Thinking Beyond the Diagnosis: PTs and Infectious Disease Response - A Q&A With Michel Landry, BScPT, PhD
Zika virus is back in the news, as new cases have now been reported in Texas, according to the Centers for Disease Control and Prevention (CDC), which estimates that 1 in 10 women who contracted Zika while pregnant had babies with birth defects.
What is physical therapy's potential role in responding to Zika virus and other infectious disease outbreaks? APTA PT in Motion News invited Michel D. Landry, BScPT, PhD, to discuss this topic. Landry was the lead author of a "Point of View" article published in the March 2017 issue of Physical Therapy (PTJ) titled "Zika Virus (ZIKV), Global Public Health, Disability, and Rehabilitation: Connecting the Dots…." The article already has begun generating discussion in the academic community.
Landry is a professor and chief of the Doctor of Physical Therapy Division in the Department of Orthopaedic Surgery at Duke University School of Medicine and is an affiliate in the Duke Global Health Institute (DGHI). For over 20 years, Landry has worked with international humanitarian aid and development agencies in Central America, Eastern Europe, Nepal, and Haiti. He worked as a disability consultant for the Nepal Office of the World Health Organization (WHO) after the country's 2015 earthquake and within WHO's Emergency Medical Teams in Geneva, Switzerland.
This interview has been lightly edited for clarity and brevity.
PT in Motion News (PTMN):
Thanks for taking the time to discuss your recent PTJ article about Zika and the role of rehabilitation.
Michel Landry (ML):
I'm really glad you want to talk about it. It's interesting, because, up to this point, a lot of what we talk about in physical therapy is our role inside noncommunicable and chronic disease management. And while that's absolutely true, it often feels to me like a "zero-sum game." Now [physical therapists (PTs)] do more of the noncommunicable [and chronic] diseases … but we have a role in infectious disease outbreaks. That's why we wrote the paper.
In the article, you're arguing that, at least in the context of Zika, the public health community needs to give equal weight to prevention and rehabilitation. Is that correct?
Yes. Much of the discourse that happens around infectious disease is: "We need to find a cure." And there's no human in the world that would say that would be incorrect. But it does feel … in the literature and mass media [as if it's] positioned as an either/or conversation, [that] we should forget about doing all the other stuff and addressing issues around disability (in the case of Zika, around those born with microcephaly) and plow all of our efforts into curbing the infection. What we're trying to say in the article is, "Yes, we need to focus on vaccines, but we can't forget about those who have a Zika-acquired disease." Among adults, that is often expressed in Guillain-Barré syndrome, and in infants it is expressed oftentimes as microcephaly.
We need to be as concerned with those who have survived the acquiring of the infection all the way through to looking at vaccine development for curbing the overall epidemiology.
That discussion is not terribly new. We've made the same arguments [about the importance of rehabilitation] as it relates to disaster response. I'm a PT, but I'm also 20 years working in disaster response. I work with WHO emergency medical teams. But the same thing holds true for that scenario—you have a disaster, you have a conflict, and we're able to preserve lives fairly easily now. It's quick action, disaster preparedness, easy access to antibiotics … . So you save people's lives. But they also live with spinal cord injuries, massive burns, amputations. We have to be as concerned with the long-term consequences and quality of life among people who survive war or sudden-onset disasters as we are with the kids and the adults who survived an infection. And that's where the overlap between rehabilitation, global public health, and infectious disease has to start to advance our consciousness.
I think we're making good headway in disaster response, but we're not quite there yet in terms of infectious disease parameters. A good [physical therapist] friend of mine from the UK treated a lot of the Ebola victims and, again, many of them survived. But they survived with a fairly important level of disability. We owe it, I believe, morally and ethically, to those survivors to gain [them] some sort of quality of life.
Getting back to the different manifestations of Zika, what are the top diseases and disorders that infants and children are showing up with after Zika?
Well, among infants, the manifestation is mostly microcephaly, which is not a diagnosis or condition but rather a collection of symptoms related to an underdeveloped cranium and neurologic tissues. The virus impacts the development of nervous tissue, in this case the brain. You will see all kinds of other related impairments. These kids often have significant developmental delay, some of them are blind, some of them would not be able to speak, and most will have musculoskeletal functional problems. Most of these [conditions], though, are treatable and can be improved with rehabilitation.
I've been trying to advance the term "rehabilitation-sensitive," meaning that the introduction of rehabilitation can improve outcomes. Stroke is an excellent example of that. When you have a stroke, if you don't get rehab … it's going to be very challenging. But with early intervention, with appropriate intervention in the long term, you actually could do quite well.
Also, not everyone who is infected by a carrier mosquito will develop the symptoms of Zika. Just because you're a woman, and you're from Brazil, and you get diagnosed with Zika doesn't mean you're going to have a child with microcephaly. And a lot of the diagnostic tools in low- and middle-income countries don't allow you to do in vitro diagnostics. One of the really concerning points we saw in the literature, and I referred to it in that paper, [was] that people [were saying] we need to start aborting these fetuses because the woman was diagnosed with Zika in a blood sample. Even among those who are born with microcephaly, there's a huge [range of severity of outcomes]. Some of [the infants] are very intensely affected, but many of them have very [low levels] of impairment. You can't predict outcomes until birth. We felt that even invoking the UN Convention on the Rights of Persons with Disabilities [UNCRPD], you just can't say, "Because the child might have microcephaly, we should abort the fetus." Doing that, I think, is fairly regressive from a UNCRPD perspective.
Do you think this is the tip of the iceberg, that we will find other effects in the long term?
Yes, we have no idea what the long-term effect [of Zika virus] is going to be. It's sort of like when people were exposed to Agent Orange during Vietnam—the symptoms only became clear much later on. Same thing with 9-11 survivors with regards to respiratory issues. So, you're quite right, we don't know, but I don't think that should have an impact on how we respond. I think it's incumbent upon [physical therapists] in 2017 to think, "how might we best support, encourage, integrate [the person]?" as opposed to turning a blind eye.
In an email conversation, you talked about how PTs can help change the public health conversation. You said PTs need to "learn a new language" and start thinking more about population health as opposed to the individual. Can you elaborate on that?
Here seems to be the point. Oftentimes we in [physical therapy]—and it's true in most health disciplines—train our students how we were trained, primarily to treat a [specific] patient with a [particular] condition. So patient X walks in with this profile, and here are the 3 different interventions we are going to [consider]. If you will, it's the N of 1. From a global public health perspective, we need to reject that equation and start thinking of N="community" or "population." We need to start thinking of what populations need, especially as it relates to infectious disease outbreaks.
As an example, it wasn't as though during Ebola people said, "Hey, we should involve rehabilitation." What happened is—again, people were surviving—they were placed in quarantined areas of the ICU, and being placed there they started to demonstrate clear functional decline. PTs [who were treating people who had returned from the affected areas], particularly in the United Kingdom, in some of the hospitals started to discuss and present the case that, "Listen, yes, it's an infectious disease, but put that aside for a minute. Think about the functional decline of this population [that's] been exposed to Ebola." PTs started to contextualize that in the future people [with infectious diseases] are likely going to survive, and we have to think about how they're going to integrate into their own communities. So the population health discussion and the "new language" is [that] we need to start thinking beyond the diagnosis and beyond the jargon, and talking about a population-based community reintegration model [among nontraditional populations].
We [physical therapists] might understand each other, but oftentimes policy makers [and] health systems have no idea what we're talking about. So we need to develop new language that would fit within those larger political discussions. That is one of the tangible ways, I think, we as a community of PTs can advance and integrate, and have an impact in fields we traditionally have not been involved in. And that would be infectious disease. Because, seriously, if you said to 100 PT students, "You have a role in infectious disease," they would say, "What are you talking about?" I think in 10, 15 years, we're going to [say], "Of course we have a role in all of the infectious and noncommunicable diseases."
Do you think that population health perspective may not make sense to students, when you're teaching about patient-centered care and also the emerging discussions about precision health?
It's a brilliant point, because we're all talking about this personalized medicine and personalized rehab, and doing a DNA test and strategically targeting individuals. I think we need to create a little bit of nuance. And we have to think that it's not just either/or, it's both/and. It has to be a combined effort. I would like to see us in the future think that the continuum [of health care] begins at the cellular level and ends in the population. And we all have a role to play in that trajectory. Right now, I don't believe we have enough effort and focus and interest in that population-level end of the continuum, [although] a lot of PTs have really great interests and skills, and are really targeting that early phase. We have to elongate that conversation.
To give you an example, let's pretend we're at CSM. Let's say you have a presentation on … a topic that's very specific and somewhat obscure—and right next to it you have a presentation on population health. If you had 100 participants, and if you took the average PT, you'd have 98 of them wanting to go to the [first presentation], and maybe 2 in the population health [presentation]. It's not as though anybody is wrong; I just believe we need to put more fuel into that population and community health policy conversation. When you talk public health among PTs, they often make the link directly [to community-based exercise programs]—but it's much more complicated than that.
Yes, when you hear "public health" and "physical therapy" in the same sentence, it's often about obesity or some other chronic disease. Can you think of any strategies for "boots on the ground" PTs to use to educate employers or physician colleagues about the importance of physical therapy in disaster response and infectious disease?
I think there are [a few] ways to look at it. One of them is financial. In an infectious disease model or a disaster scenario, or even in a plain old population perspective, if we're ready to invest in that early phase of life preservation and intensive care units, and all of the things that are required to preserve life, it seems to me counterintuitive not to invest in a continuum, which will at least allow that person who's survived [to gain] some quality of life. Quality of life also means [enabling a person to] go back into employment, take care of their family. It makes no sense to me to invest high resources into the early phase of [treating] an individual or population without investing in interventions like rehab that amplify those early successes and facilitate longer-term outcomes.
Morally, ethically, I think [rehabilitation in a disaster scenario] is also something we might [look at through] a different lens. [We] preserve life, but we can't just stop there. Can we really just leave that person to fend for themselves in communities that are often hostile to persons with disabilities? In my mind, we just cannot and must not think this would be morally acceptable. It affects the whole community. We should not look at it as an individual going back to live independently or by themselves. [The patients] often, especially in low- and middle-income countries, go back to live among their family and community. If we send them back into their previous environment with poor function, what often happens is that the community has to somehow take care of that person, or there is a feeling that [the community] must care for them. And what that means, usually, is that [the caregiver] can't be working to earn money for the family. The next stage is you start to propel [individuals and communities] into poverty.
So there is a moral/ethical reason to say, yes, in an infectious disease you need the early emergency medical interventions, but in order for them to go back and be part of their community they need to have some sort of rehab. If you don't do it, basically you're risking and promulgating further poverty in an area that already knows poverty very well. And that is exactly the case in places like Brazil.
The third [argument] has to do with just using an evidence-based perspective. If a child were born here, in Durham (NC) or in Washington, DC, with microcephaly, what kind of care would we provide that child here? And if we were to say we would provide some sort of continuum [of care because] there is a social welfare safety net for that child and that family—should we not seek to recreate that same scenario? Maybe at different amplitudes and at different levels, but should we not seek to do that [for people] in low and middle-income countries?
If there is something that is known to facilitate and improve function, should we not, as a global community, engage in that action, whether they are born in Washington, DC, or in São Paulo?
What is the next step that needs to be taken to get this conversation going among the public health community, the broader medical community, the physical therapy community?
Here's what I'd like to see, and it's actually kind of happening. The paper that [we wrote] has no [primary] data. We didn't collect any data; it's an editorial. And I have had more requests for that article than many of my other publications I've ever written. So it is striking a chord because people outside of the physical therapy world are recognizing that public health and infectious disease actually means people are now likely to survive. [The global public health community] needs to think about what that long term is going to be. The medical community, the nursing community, don't oftentimes know what that [rehab] stage is. They know it's important, but they're not really sure what to do about it.
I'll give you a quick example, in Nepal [after the earthquake]. There was some unclarity among the WHO [emergency] deployment teams regarding people with spinal cord injuries [SCI] who had survived, where they were, how many there were, etc. Many SCI survivors were in the acute medical setting and were medically stabilized, but because of uncertainty about the community resources for these people, they remained in the acute setting and were blocking beds for other trauma victims. [The medical system] called in rehab providers and said, "Listen, you need to get in here and help to facilitate discharge. We don't know how to deal with this situation." Previously they would have just sent those patients home. So there is now an acknowledgment that rehab has a role to play, although they don't often know what that role is. It's incumbent upon us to start to articulate what that role is, and what the effects would be in austere settings and environments. But we can't make that articulation or make that argument as we have been for the last 100 years, which is about [the clinician-patient relationship]. We have to look at from a multidisciplinary and public health perspective. We in PT [say] that we do that, but in practice I don't know that we do it that well.
On a global scene—and that's why I'm saying we need to learn a new language—we need to be able to communicate with people who often are totally unclear why we should be having rehab, or what rehab is, especially in emergency response. It's 2017—we have been around for [almost] 100 years. [Rehab is] still not very well perceived or very well defined. We need to articulate that rehab is not just about chronic disease, but that it has a role all across the continuum, including in infectious disease.
Not to scare anybody, but we all have this assumption—because we all watch too much television—that when there's some sort of nuclear attack or a spill, all of a sudden there are all these emergency teams from some military base who arrive with gas masks and other things. But actually that doesn't really exist in life.
So we need to be prepared not for what has happened in the past but what might be occurring in the future. You see now in Syria, there actually has been [evidence of] gas attacks. What is the PT role in that [scenario]? Have we ever talked about it? Have we ever decided what it might be? I don't want to leave it up to chance for maybe a physician who's deployed saying, maybe after a gas attack, "This sort of looks like a burn, maybe we should include a rehabilitation provider." We need to be way ahead of the curve, and not just responding to it.
How difficult will it be to engage physicians in thinking about this as a multidisciplinary effort? There are recent reports, for example, of physicians not always following CDC guidance to ensure that infants exposed to Zika receive brain imaging, even if microcephaly is not present at birth.
How do we instill change? I think it's difficult. Maybe if we start using the language of physicians and emergency response teams, as an example. But we also have to be present at the right place at the right time. We need to have strong advocates strategically placed along the trajectory. Our health system in the United States is extremely disjointed, at best. So it's not as if those physicians are trying to do harm. Everybody [in the health care system] is doing what they think is the right thing, but we've never taught people how to work together. And so we've never actually integrated [how] these multidisciplinary teams [need] to be thinking and working differently [in practice].
I think we need to do a better job [of] professionalizing how we look at advocacy [in global health]. There are a lot of areas we could probably improve. Sometimes it's easier to make changes in a global world than in our own backyard. Maybe it's time to hold a special session about our role in infectious disease and articulate some guidelines. The only way to encourage people to change, in many ways, is if there's an approved guideline or recognized standard. Maybe it's time to sit down and say, "What is our role the next time we see another Ebola or another Zika?" Or, heaven forbid, when it happens in our backyard. Are we ready to respond? The answer, truly, is no. We are not ready, in the United States, for a major outbreak on the order of what happened with Zika or Ebola.
To switch gears, aside from looking at long-term physical disabilities that often result from Zika, what are your thoughts on the role of early intervention and its impact on disability outcomes?
This is a relationship that's very stable in the literature. Early intervention mediates the outcomes in the long term. With Guillain-Barré as an example, in the early stages, if there are no passive range-of-motion exercises, and [if there is no education to help] the person understand what the disease state is, the outcomes are often poor. Early intervention pays off dividends in the long term.
Same thing holds for early intervention for children. If you have [a child] born with microcephaly, oftentimes they're overprotected by the parents. That's actually the last thing you want to do in many cases. It's kind of counterintuitive, but you need to be intervening (and I'm not a pediatric specialist) early in terms of identifying the specific impairments. If it's sensory deprivation, you're going to start thinking about how you're going to stimulate sensory [systems]. The kids we're talking about [after Zika infection] are now about a year-and-a-half, or 2 [years old]. [In Brazil] there is very little capacity among these rehab providers to be doing these newer evidence-based approaches. [The children] likely are not getting that care. And their outcomes are going to be poorer [than if they had received early intervention]; there's no doubt about that.
Maybe one thing I haven't yet said: What we need to do as emergency responders right from the start is think about capacity-building in the local context. Had we, for instance, as rehab providers, been heavily involved in the Zika outbreak, we could have been there at the forefront, alongside the emergency teams, addressing the early stages [of medical and rehab interventions] but also building capacity among the other providers, so that when we depart we leave something behind, some level of feasible infrastructure. We can't recreate a Shepherd Center in São Paulo [for people with SCI], but we can create better capacity among those [providers and institutions] who are there.
It has nothing to do with the existing quality of care with [the local] providers, but they have never really had to deal with this kind of context before. A quick story; I'll never forget this one: I was in Haiti within a couple of days after the earthquake [in 2010]. We were admitting patients with spinal cord injury in a small, make-shift, barracks-style facility. At the end of 2 days, we admitted 18 patients with spinal cord injuries. It was a brutal 48 hours. At the end of the second day, we were sitting and having drinks, and 1 of the Haitian nurses said to me something I'll never forget. She said, "What kind of earthquake did you have in Canada that you have all this experience with spinal cord injury?" It occurred to me at that moment that she had about 2 days of spinal cord experience, but we in North America have been doing spinal cord rehab for over 60 years. So right away it demonstrates in much of the lower and middle-income countries, they never had to manage some of these complex disabilities and conditions. You know, so it's incumbent upon us to say, "It's not that they don't have the capacity, it's that they've never been exposed and have never had the training." Part of our MO [as emergency aid workers] has to be to deploy, be involved, and capacity-build right away.
Is there anything we can do to better prepare parents or potential parents of children affected by Zika, based on what we know about it?
You know, I think so. We've never had any conversation in the rehabilitation community about Zika. I don't recall anything major happening. We don't really have good guidelines. We often borrow from other pediatric conditions and say, do this, but despite all the events, because it had such a low impact in the United States relative to other countries, we didn't go to the next step. Had all of this happened in the US, we probably would have said we need to develop guidelines, we need to do all these different things. Could we create more specific emergency guidelines on rehab for infectious disease? One hundred percent, absolutely. I'm not sure why we're not doing this. Maybe we need a disaster committee within APTA that is going to start thinking about what our role might be. We need a call to action, I think, and one that takes the conversation out of small groups of individuals and into the larger national strategic conversation.
Transformation Requires Reinvention
By Mike Eisenhart, PT
The health care environment is changing, and it seems increasingly clear that there is no going back. Although none of us knows exactly how the landscape will look when we get to the end of this journey, the high cost and comparatively low return nature of our current models of care, coupled with the need to service many more consumers, make it clear that a fundamental shift in the way we do things will be required.
I believe there are opportunities for physical therapists (PTs) to take the lead in this shift—including a project I'm calling the "employer initiative." I'll get to that later.
But first: what kind of shift am I talking about?
It's a shift that's not solely an "us" (PTs) or even an "US" (our nation) thing. Global megatrends, most notably the rising dominance of noncommunicable diseases as the leading causes of death and disability worldwide, are pushing all stakeholders (payers, providers, governments, and end-users) to find better ways to, at a minimum, evolve current systems to enable consistent delivery of better outcomes at a lower burden.
The thought of continuing to lose ground in the management of modern chronic conditions by trying to leverage tools better suited to infectious diseases of the industrial age while being paid less and less has contributed to more error and burnout than we can in good conscience allow. The outcome is not good for users, providers, or those, such as employers, who ultimately pay for this "care-of-diminishing-returns."
Since the current model seems ill-equipped to meet the need, and the current trajectory appears to miss the target, it is quite possible we will need to reinvent things entirely.
For example, we currently apply treatment approaches that severely limit the number of lives we can interface with and thus our likelihood of success in our quest to transform society, but we can change this. We can move toward population health models in which cohorts of individuals are impacted by not only the techniques and interventions we apply but also the knowledge we have gained.
It will require a reexamination of our policies, consideration of how we can best work with other providers in teams, a research agenda that empirically validates our effectiveness in these approaches, and, likely, fairly aggressive funding of projects that can demonstrate how we can leverage the rather nuanced skills required to work at the population level in a way that yields dramatic, life-altering results for our clients and a challenging yet fulfilling work life for our peers.
This may not feel comfortable, and, admittedly, it is certainly not what we're used to. However, we can start by continuing to refine models that reward providers who help people stay healthy, such as the ones employers are increasingly seeing strategic value in and paying for directly, the same type that a few of us have been delivering and advocating for for many years. If as a profession we are willing to recognize and react to the urgency, we can begin to reposition ourselves to actually deliver on the mandate of our vision and, in so doing, deliver on the essential promise that we help individuals and populations alike move away from disease and toward improved health and quality of life.
To that end, and with the help of a great group of APTA members and staff, I have begun working on an initiative that aims to help our profession gain some much needed traction in this area. The purpose of employer initiative is to build both a demand (increase the number of employers who want to work with PTs) and supply (increase the resources available for PTs who are interested in population health approaches). We recognize that although they are not the only avenue, employers may be the ideal starting point as they have a direct interest in lowering health care costs and maintaining a productive workforce—2 goals that we know can be achieved with better health.
You will hear more from the work group as we continue ramp up our efforts and connect with various stakeholders in this process. However, as an initial step, a free-to-members webinar-style presentation was launched recently on the APTA Learning Center, and we are following that up with a live Q-and-A session on March 9. We hope you join the discussion!
Undoubtedly the effort required to make a fundamental change in the way we do things will be significant. To rework our individual-upward "treat the person in front of you" approach to one that features a population-downward "manage resources in the most efficient way possible" approach is a major shift in the way we do things. Moving from a conceptual framework of physical therapy as a service (to be marketed) to one of physical therapy as a solution to a societal problem will not be a simple plug-and-play for us.
And yes, this may seem daunting (as fundamental change sometimes does), but it is not entirely different from the change we promote when asking our patients and clients to move differently, to thoughtfully consider lifestyle choices like eating better, or to quit smoking as a means to improve their healing rate, prognosis, and ultimately their health arc.
Professionals who minimize the total cost of care by effectively providing conservative (lifestyle) interventions such as exercise, nutrition, and recovery strategies—early enough in the health continuum to prevent, slow, or ultimately reverse the progression of noncommunicable disease—will more effectively deliver on our ultimate brand promise: to help individuals live the best possible version of themselves.
Mike Eisenhart, PT, is the managing partner of Pro-Activity Associates, a prevention and population health practice located in Lebanon, New Jersey, and a founding member of the Academy of Prevention and Health Promotion Therapies. Eisenhart is also the president of APTA of New Jersey and a member of several sections. You can follow him on Twitter @MikeEisenhart or email him at Mike.Eisenhart@aphpt.org.
All-Size Health Care Should Fit One
By Stephania Bell, PT
It was impossible to read Eric Topol's recent Washington Post article without cringing. In it, he describes enduring "three months of physical torture" in a physical therapy setting after undergoing a total knee replacement.
Eventually Topol discovered he was among the "2 to 3 percent of patients" who develop arthrofibrosis following knee replacement, a condition he—a physician—had never heard of prior to his personal experience.
The real problem, Topol concluded, was that he was suffering from "one-size-fits-all medicine." Topol makes reference to standard protocols and preprinted exercise sheets that did not account for his worsening condition when describing his initial course of physical therapy, implying an impersonal encounter that overlooked the patient in patient care.
Stories like this are disheartening, whether they appear in a major news publication or are shared in a casual conversation. But as tempting as it might be to pick apart the various missteps Topol ascribes to his initial physical therapist (PT) team, the more important takeaways come from how the story takes a 180-degree turn.
Topol reluctantly embarked on a second course of physical therapist treatment, transferring to a practitioner recommended to him by a friend. He then experienced, as he described it, a "dramatic turnaround" within days. It quickly becomes apparent why this second round of physical therapy was so much more positive: the PT addressed Topol as an individual and built a plan of care accordingly.
I couldn't help but be drawn to the language Topol used to describe this new physical therapy experience, and I have excerpted some of it here along with a few thoughts of my own.
For instance, Topol writes, "In taking a detailed history, [the PT] zoomed in on my decades of osteochondritis dissecans and that I had a frozen shoulder five years ago, which meant that I have a propensity to scarring in joints."
(Me: This level of history taking should be standard for PTs. Underlying health conditions can hint at challenges that may lie ahead. Explaining to the patient how those conditions can potentially impact the course of care can go a long way toward proactively intervening.)
Topol adds that the PT "carefully examined" his knee, then made recommendations for alternate exercises, something he describes as an "individualized" new plan, "epitomized by her handwritten page of instructions."
(Me: PTs' hands are among their best tools. Careful yet deliberate physical examination is integral to establishing trust with a patient, as happened in this case. The prescribed exercises may not have been unique, but the PT's personal touch made an impact here, conveying a plan of care specific to the patient. While there is nothing wrong with using technology to be more efficient, such as computer-generated exercise sheets, personalization of those exercise sheets with patient-specific notes can reinforce that a program is uniquely designed for the patient.)
Topol also notes that his PT would text him every couple of days to check in on "their" knee. He writes, "We built on the initial success with additional gentle exercises."
(Me: Interesting that he says "WE built on the initial success …" His view of the physical therapy experience had become one of a team working successfully together toward a positive outcome. The PT demonstrated genuine concern for this patient by communicating outside of the clinic visit to ensure he was progressing. The patient recognized the therapist's concern for his unique situation.)
The other noteworthy element is what isn't stated. Other than referring generally to exercises, Topol makes no mention of any specific therapeutic intervention. The biggest impact to his experience was not the PT treatment; it was the PT's treatment of him as an individual.
In the end, it wasn't just Topol's first PT who failed him. He resorted to numerous treatments "for which there were no clinical trials to show benefit," yet his symptoms continued to worsen. He received limited guidance from his orthopedic surgeon other than the prospect of additional surgery. After discovering arthrofibrosis, Topol says he was getting desperate: "My surgeon had little to offer except to say that by a year the inflammation should burn out and he could go in through a scope and take out the scar tissue."
The entire health care system should be better than this.
In a better system, all members of the team maintain open dialogue about a patient's care. Is an orthopedic surgery patient's experience not enhanced when the surgeon and the PT communicate with one another? As someone who has had the good fortune of working side by side with orthopedic surgeons, primary care physicians, and other health care providers in both a university sports medicine setting and a multidisciplinary clinical setting, I cannot imagine it any other way. Even if not sharing the same physical space, we as PTs serve our patients better when we work in collaboration with other providers instead of in isolation.
We are not the only providers who subscribe to this concept. Orthopedic surgeons will often tell me they value the perspective the PT has when seeing the patient repeatedly over time instead of in the operating room or brief clinic visits as they typically do. One surgeon offered this analogy: Surgeons get the snapshot of how a patient is doing at 1 specific moment in time; PTs get the whole video.
Robin West, MD, chair of Inova Sports Medicine and head team physician for both the Washington Nationals and Washington Redskins, had this to say in response to Topol's story:
"Dr Topol tells a great story of how important ‘precision medicine' is in all aspects of health care. As an orthopaedic surgeon and professional team physician, I always focus on personalized care and emphasize the importance of working with like-minded physical therapists. Treating patients is not ‘cookie cutter' medicine, and the care from all health care professionals should be focused on individualized care incorporating a comprehensive history, physical exam, and rehabilitation plan. Frequent communication amongst the ‘medical team' is key and will offer patients a chance for the best recovery. The medical team is made up of everyone involved in the patient's care: physicians, physical therapists, athletic trainers, nutritionists, coaches, nurses, and others."
West's perspective is doubly meaningful since she recently has been on the receiving end of physical therapist treatment after sustaining several severe injuries in a bike accident.
"I got to experience the importance of individualized care firsthand a few months ago," West said. "I required two surgeries and extensive physical therapy. I not only had phenomenal surgeons, but I was also blessed to work with exceptional physical therapists. The surgeons and physical therapists provided me with the best individualized care, emphasizing my specific injuries. They constructed a rehabilitation plan based on my injuries, surgeries, and personal goals."
In covering athletes' injuries and recovery processes for my current role at ESPN, these types of stories of one-size-fits-all medicine are relatively rare. While it isn't to say that athletes don't have their own unique challenges, many of them are of a high-enough profile that their care is being closely monitored. Rehabilitation efforts typically are uniquely constructed to fit the athletes as well as their sport and the position they play within that sport. Multiple providers communicate with one another regarding the status of the athlete, and there is no shortage of attention to their progress.
That approach should apply to the care of all patients at all levels. As West points out, "All patients deserve personalized health care and should seek out the medical team that will offer it to them."
When I originally elected to pursue a career in physical therapy, it was a direct result of time spent as a student working in the training room at Princeton University, observing the relationships that formed between patients and their PTs throughout the course of their rehab experience. I chose physical therapy because I believed I would get the opportunity to collaborate with my patients to develop a personalized plan of care—a roadmap of sorts—toward achieving their goals. The execution of the plan would represent the journey with the arrival at the final destination representing mutual success. I was fortunate enough to practice in clinical and teaching environments with peers who shared this view of tailor-made health care, in collaboration with one another and, most important, with our patients.
We ask patients to trust us with their care when they make a choice to seek out PTs. The least we can do is give each one of them the individualized care worthy of that trust.
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Stephania Bell, PT, is a board-certified orthopedic clinical specialist and a certified strength and conditioning specialist. She works full time as a senior writer and injury analyst for ESPN and cohosts ESPN Radio's weekday Fantasy Focus Football podcast. Bell also regularly appears on SportsCenter, Fantasy Football Now, and Fantasy Football Kickoff, and she contributes to NFL Insiders, NFL Live, Outside the Lines, and Baseball Tonight.
The Link Between Nutrition and Pain Is too Strong to Ignore in Your PT Practice
By Joe Tatta, PT, DPT
Here's a situation I bet you see all too often in your practice: a patient or client comes to you to overcome pain and increase mobility, and you see almost immediately that working on the mechanics of motion won't be enough—they could really benefit from some lifestyle changes as well. Frequently, one of those changes involves thinking more carefully about the food they're putting into their bodies.
Despite Hippocrates' oft-quoted "Let food be thy medicine," most physicians receive only a few hours of instruction about nutrition and coaching to help patients change their eating habits. Yet studies like this one from the National Institutes of Health show nutritional education becomes an incredibly useful tool to improve overall health outcomes for patients and specifically reduce inflammation.
As PTs, we are presented with a real opportunity here. Research shows that PTs can play an active role in lifestyle-related interventions such as nutrition. Providing information on nutrition will put you ahead of the curve with your peers while improving your patients' results.
Early in my practice, I saw how obesity often contributed to my patients' pain. Once I began providing information on some simple diet and lifestyle strategies with my patients, many lost weight, felt better, and dramatically reduced their pain. Nutrition became the missing link to help my patients manage and relieve pain.
Over time, I've found that nutritional screening and informational strategies can make a difference in 5 conditions associated with pain that we often see in our practices:
Inflammation. Copious inflammatory foods, including vegetable oils, populate the Western diet. Most observational and interventional studies show a traditional Mediterranean diet, rich in healthy fatty acids, fruits, vegetables and fiber, provides anti-inflammatory benefits. Among specific conditions, studies show a Mediterranean diet rich in polyunsaturated fatty acids and antioxidants provide anti-inflammatory effects that benefit individuals with rheumatoid arthritis. Epidemiologic and clinical evidence likewise shows an optimal diet can reduce inflammation that, among other things, contributes to metabolic syndrome.
Obesity. As we all know, a vicious cycle ensues as obesity contributes to numerous chronic pain conditions, and the pain in turn can lead to sedentary behavior that increases obesity. Studies prove what I've seen countless times in my own practice: weight loss must become a crucial aspect of overall pain rehabilitation.
Osteoarthritis (OA). Studies have shown a relationship between pain and food intake among overweight and obese patients with OA. Fortunately, obesity is the most modifiable risk factor for knee OA. Of course, pain management is crucial to reducing OA symptoms. But even that may have a nutrition connection: one systematic review found scientific evidence to support some specific nutritional interventions–including omega 3 fatty acids–to relieve symptoms among patients with OA. Studies also show various nutrient deficiencies, including vitamins C and D as well as selenium, contribute to OA.
Autoimmune disease. NIH estimates that 23.5 million Americans have an autoimmune disease (compare that with cancer, which affects 13 million Americans). Over 80 autoimmune disorders exist, including Crohn's disease, rheumatoid arthritis, multiple sclerosis, and type 1 diabetes. Of course, genetic predisposition, environmental factors (including infections), and gut dysbiosis play major roles in autoimmune disease development. But increasingly, researchers believe adverse dietary changes over the past 50 years–including gluten intolerances, altered gut bacteria, and vitamin D deficiencies–also contribute to that increased rate of autoimmune diseases. Chief among those changes is our prevalent high-sugar, high-salt, processed-food heavy diet that paves the pathway for autoimmune diseases. Nutrient-poor diets only exacerbate that problem: evidence shows vitamin D, vitamin A, selenium, zinc, omega-3 fatty acids, probiotics, and flavanol deficiencies contribute to autoimmune diseases.
Prediabetes and type 2 diabetes. Type 2 diabetes affects 29.1 million Americans (that's over 9% of the population) and paves the way for serious complications such as heart disease, blindness, kidney failure, and lower-extremity amputations. Diabetic neuropathic pain, a common diabetes complication and the most common form of neuropathic pain, affects over 90% of people with diabetes. Studies show increased musculoskeletal pain in patients with type 2 diabetes adversely impacts body mass index, quality of life, physical function, and physical activity abilities. The link between diabetes and nutrition is a fundamental one that should never be set aside.
Working with patients suffering these and other conditions, I'm often impressed how optimal nutrition becomes the needle-mover to alleviate pain and help people heal. So how can a PT incorporate these considerations into practice? Here are a few simple tactics you can use right now:
Ask nutrition-related questions during your initial consultation. Simple things like "do you take a multivitamin" or "about how many vegetable servings do you eat a week" can help lead to gradual dietary tweaks that yield impressive results.
Have your patients keep a 24-hour food diary. Beyond establishing adherence and accountability, asking patients to write down everything they eat for 24 hours provides insight to their daily eating habits. Once you have that insight, you can help them gradually improve those habits.
Offer some simple information. Rather than impose a major dietary overhaul, ask patients to do things that don't seem so overwhelming; for example, to increase their water intake, or eliminate processed foods and sugar.
Create simple, attainable goals. Begin by allowing your patients to experience success in some way. You might ask a patient to lose 5 pounds over 3 weeks, or provide information about incorporating more omega-3 fats into their diet combined with their exercise program. These goals are doable, and they can provide your patient with the confidence to take on more challenging targets.
Offer your patients other ways to access information on better nutrition. Providing your patients with collateral sources of information—a helpful blog post, or an engaging book on nutrition—helps to reinforce the idea that the benefits of what they're doing are well-established, and that they're not alone in their journey toward healthier living. During a subsequent visit, ask patients if they got anything out of what you shared. The more reliable, readable information they receive, the better the chances that they'll begin to become genuinely interested in the topic themselves, and for the long run. Over time, I've even had a few patients recommend books and blogs to me. Refer patients to nutrition and dietary professionals when their needs exceed the professional scope and your personal scope of practice.
If you've incorporated nutritional screening and information into your practice, what did you find was the most challenging aspect? Did you see results when patients made those changes? Share your thoughts below.
Joe Tatta, PT, DPT, is a board-certified nutrition specialist and functional medicine practitioner who specializes in treating lifestyle-related musculoskeletal, metabolic, and autoimmune health issues. He is the creator of the Healing Pain Online Summit and The Healing Pain Podcast, and is the author of Heal Your Pain Now: A revolutionary program to reset your brain and body for a pain-free life by Da Capo Press. Learn more by visiting www.drjoetatta.com/apta.
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Confessions of a Tech-Challenged PT: Asking Searching Questions – And Getting Useful Answers
By Stephanie Miller, PT
I'll admit it: I’m excited about all that I can do with PTNow. This is somewhat unusual for me, because I've always felt a little daunted by technology (see my first post for more on that).
But this thing is awesome.
And yet, the fact that PTNow is so awesome—that it contains so much information—can feel a little … overwhelming. I mean, where do you start? How do you start?
Here's how I got my feet wet, and a few tips based on what I've learned along the way.
To begin with, I decided early on that I’d focus on small chunks, and get comfortable with bits and pieces at a time. I mean, anything new I learn today is more than I knew yesterday, right? Since I’d like to do a better job at searching articles, I thought ArticleSearch would be a good place to start. Seemed easy enough.
As heart failure is a common diagnosis in my practice area of home health, I decided to search on that topic. I began with the "basic search" option. The search window is what you'd expect: a box in which you can type in whatever search terms you're looking for.
But then came the challenging part … all of the databases. ArticleSearch lets you choose which databases you want to use in your search, and although I vaguely recognized a few from grad school, I hated to admit that a lot of them were foreign to me. But where there’s a will, there’s a way! I was determined to understand the value of each and identify why I would select one over the other. Fortunately, the PTNow tutorial video helps to explain the differences.
The abstracts to the best articles are found using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ProQuest Health and Medical Complete, ProQuest Nursing and Allied Health Source, and SPORTDiscus. There are differences between them. Here's a quick comparison, based on what I learned from the PTNow tutorial.
- Topics: nursing, allied health, general health
- Over 1,300 journals
- Evidence-based care sheets and quick lessons
ProQuest Nursing and Allied Health Source
- Topics: nursing, allied health, alternative and complementary medicine
- Journals, clinical training videos, evidence-based resources
- Over 1,000 full-text articles
- Over 15,000 full-text dissertations
ProQuest Health and Medical Complete
- Topics: clinical and biomedical, consumer health, health administration
- Over 1,500 publications; over 1,000 of them full-text
- Topics: sports and sports medicine, fitness, health, sport studies
- Full-text for 550 journals
Cochrane Database of Systematic Reviews
- Full-text articles, all systematic reviews
- Protocols and evidence-based data
- Updated regularly
- Investigations of the effects of interventions for prevention, treatment, and rehabilitation
If you're looking for a specific kind of research resource, here's what the tutorial suggests:
CINAHL Complete, Proquest Nursing and Allied Health Source, Proquest Health and Medical Complete, SPORTDiscus (be sure to select the "full-text only" option on the search page)
Cochrane Database of Systematic Reviews
Physical therapy-specific research
CINAHL Complete, Proquest Nursing and Allied Health Source, Proquest Health and Medical Complete
As for my own search …
After becoming more comfortable with the benefits of each database, I decided that the Cochrane database was the place I wanted to begin my investigation into the effects of exercise on patients with congestive heart failure. I clicked on the link, typed in "effects of exercise on patients with congestive heart failure" in the search bar, and chose the Cochrane database. In a few seconds I found articles on the beneficial effects of combined exercise training on early recovery, the effects of specific inspiratory muscle training on the sensation of dyspnea and exercise tolerance, the role resistance exercise training can play in improving heart function and physical fitness in stable patients with heart failure, and the effects of short-term exercise training and activity restriction on functional capacity in patients with severe chronic congestive heart failure, to name just a few. Wow.
Through this whole experience, I not only learned some of the details of how ArticleSearch works, I also got a better sense of how to get the most out of my searches. I suggest a few general tips:
Take time to learn. Invest the time in learning each database and the benefits of using one over the other.
More isn't always better. Avoid searching every database. You can end up with so many potentially irrelevant options to review that it’s easy to get overwhelmed as you attempt to weed out the information you want. Choose only the search engines that can best target your specific topic, using the above information to guide your selection.
Get help early on. If you start feeling confused, your time will be better spent if you take a break from your search and learn more about the resources you're working with—trying and trying again when you don't really understand the system can be frustrating and may result in you missing out on some valuable information. If you start to feel a little unsure of yourself, take a few minutes to check out the PTNow Video Tutorial and FAQ page. Have a more specific question? You can even access an actual PTNow librarian at ArticleSearch@apta.org.
If, like me, you sometimes wrestle with technology, you'll understand this mixed bag I feel when I'm faced with something outside my technological comfort zone: I know technology can make my professional life easier, but I worry that the technology itself won't be easy. I was happily mistaken with ArticleSearch. It was so easy!
How easy? Let me put it this way—I have a lot of reading to do.
Stephanie Miller is a staff development specialist with Celtic Healthcare.
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Leading Evidence-Based Innovation at Your Facility, Part 3: The Team's the Thing
By Kelly Daley, PT, MBA
In earlier posts, I touched on some ideas around how to achieve leadership buy-in for a systematic, evidence-based change in your facility's practice, and how to prepare for and measure effectiveness. Now comes the third step (and the step many consider the most fun): bringing a core team together.
Why can this be so much fun? Because this is where the magic happens. And it really does take a team. Although you may be at the helm of this new program, you'll want to engage several others who offer needed skills as invested team members. In other words, don't make the mistake of seeing this as all yours just because you are leading it.
If you're finding yourself stretched thin, you may want to identify an operational leader. Get help from someone who sees and understands the big picture, and can assist in overcoming barriers, garnering resources, and creating sustainability.
And if you really want to power up your team, consider adding a statistical star. It's very helpful to engage someone who can add statistical and analytics power to your program. This may seem intimidating if you are not in a facility where this type of support already exists (and believe me it doesn't readily exist for 99% of us), but there are ways you can make it happen.
First, remember: you have critical clinical knowledge of the most appropriate outcome measure and its related levels of MCID (minimal clinically important difference). I talked about that in my last post.
Just because your facility doesn't have an identified staff member focused solely on statistics doesn't mean nobody has those skills, so look around internally first. Alternatively, try your DPT university partners—if you provide student internships, then this type of support may be a reasonable trade off.
And here's another avenue: Think about reaching out to known physical therapy researchers who may be willing to be involved in some way. This isn't as impossible as it might sound. You can contact APTA's Professional Affairs Unit at email@example.com for help on identifying the availability of potential researchers. You never know who may be interested in what you're doing.
It is powerful to connect with someone who buys into your evidence-based initiative and can contribute statistical knowledge for the design and production of analytic reports. These reports will speak to the baseline (pre-pilot), initial evaluation, and post-treatment improvements in value. And a statistical specialist can help you think about how you want to slice your data to best suit your facility. Do you need to see these measures as they relate to clusters of ICD-10s? By stratification of patient demographics? By individual therapists? And so on. Having a statistics-minded team member on hand can help you not only get the data, but also think about which data are the most important, and how they should be teased out and presented.
Regardless of whether you're fortunate enough to include both a statistics person and an operational person on your team, the most important thing is to create a team of some kind, and honor it. A strong, engaged core team means local buy-in. You're no longer trying to get everyone to follow "your" idea, because a team approach invites everyone to take ownership in the idea. And that's a good thing. With coworkers on board, you can concentrate on maintaining appropriate momentum, and ensuring no single team member is unduly burdened.
One final tip: never be afraid to ask for advice. You may be championing a truly wonderful idea that could change the lives of your patients, but that fact alone won't make your vision a reality. You need the support and input of others, from assistants who know the on-the-ground realities, to the administration insider who knows the ins and outs of your facility's leadership dynamics, to fellow therapists who may have attempted to introduce innovation at your facility or elsewhere. Ask for their input—and then listen.
Implementing evidence-based innovation can be complicated, confusing, and frustrating. But you can do it. And the payoff—seeing how the change actually makes your facility a better place for your patients, and watching as patients reach better outcomes—is more than worth the effort.
Go for it.
Kelly Daley is clinical informatics program coordinator for Johns Hopkins Hospital, in Baltimore, Maryland.
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Leading Evidence-Based Innovation at Your Facility, Part 2: Knowing What Success Looks Like
By Kelly Daley, PT, MBA
Welcome to part 2 in a 3-part collection of tips on how to introduce evidence-based systematic change in your facility. In part 1, I discussed getting buy-in from leadership in order to launch the change. Now let's discuss what happens after you get that support.
The next step? Considering the best measures of success.
You really believe in this change, and you've convinced leadership of its value, so now you need to figure out how you're going to know if the change is really working for your facility. This can get tricky, but stay focused and summon up all your analytical abilities, and you'll be fine.
Of course you'll want to demonstrate that the initiative is actually helping patients to improve by, at the very least, showing incremental improvement over baseline, through a difference in scores between evaluation and end of the episode of care. But you also will need to make the value case (the "amount of improvement, per dollar spent, in outcomes your patients care about" that I covered in the first post in this series). And even more to the point, you'll need to make the value case for the initiative compared with the ways your facility operated before the change.
For instance, for a low back pain initiative you may choose to use the Oswestry score and a count of visits per episode to verify improvement over time, and then multiply the approximate per-visit cost by the average number of visits per episode. You will have not only an understanding of how much improvement patients experienced, but just how much it cost to achieve that level of improvement. After that, you can compare these with similar data from the previous approach, and if all goes as expected, you'll be able to demonstrate value.
If these data are collected and reported by your electronic health record (EHR) or other software, then that's great, but there are other ways to get that information. These other ways could include paper collection (simple, cheap, and low-tech, but takes a lot of manual entering of information to get at value), tablet entry to a database outside of the EMR (such as in a waiting room), or data collection from wrist fitness bands or other devices. And there's always the possibility that you might partner with payers, such as Medicare or private payers, that offer their own analytics around your care patterns for a given diagnosis.
But having a solid source of data isn't enough by itself. It's how you approach it and what you do with it that matters. So ...
Be deliberate. Consider taking your measures of baseline first, before starting a pilot. Then, with leadership's approval, try your pilot with a few patients (and therapists if there is more than 1) for a fixed amount of time.
Evaluate. Gather data from the measures used in your pilot, then carefully consider what you've learned. What incremental improvement have you seen? Have you seen indicators of enough incremental improvement to continue to build this initiative? Remember, it's possible that the pilot didn't do what you had hoped—that's important information too.
Refine. Provided that your pilot has produced outcomes that show promise, combine your pilot information with scholarly evidence (such as clinical practice guidelines) to finalize your proposed initiative. A 2008 article in BMJ titled "Translating evidence into practice: a model for large scale knowledge translation" can give you more insight on the process.
Keep the loop going. Initial buy-in is important, but you also want to ensure long-term engagement from both your leadership sponsor and from the team actively involved in implementing the change. Keep up the monitoring and bring back findings on a regular basis, especially as the formal program takes shape.
(A quick tip: if you want to get a better idea as to whether your approach is on target, a good resource is the "Plan-Do-Study-Act" template offered by CMS—it provides clear, easy-to-follow guidance. Just remember that you're looking toward making systematic, clinic-wide change here—maybe bigger than that—and not just looking at what your own patients are doing.)
It's easy to get excited about implementing a change you believe will make a difference in the lives of your patients, but don't let that excitement turn into impatience. The transition from plan formulation, to pilot testing, to refining the actual program requires a careful approach—but that only increases the chance that the end result will be what got you so excited in the first place.
Coming up in the third and final installment in this series: a few tips on assembling a great team to make the change happen.
Kelly Daley is clinical informatics program coordinator for Johns Hopkins Hospital, in Baltimore, Maryland.
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