One of the The American Physical Therapy Association's events is quickly approaching! The Combined Section Meeting will be happening in Chitown from February 8-11 (in a couple of weeks)!

I love to learn and share who's speaking, when and topics of interest. Well, this year, the format of the online information isn't conducive to efficiently check out topics and speakers. My apologies for dropping the ball - this year the formatting is too labor and click intensive for me.

Back by demand... the 3rd Annual CSM Very Unofficial Meetup & Mixer. It's been planned and the information has been sent out to previous attendees. (And a whole group of tweeps have spread the word too! Thanks to those who have shared the event information.) If you plan on going to CSM... if you'd like to mingle with those of us active in the online world, come! The Mixer will be at Jimmy Green's (a sports bar) a couple of blocks from the Hilton. Lots of beer options... bar food... free wireless... and the best part, some really neat people! Don't wait to the last minute to register because you'll miss out on receiving the free attendee synopsis!  

I will admit, I'm not feeling as excited about CSM - it took too long and too many clicks for me to come up with a game plan of who I'm interested in hearing present. So... please, please take this opportunity to share if you are presenting. Please comment and share information about your session(s)! I want to get excited, but I think I'll need the help of all you presenters to step up and put in a fun plug for yourself!

Also... for those of you using Twitter... you'll be interested in joining in conversations or following along the happenings at CSM using hashtag: #CSM2012 Of course, the Very, Unofficial has a hashtag too! It is wise to keep the "Very Unofficial" separate from CSM educational content. I'm pretty sure Twitter rules will be broken by the motley crew currently attending the Very Unofficial. The after 11 pm rule - it's gonna be broken! For the Very Unofficial, use hashtag: #CSM2012CHItown (And.. it really doesn't matter if caps are used.) Too bad we can't have a video or photo contest of some of you meeting for the first time. For those of you curious about Twitter - pull me aside and I'll give you some quick tips and a crash course (if needed) on this venue of social media.

Looking forward to seeing/meeting you! And DO comment and share your sessions - I want to feel excited about CSM!

~Selena

Mental challenges keep you on your toes and your brain spinning. And just when you think you have a grasp of a concept, you can't put words to it - OR in my case, twisting words and concepts and trying to understand what is actually being said and then trying to convey thoughts and hopefully not failing. I decided to step out of my comfort zone and trust a person I follow on Twitter. Via the recommendation of @jorge_ze I visited Edupain. What was Jorge doing to me? He already knew I was overly challenged in responding to his tweets - Tweetdeck wasn't translating. I understand a few words here and there (enough to be wrongly dangerous)!

I got some help from @lightchronic in learning how to have pages translated. Wish there was an add-on for that! And, then, in trying to share pages while not overburdening my followers with Spanish, @lightchronic came through again letting me know a link I shared worked fine and was in English.

Por mi nuevos amigos: Gracias para trabajar sobre dolor. No comprendo Espanol muy bueno y me tengo dolor de la cabeza cuando estudio tus blog. :) Creo fisioterapia importante para ayuda con dolor y physiotherapist importante para mucho gente. Lo siento para tu que gente en Espana no tienen fisioterapia para dolor. [And yes, I did all that on my own and THEN double checked in translator to make sure I didn't say something horrible!]

Via a post in the Edupain blog, I came upon this really neat paper by Nijs and colleagues that actually gives some practical guidelines on explaining central sensitization to patients. During the same time, I had been in an email discussion with @AussieLouie about - take 3 guesses and the first 2 don't count! Adriaan Louw et. al recently published in Archives of Physical Medicine & Rehabilitation The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain I considered myself lucky in the sense that Chris Kramer shared the article with me. This opened the door of discussion with Louie and he shared an article recently published entitled, Use of an Abbreviated Neuroscience Education Approach in the Treatment of Chronic Low Back Pain: A Case Report. Thinking and discussing pain and interventions that impact the pain experience is always stimulating for me.

The hot debate this week was over on Mike Reinold's blog - last count was 79 comments on trigger point dry needling authored by @PranaPT. How can I summarize 79+ comments? I can't... but the debate was two-fold: reliability of assessing trigger points and how trigger point dry needling fits into what we know about pain science. (As a side note, the neuromatrix of pain diagram does indicate "trigger points" as providing input to the brain.)

This whole week I've been inundated with the thoughts of others and their interpretation and perception of pain and how they have chosen to implement what they know about pain into their practice. The "easy" part of pain is that patients will tell you they hurt. The difficulty lies in determining which factors might be involved in perpetuating the pain experience.

I'm sure many of you are aware of this figure (Melzack 2001) which helps with understanding the vastness of the pain experience. My intuition tells me it is missing a genetic component, peripheral mutations, spontaneous firings, how body awareness can be altered/reduced, and how the pain experience can be explained for individuals with phantom pain from nonexistent limbs. If there is a newer model, I'd love to be enlightened!

All these conversations have been rattling around in my brain. It was the frustration of our Spanish colleagues that really hit my heart. First, physical therapists need to understand pain science and second, we really do need to be able to connect with our patients to help them to understand too. Last night, I had the inkling of an idea. David Butler and Lorimer Moseley have done a fabulous job telling a "pain story" and bringing the diagram of the above down to a level of a lay person via Explain Pain. We all learn by doing. And although a book is good, it may not connect with all individuals to readily understand the concepts.

There is nothing better than looking for an image and then finding a public one of a colleague! So... here is @mpascoe playing the exact game that I think could be repurposed to add value to discussions with patients about pain. I didn't ask for permission ahead of time - figured if it was public, it was public. Hope I figured correctly, Mike.

Why not create a little plastic brain (like the travel Operation game)? Have it similarly wired like the old Operation Game. The red light bulb would represent the brain interpreting something as pain. The difference with the Pain Game is simply there are only two metal connections and multiple wires. The wires would represent various factors that impact the pain experience. The wires would be labeled and could be different colors or groups of different colors. Each labeled wire would represent a factor involved in a pain experience. Wires would either be conducting in nature or nonconducting. If a conducting wire hits the connection in the brain, the light shines. Pain output. Obviously, nonconducting wires would also need to be included. It is just as important to convey factors that can reduce pain output because I think this creates a positive impression and hope that the pain experience can be changed. Change the input = change the output. So... the "napkin" drawing of what's in my head for the moment.

Many thanks (gracias) to so many individuals who 1) are thinking 2) are not accepting status quo 3) are trying to promote change.

~Selena

Below is the text from a talk I recently gave via Skype at the PPS Graham Session this weekend in Charleston, SC. I unfortunately was unable to attend due to a last minute military deployment. Many thanks to Steve Anderson and the Graham meeting participants (and as I understand it, was record attendance and a terrific meeting) for allowing me to be there virtually via Skype to deliver my talk. As always, it's a genuine privilege to be in the same room (whether face-to-face or virtually) with friends and colleagues who are members of the greatest profession on Earth.

John

Delivered via Skype on Saturday, Jan 14 at the recent PPS Graham Session in Charleston, SC
Despite positive reforms in physical therapy education in recent years including the transition to a doctoral level education, clinical education has lagged. Physical therapy clinical education remains a highly fragmented and ill equipped system, marked by an inefficient 1:1 student to instructor format consisting of several short duration clinical affiliations, which leads to disjointed, highly variable, and non-collaborative learning. If we are going to be a meaningful contributor to health care reform and more importantly, play a prominent role in the reform process, we must hurriedly wake up from our delusions of grandeur, embrace the fact that we have a deep chasm in clinical education that must be closed, and wholeheartedly distance ourselves from the status quo.

The current physical therapy clinical education system leans heavily on a ‘barter arrangement’ completely dependent on the altruism of clinical practices at the sheer mercy of the academic program. For example, the short duration of the average clinical affiliation combined with the Interns’ limited skill set mitigates their potential to become a productive, value added member of the staff. Clinical resources are inefficiently expended to help the Interns learn the various systems, documentation standards, billing procedures, etc., only to have the student move on to their next clinical affiliation immediately after their useful assimilation into the practice. In short, the indirect costs for clinical practices to provide clinical education under the current model are steep and bothersome. Other than altruism, it is curious how academic programs have been successful in affiliating with clinical practices at all. Yet, in our typical peace gene like fashion, we oblige the “predatory” behaviors of academic programs who have duped us into believing that it is our professional duty to provide free clinical education for students while the academic program rakes in substantial tuition dollars during clinical affiliation semesters for which the academic program provides virtually no services!

Before I offend those of you in the audience who are on faculty in an academic program (ok, I probably already have!:)), think about this with me for a moment in practical terms. As educators in entry-level academic programs, we sit in many a faculty meeting debating the pedagogical pros and cons of adding “ABC” content, taking away “DEF” content, dedicating more time to topic “X”, less time to topic “Y”, etc. In fact, many of our curricular “experts” even get passionately defensive when making such arguments. You should see some of the heated debates that ensue when it comes to determining what content should be included in the didactic phase of physical therapy education! As a result, our students tend to progress through a highly organized and systematic curricula during this phase, evidence by a detailed schedule and syllabus. Nothing is left to chance. For example, it’s no mystery to the student as to what books they need to buy, what time they need to be where for what class, and what content to review prior to each class. We diligently measure student performance through countless rigorous written and practical exams. What strikes me as most odd then is why we don’t appear to be bothered by the lack of a clinical education curriculum that you can "touch and feel". For example, can a single DCE in the country tell me what content their students are learning on week 4 of their clinical education experience? How about week 18? What about week 23? Unfortunately, the default strategy for clinical education hinges on a “hope and prayer” strategy in which we send our students out into widely disparate learning experiences with little to no connectivity between clinical sites or even to the academic program. We then sit back and “hope and pray” that our students have a good experience. Think about the lunacy of our current 1:1 model with me for just a moment. Even the most highly capable clinical faculty do not have the depth and breadth of knowledge and experience necessary for a comprehensive clinical education experience. By the way, if we are to achieve meaningful reform in clinical education, clinical faculty must have the same faculty status and privileges of full time core faculty, if not higher!

Complicating matters, there are only 3 prerequisites for qualifying as a clinical instructor in our current model. First, you must have a PT license. Second, you must have a heart rate and pulse. Third and final, you must not be in a coma. If you meet these 3 criteria, you will be inundated with requests from DCEs around the country to affiliate with their program. Lest you doubt me, just ask any DCE how many contracts he or she attempts to manage under the current system. Most will answer somewhere between 250-500 contracts, yet the program is only able to assign 1 or 2 students each year per location in most cases. Therefore, the DCE inefficiently spends countless hours managing affiliation agreements with practices that take very few students in aggregate over time. As a result, the clinical education sites are rarely connected to each other in an organized way and frequently even remain at an arm's length from the academic program, tethered only by the clinical affiliation agreement. You don’t have to be an ISO 5000 certified quality engineer to understand that quality assurance across this many educational experiences is impossible.

Fundamentally, the potential transformation of physical therapy clinical education is dependent upon the ability of academic institutions and clinical practices to align themselves in a symbiotic relationship that delivers mutual benefit and value for all stakeholders. The medical model of clinical education has long proven useful in the training of residency-trained physicians. Interns would train collaboratively in group settings rather than a far more narrow learning experience that occurs when you only have 1 clinical faculty member. We should foster the development and evaluation of a standardized internship curriculum that leverages online learning management systems and team-based learning to deliver a consistent learning experience regardless of location. In other words, we need to “crowd source” clinical education so that the full “universe” of knowledge is available to them, not an isolated slice. One could even envision a matching process whereby students are competitively matched to specific residency programs…the right student to the right clinical education experience at the right time, the results of which would further incentivize quality and standardization and create a win/win/win proposition for students, educational programs, clinical practices, and most importantly, the patients to whom we provide care.

Finally, it’s an outrage that our graduates currently have debt that is completely out of proportion with their ability to recoup their investment. As it currently stands, there is no compelling economic argument to pursue a career as a physical therapist because of the inability to achieve a return on investment that justifies the necessary debt burden of the average student. Unfortunately, academic programs are in a negative incentive situation when it comes to such reform because students currently pay tuition to their academic institution while completing their clinical rotations, creating a veritable cash cow for the academic program, yet the academic program provides few services during this period. In fact, I routinely advise students that when their DCE calls them during their clinical affiliation to check in on how things are going, they should make the DCE stay on the phone for at least 100 hours to even begin recouping the value of the investment of tuition dollars the students have poured into the program.

We must disruptively innovate within clinical education to attract the best applicants into our profession, many of whom currently pursue careers in medicine instead. Similar to the medical model, students should attend physical therapy academic programs for didactic learning experiences, graduate once that component is finished, sit for licensure, and immediately begin a formal internship/residency lasting a minimum of 1 year. Interns would receive a modest stipend in exchange for receiving a high quality standardized training program delivered under the auspices of a credentialed graduate medical education system that adheres to rigorous accreditation and quality standards. Migrating the preponderance of clinical education to the post professional, post licensure setting would shorten the typical academic program by 1/3 (2 years rather than 3), trimming tuition accordingly.

In summary, we can no longer justify clinical education being relegated to 2nd class citizen status, and surely such a low view is inadequate for the contemporary Vision 2020 physical therapist. We are starting to see some innovative internship models emerging, such as those at the University of Pittsburgh, MGH Institute of Health Professions, the US Army-Baylor Doctoral Program in Physical Therapy, and Rocky Mountain University, among others. However, the rate at which the transformation is happening is far too slow. Fundamental reform of clinical education is critical for guiding the future of physical therapist education, and the immediate possibilities for such reform are real and tangible. In doing so, clinical education can be transformed into a collaborative and highly effective experience that will serve to elevate the role of the physical therapist in our health care system. Disruptive innovation is needed…and needed fast!

I'm against New Year's resolutions. Life isn't about resolutions. Resolutions don't emotionally touch me. I've never made a resolution in my short life... and I don't think I ever will.

Dreams... pursuing dreams and actually experiencing a dream come true are far better than any resolution. It literally brought me to crying tears when a childhood dream of mine came true. For as long as I can remember, I've wanted a horse. There was nothing better than the gift of a horse my husband got for me on our 10th anniversary. (Okay - it wasn't a surprise because we made a trip to Kentucky to check out a particular horse & I fell in love riding one particular spotted saddle horse.) My horse is better than any ring or piece of jewelry that could have been given to me. Don't make a resolution - chase a dream! What are your dreams? Chase it with a passion and hold on to that fabulously wonderful feeling when it comes true. And, honestly, if you don't have a dream... help someone else's come true.

Fears... don't walk away from them. Just don't. Face your fears. If you haven't tried to overcome a fear, you are missing out on the most exhilarating feeling ever! What is it that scares you the most? Tackle it! Slowly but surely, it will dissipate.

I've had two major fears in my life. For me, I knew I had to do the work to overcome the fear, but I had to learn I wasn't alone. I'm a stubborn person, so it took me time to realize my family and God were with me every step of the way.

My childhood dream became a huge factor of fear and anxiety after he bit and kicked me. He busted up my collar bone and turned into a rearing, attacking beast any time I came near his stall door. The anxiety and fear were bigger than anything I've ever experienced in my life - and he came close to being sold for glue. (Well, not really - he was a good animal just maybe not a good fit for me.) I came close to giving up and not facing my fear and anxiety, because 1,200 pounds of power lashing out at me just seemed too hard to overcome. It took over 6 months, but I overcame it. I have a healthy respect for him, yes, but I'm no longer anxious or fearful of him.

My other fear was completely irrationally crazy! It revolved around a combination of 2 hydrogen atoms and one oxygen atom. Eliminate any chlorine atoms and instead toss in some wind, waves, (a leaf!), fish, weeds, murkiness and odd tastes and you have the open water situation. Open water can generally be completely avoided, yes, unless of course you decide to embark on a triathlon journey. It took 3 years of competing and lots of mental imagery, self-talk and prayers to finally bury that fear. The day I buried that fear was in August 2011. Not only did I bury it, but I kicked butt in a one mile open water swim and placed 5th in the master swim group. Elated, charged, proud... I learned it can take time to overcome fear but it is so worth the feeling.

The power of forgiveness... words don't even describe how difficult it is to put aside feelings of hurt and broken trust. The magical feeling that happens when you truly forgive someone immediately removes the heaviness and anger. It's not easy. Refreshingly, your mind opens; you can focus on rebuilding trust.

We grow and become better whenever we face or focus on things that matter most to us. When something is easy or natural, we don't grow in the same was as when we challenge ourselves. The things that matter most won't change or happen overnight, take commitment, take patience and result in a deep emotional response.

Our profession has a "nice" vision. It's all on paper. It won't happen until the dream is believed... until fears are faced... We each have an opportunity to make the future of this profession bright... we are a solution to the musculoskeletal problems in the health care world... we add value.

Forget resolutions... what do you see for yourself professionally? What do you dream for this profession? Can you face your fears and whatever obstacles to help make what you envision happen? Are you ready to forgive others as you pursue your strategy to make you and this profession better? (There isn't room for anger or pointing fingers or blaming.) Who or what organizations can support the endeavor? Can you handle the discomfort that will be part of the journey? Do you have the fortitude to persevere? Are you ready to learn from failure? Things don't always have a happy ending - failure is just another avenue for learning. Putting what you learn to use from failure has value.

Embrace 2012... you don't need a resolution... grasp opportunities and experience life.

~Selena

I received this interesting email below from Richard Don Tigny, whose views on the SI joint bring back memories of the 1980s and 90s...way out of touch with reality. Nevertheless, I thought his comments were instructive on a couple of points. First, if we are to become an evidence-based profession, we have to learn to respond in a timeframe faster than 5-6 years. He is apparently responding to some critical comments I made back in 2007 regarding his views being inconsistent with current evidence (view which are even further away still in 2012).

Also, before you criticize me for posting what was intended as a private email on a blog, I did ask for and receive his permission to post his comments here, which brings me to my second point. Some individuals don't mind sharing their lunacy with the entire world, which reminds me of a quote by Epictetus who said, "We have two ears and one mouth so that we can listen twice as much as we speak." In all seriousness, and with no intent to make this a personal attack, it's helpful to realize that there are a few who still cling to views that are completely out of step with current best evidence. Although I hesitated to even post his viewpoints because doing so might give them more credibility than they're worth, it's sometimes instructive to see a stark contrast of what EBP is not to help determine the way forward as this represents a known point from which we can run clearly in the other direction. The below example is the epitome of times gone by in PT and hopefully a place we will never return.

Richard and others are certainly free to disagree (and I can count on an email from him shortly I suspect as to why I am wrong), but trying to convince someone that the SI joint moves in a clinically meaningful way is not a defensible position.

John

Email from Richard Don Tigny

HI John,
I just ran across you 2007 comments regarding my research.
Just thought I would bring you up to date on my more recent observations.
Pelvic dynamics have been essentially ignored for many years because it has been assumed that they were far too complex for anyone to analyze and because an early researcher reported essentially no movement in the sacroiliac joint. In 1965, I saw a patient who had recovered immediately from common low back pain through a fortuitous accident and I realized her pain was caused by a reversible, biomechanical lesion. Through the succeeding 45 years I have been able to successfully analyze these pelvic dynamics. Others probably could have done this in much less time, but none have chosen to do so.

Among some of the various items that I have uncovered are:
1. A bony transverse loading axis of the sacrum posterior to the S3 SIJ segment, verified by Gracovetsky.
2. Form and force closure ( Vleeming) only occur in the unloaded pelvis or in the cadaver pelvis. After the sacrum is loaded and the pelvis is symmetrical, a system of balanced ligaments causes a net 0 closing force at the sacroiliac joint.
3. The sacrum hangs from the posterior interosseous ligaments and the sacroiliac joint (SIJ) is essentially a non-weight bearing joint.
4. When the pelvis moves into asymmetry during normal gait, the innominate on the side of loading rotates caudad on an axis through the pubic symphysis and moves the sacrum caudad, but does not move caudad on the sacrum.
5. When the pelvis is asymmetrical the sacrum flexes laterally in the long straddle position to create an oblique sacral axis.
6. The sacrum moves on that oblique axis to drive counter rotation of the trunk in order to decrease loading on that side. This has a major effect on normal gait.
7. There are two prime movers of the sacroiliac joint, the piriformis and the sacral origin of the gluteus maximus, which function to restore pelvic symmetry at mid-step.
8. A biomechanical vulnerability of the pelvis to injury through minor trauma occurs with anterior rotation of the innominates on the sacrum and a loosening of the sacrotuberous ligament.
9. A shift in the line of gravity anterior to the acetabula disturbs the ligamentous balance and allows the innominates to move cephalad and laterally on the sacrum at S3 to subluxate and fixate. This is the cause of acute idiopathic low back pain with or without a non-disc sciatica.
10. The ilial tuberosities function to prevent any posterior functional or dysfunctional movement of the innominate on the sacrum.
11. Posterior rotation of the innominates on the sacrum and upslips are clinically insignificant, occurring at the S1 SIJ segment.
12. The dysfunction in anterior rotation causes a vertical shear on the conjoint origins of the gluteus maximus and the piriformis at the S3 SIJ segment, which is the cause of the piriformis syndrome.
13. The dysfunction in anterior rotation increases the lumbosacral angle and loosens the iliolumbar ligaments and increases shear on the lower lumbar discs. This may initiate a spondylolisthesis and is probably the cause of disc disease.
14. The dysfunction in anterior rotation may cause a reversible, biomechanical asymmetry of the pelvis with a reversible change in leg length.
15. Pain in the abdomen at Baer’s sacroiliac point is not uncommon with SIJD and is commonly the cause of unnecessary surgery. This point is on a line from the umbilicus to the anterior superior iliac spine, two inches from the umbilicus and pain there is relieved with corrections or injections to the SIJ.
16. It is possible to make a diagnosis of the dysfunction of the SIJ in anterior rotation merely by identifying a painful point at the posterior inferior iliac spine.
17. The conventional side-lying treatment of this dysfunction by chiropractors and physical therapists will eventually cause the long posterior ligaments to become unstable and is probably now the chief cause of chronic low back pain.
18. Increased loading of the femoral head from a non-functioning SIJ may cause microfractures in the subchondral bone with roughening of the joint surface and eventual arthritic changes.
19. Dysfunction of the SIJ in anterior rotation loosens the muscles and ligaments of the pelvic floor and correction to the balanced position tightens the pelvic floor.
20. Sturesson made a procedural error in his measurements of the SIJ and wound up measuring a symmetrical pelvis in the long straddle position. Smidt was correct. See x-rays at www.thelowback.com .
Sturesson B, Selvik G, Uden A: Movements of the sacroiliac joints. A roentgen stereophoto-grametric analysis. Spine 14:162-165, 1989
. Smidt GS, McQuade K, Wei SH, Barakatt E: Sacroiliac kinematics for reciprocal stride positions. Spine 20(9):1047-1054, 1995
DonTigny RL: Sacroiliac 101: Form and Function - A Biomechanical Study. J of Prolotherapy, 3(1): 561-567, 2011
21. With full correction of the dysfunction of the SIJ in anterior rotation, at least 85-90% of all patients will be essentially free of pain within about ten minutes.
X-ray evidence of SIJ movement is on my website as well as many illustrations of pelvic dynamics.
I invite you and your colleagues to visit at www.thelowback.com, How it works, why it hurts and how to fix it. My bibliography is also on that website. I also have a CD for professionals with over 650 slides and 150 illustrations.

Every year, a good sized group of physical therapists gather to discuss, debate, and present issues that impact private practice physical therapists.  The "Graham Sessions" has become a great venue for many things-including a great spot to grouse about all the threats impacting the profession as well as the presentation of new and different ideas.  The Private Practice Section (PPS) originated the concept with support from APTA .  Last fall, a special regional Graham Session included sponsorship by the newly formed Physical Therapy Business Alliance. The concept for EIM's Executive Management Program in Private Practice in part originated out of these sessions and continues to enjoy a great strategic relationship with PPS.  This year there is an added dimension with short TED like talks.  I was asked to do one and originally consented until I found out that it was next to a weekend of the RC-3 Task Force (it has another name which is quite long and impossible to remember) and just weeks before CSM and Foundation for Physical Therapy meetings where I am privileged to be a Trustee.  In other words, I just can't justify more time on the road for volunteer work!  However, I do want to present my idea which I am calling the "PT Fix".

For the last 15 years, the formula used to determine how much doctors  (and us PT's) get paid has not kept up with the growth in health-care costs.  Very predictably over the years (sometimes even 30 days or most recent 2 months), Congress has reliably passed a "doc fix" and additional funds are found to cover the shortfall, in some cases actually providing a slight raise.  The root of the problem is in the formula called Sustainable Growth Rate (SGR).  Medicare in their own stupidity used their 1990's spending as a baseline that when combined with their prediction in overall economic growth would serve as the future medicare budgets.  While reminiscent of the former commissioner of the U.S. patent office, Charles Duel's quote in 1899 that "everything that can be invented has been invented", the formula never factored innovation in healthcare or an aging population that not surprisingly causes health costs to outpace the general economy.  The impact is devastating economically leaving the entitlement of medicare with multi-billion dollar shortfalls.  Rather then get to the root of the problem (a recurring government theme) the options when medicare money runs out include cutting doctor's pay or provide additional funds.  At least twice in the past three years, their has even been a creative in between solution felt by those in private practice during the August months when they delay payment so that it can carry into a new fiscal year.  The most fruitful year of the "doc fixes" was 2010 when there were five separate fixes, none longer than six months.  In 2011, the "doc fix" cost $19 billion.

The Obama administratively has endorsed repeal of the SGR formula as well as essentially every professional medical society.  This is obviously more easily stated than done when you factor in that CBO estimates that it would take an additional allocation of $300 billion which is harder to find than snow in Colorado this year.  My opinion is that this theatre of the absurdity will continue for awhile, not exactly a Nostradamus prediction.  Of course, PT's who are incredible at grass roots efforts will get numerous emails encouraging them with form letters and scripts to write their legislators and extend the "doc fix" when it sets to expire in under two months.  Along side of this effort, will be instructions on extending the exception's process-something that I started writing about its craziness in Nov of 2007 which you can view here and here.  While it's analogy to the "doc fix" is uncanny, it doesn't have anywhere near the economic implications.

My idea is the "PT Fix".  Under the premise that don't complain about a problem unless you have a solution, I would propose that we have CMS eliminate the group therapy code-97150. According to CMS' 2010 data, this code was allowed 674,473 times and CMS paid out over 10 million dollars.  The problems with the group therapy code are the fear of using it, its counterintuitive definition, cost of compliance and monitoring, and the high variability of its use or lack of appropriate use.  My personal experience and review show that it is likely used too little with this CMS "billing scenario" document adding to the confusion and fear. Along with eliminating the code, CMS would also amend their explicit provider rules and allow PT's to act within the scope and their authority.  Part 2 of the "PT Fix" is amending the inconsistent CMS document: Skilled therapy: Benefits Policy Manual, 100-02, Chapter 15, Sections 220 and 230.  This is the document that defines everything from PT to Non-physician practitioners (NPP) and everything in between and introduces my number one pet peeve in the world, the term  "skilled" physical therapy. While you would need the largest super bubble bub's daddy gum, to stay awake while reading this document, you can't help notice a recurring theme of referring to "licensed or otherwise regulated in the state in which practicing" regarding a practitioner's scope and authority.  Simply removing the document's explicit provider list of "skilled" physical therapy would allow PT's to practice within their licensed craft.  There is plenty of precedence for this-namely physicians who would never allow the creation of such superimposed lists. By the way, here is the Policy Manual's definition of Qualified Professional of physical therapy and many will find the list of available providers surprising:

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies.  Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law.  Assistants are limited in the services they may provide (see section 230.1 and 230.2) and may not supervise others.

Part 3 of the "PT fix" is the easiest. The therapy cap and exceptions process should be eliminated.  CMS' own data show that despite a competitive advantage that hospital's have had by not having a therapy cap, there continues to be less patients accessing hospital based departments.  In 2010, independent PT's had about $1.7 Billion of the approximate $4.5 of the outpatient therapy pie and it is unknown which part of "independent" is really self referral as this blog has discussed.  What we do know is that physical therapy overall is a very small part of the CMS outpatient expenditures with only 5 codes even showing up in the top 200 CPT codes that CMS paid (no breakdown of those 5 codes to determine if licensed PT was the provider).  While I believe a part 4 of the "PT fix" should be direct access, it has already been proposed and its only successful sniff has been a proposed demonstration project in a supposed CMS innovation center.  Therefore, I won't spoil "PT Fix" with an initiative that has been attempted.  We want this to be fresh.

To summarize, the "PT fix" consists of savings in the form of elimination of the group therapy code with amending the language of qualified professionals in the CMS benefits manual and elimination of the therapy caps and the current exceptions process.  In the lingo of TED, which has inspired these type talks at the Graham Sessions, I believe this is "an idea worth spreading".

@physicaltherapy

When it comes to back pain, tradition and the dirtiest little secret in the health care world perpetuates the pain (both physical and financial) in our society. I'd like to think that way back in the beginning of time, yes, physicians did their best to help individuals with back pain. But you know what? I'm beginning to believe today's current problem in treating individuals with low back pain is simply the lack of patient-centered care.

If our health care system *really* had the best interest of individuals with low back pain as a priority, why does the "old way" persist?

 There is a lot to lose in the new way... the new way looks like this:

Physicians and health care systems have *way* too much to lose in the new approach. Initial visits, follow-up visits, diagnostic testing, drug prescriptions... all of those equate to profit. For too long, the payment system hasn't been geared toward rewarding value.

The new approach alters the current impression of physical therapists and physical therapy services. The idea of physical therapists and physical therapy services as a commodity or ancillary is negated. Sadly, the new impression centers around threat. Physical therapists and physical therapy services are now truly viewed as a threat to the current physician and health care system business models.

In the two instances of the "new" way... who spurred change? Employers. I think if we add that little calendar image, consumers will want change too. Who wants to have back pain for as long as the old way?? Should profits prohibit patient-centered care?

~Selena

Selena Horner noted in her Twitter stream: "Data doesn't create change... stories that evoke emotion create change..."

Collaborating Reduces Costs of Health Care is such a story.

The story appeared in the Money section of USA Today on January 6th, 2012. The article tells a story about an employee of Intel Corp. and its insurance company, Cigna of Oregon.

Peter Cady, who works 12-hour shifts on his feet at Intel's plant here, occasionally suffers severe lower back spasms. But he nearly gave up seeking medical help because in the weeks it took to get a doctor's appointment and a referral to physical therapy, the pain usually subsided.

These days, he's much happier with his care.

Rather than waiting to see a doctor, Cady and other patients with routine back pain now see a physical therapist within 48 hours of calling, compared with about 19 days previously, Intel says.

They complete their treatment in 21 days, compared with 52 days in the past.

The cost per patient has dropped 10% to 30% due to fewer unnecessary doctor visits and diagnostic imaging tests. And patients are more satisfied and return to work faster.

"It's a real bureaucracy buster that gets you right straight to someone who can take care of the problem," says Cady, 47.
"Before, the doctor wasn't helping me or explaining anything. But the physical therapist educated me, gave me stretches and exercises to do, and cleared it up."

Why is USA Today breaking this story?

Physical therapists are REPLACING physicians as the primary providers of musculoskeletal care. Physical therapists are stealing physicians' caseloads.

Why aren't the physical therapists involved in this pilot project speaking up, blogging, tweeting and shouting from the rooftops?

The Intel/Cigna model is much like the Starbucks/Virginia Mason model of distruptive innovation - market-based solutions, rather than government mandates, that lower the cost of healthcare to employers and patients.

Physical therapist employees will see more work by disrupting traditional physician caseloads - but what about physical therapist employers?

What about the private practice physical therapists who employ physical therapists?

Will we be disrupted, too?

I'd like someone to tell THAT story.

Tim Richardson, PT

PhysicalTherapyDiagnosis.com

The USA Today and Kaiser Health News reported on yet another example of early access to PT reduces costs and improves patient satisfaction.  As 2012 begins I look forward to this being the year where new models of care finally take center stage.  Early access to low cost effective care seems so simple yet in our current health care system it remains the exception and not the rule.  Hopefully 2012 brings a disruption of old models of high cost, high risk, and inefficient care in musculoskeletal pain disorders and a move to lower cost, lower risk, effective and efficient care.

Happy New Year,

Tim

People don't like uncertainty. People don't like ambiguous. Okay, it's actually more than dislike. Uncertainty creates anxiety and fear. Uncertainty reduces the expectations of any benefit. Uncertainty lowers confidence and trust in information.

Physicians know this... physician's may actually try to protect their patients from uncertainty. Sadly, when physicians try to reduce uncertainty by ordering diagnostic tests, the diagnostic test results may not correlate with the patient's subjective and assessment findings. The patient mentally believes uncertainty is reduced.

Physical therapists enter into this web of disillusionment on a daily basis.

I wonder what would happen to costs of medical care if we all learned to accept uncertainty? What if instead of focusing on the uncertain, we could change comfort levels so people are educated on when it is reasonable to be anxious and fearful? What if the truth got out? Think of someone who comes to you with chronic back pain...what if we all fessed up that for now nonpathological pain is an uncertainty?

What if it could become reasonable to substantially reduce the search for the holy grail of what structure is the anatomical source for pain in the musculoskeletal world? In the absence of red flags, why not jump into intervention? Searching to decrease uncertainty as the first option in musculoskeletal care has failed us. It's time as a society we become comfortable with uncertainty and learn to focus on resolving the physical and functional deficits.

Are you ready for changes like this? Are you ready to ignore your own Ellsberg Paradox? How much uncertainty are you willing to tolerate as you practice with true direct access?

~Selena