of 97110 (Ther-Ex) reimburses the local hospital system $72.
A unit of 97110 reimburses us $27.
That’s an over 250% increase.
There’s so much to unpack with the fact that this is the basis of the healthcare insurance.