Tools to Treat the Whole Patient
Estimated Reading Time: 3 minutes
Many of us enter and graduate from physical therapy school with a fairly good idea of where and what we want to practice.
Whether it is in an outpatient or inpatient setting or one of the many different specializations offered, the general message is "pick one."
But what if you don't know which one to choose?
I'm here to say, maybe you don't have to.
During my time in physical therapy school I knew that I wanted to go into neurologic rehabilitation. I also knew that I had exactly zero interest in orthopedics.
Fortunately, my program offered electives our third year and I capitalized on the ability to spend time teaching neurologic-based coursework, dissecting brains in the cadaver lab, and participating in a service trip for survivors of stroke in Jamaica.
Then like many new therapists do, I accepted a position in a residency program with a full expectation to receive advanced training in the specialty field I wanted to pursue. It was an incredible experience. But as I started treating patients in an outpatient day program setting, I started realizing that I was missing a big piece of the puzzle.
Sure, I had learned about early mobilization techniques, proprioceptive neuromuscular facilitation (PNF), neurodevelopmental treatment (NDT), amplitude training, and various other traditionally neurologic-based skills. But there was one impairment that I struggled to address—pain.
I found that many of my patients with hypo or hypertonicity, spasticity, or chronic postural deficits frequently struggled with neck, back, or extremity pain. This pain often was one of the primary causes of functional limitations. And I and many of my coworkers would subsequently hand off these patients to the orthopedic therapists.
Although our patients certainly improved significantly in our care, I couldn't help but think how incorporating manual therapy skills and strengthening and conditioning principles might further improve our patients' quality of life and add to my toolbox.
In school we are frequently taught orthopedic and neurologic principles in separate semesters and in complete isolation of one another. But in reality, these principles from both specialties are highly interwoven within just about any patient with a traditionally orthopedic or neurologic condition.
A patient who enters your clinic with knee pain is more than just their diagnosis, the same as an individual with Parkinson disease. Limiting yourself to being an orthopedic or neurologic therapist makes it more difficult to see the whole person, not just their condition.
So how do you do it? Can neurologic principles really benefit your orthopedic patients and vice versa?
At APTA's National Student Conclave 2018, I will talk about how to bridge the gap between orthopedic and neurologic rehabilitation. Having now completed both an orthopedic and neurologic residency, I have gotten to experience practice settings ranging from the neuro ICU to the football field.
And while the patient populations in these settings are vastly different, I am able to pull techniques and principles from each that can be applied to a wide variety of individuals, from those with chronic strokes to postoperative ACLs. I have been able to fill in those missing pieces from earlier in my career, and my goal is to help give you the tools to do the same.
Lindsay Walston, PT, DPT, is a board-certified neurologic and orthopaedic clinical specialist. She currently works as national education coordinator and physical therapist for PT Solutions. She has taught multiple continuing education courses and frequently guest lectures at several nearby universities. She is an active member of the Georgia Chapter and the Programming Committee vice chair. Walston graduated from Emory University's Neurologic Physical Therapy Residency in 2015 and PT Solutions Orthopaedic Physical Therapy Residency in 2017. You can contact her at Lindsay.Walston@ptsolutions.com.
Cancer Rehabilitation: Challenging and Incredibly Rewarding
Estimated Reading Time: 3 minutes
Imagine the following 3 patients are referred to your physical therapy clinic.
The first is a 54-year-old man, referred for "deconditioning." He feels worn out and too fatigued to perform his work duties as a construction worker.
The second patient is a 46-year-old woman, referred for "decreased right shoulder ROM." Her chief complaint is difficulty getting dressed and an inability to participate in her regular exercise routine.
The third patient is a 63-year-old woman referred for low back pain that began insidiously and is worse when sitting.
Even as a student, you may feel confident that you have knowledge and tools to address these patients' complaints. A closer look at their medical histories, though, reveal more complexity.
You find that the first patient has a history of prostate cancer and is currently undergoing androgen deprivation therapy. The second patient is 8 weeks status post right-sided partial mastectomy and lymph node biopsy for invasive ductal carcinoma. The third patient, diagnosed with stage III ovarian cancer 2 years ago, underwent a total abdominal hysterectomy and salpingo-oophorectomy.
How do you feel now? Has your confidence been cracked? Do these medical histories complicate the approach that you had envisioned? Is your mental list of potential red flags growing? If your answer to any of these questions is yes, fear not! You are certainly not alone. I felt the same way just a few years ago.
The population of survivors of cancer, like the ones listed above, is growing at an unprecedented rate. Evidence demonstrates that a large portion of these survivors have unmet physical needs, many of which may be amenable to physical therapy interventions.
As cancer care continues to be disseminated throughout the country and into rural communities, we, as physical therapists, regardless of practice area, must be well prepared to evaluate and treat this population.
As physical therapists we have an opportunity to play a key role on an interdisciplinary team for cancer survivors. It's well within our scope of practice to understand the potential impact of cancer and its treatments, including chemotherapy, hormone therapies, surgery, radiation, and immunotherapy.
So how do we tailor our approach to safely and effectively treat survivors of cancer like the ones proposed here?
How can we root our interventions in current evidence to effect a positive change for these patients?
Beyond our physical therapist interventions, what can we learn from survivors of cancer?
At APTA's National Student Conclave 2018, I will present the essential components of oncologic rehabilitation. My goal is to provide the latest evidence and information that will expand your interest and your confidence for when you next have the opportunity to work with a survivor of cancer, whether it is on your next clinical affiliation or as you enter into the professional phase of your career.
Cancer rehabilitation is a realm of physical therapy that I have found challenging, though incredibly rewarding. I look forward to sharing my own experience and the pathway that led to discovering the world of oncologic rehabilitation.
Steve Wechsler, PT, DPT, is a board-certified clinical specialist in neurologic physical therapy and a clinical specialist at Memorial Sloan Kettering Cancer Center in New York City. He serves as secretary for APTA's Academy of Oncologic Physical Therapy, and he received an Emerging Leader Award from APTA in 2017. You can find him on Twitter at @SteveWechslerPT.
My Incredibly Unique PT School Learning Experience
Estimated Reading Time: 3 minutes
According to the American Physical Therapy Association, there are 260 accredited doctor of physical therapy (DPT) programs across the United States, most of which are considered a lecture-based learning (LBL) environment.
The LBL style is what most people experience throughout the entirety of their American education: go to class, someone gives you lectures, you take notes, you study the notes, you take a test based on the lectures, and do it again.
My experience is a little unique. I attend a school with a problem-based learning (PBL) model as the primary learning environment, and it's entirely another world.
My main learning environment isn't a classroom with a projector, it's a conference table with white boards for walls. We call it "tutorial." In a sense, we are the guardians of our own knowledge and as many hours as possible are hands-on.
Five of my classmates and I sit together for 6 hours a week, analyze case files, create treatment plans, and work through it all with a local clinician overseeing our sessions.
Each case gets more complicated and with each tutorial session the story unfurls as we get more information about our "patients."
On the first day of physical therapy school, without a clue as to how to read a case file or what to think about what was in it, we had a tutorial. All through school we will have continuous interaction with the environment that we will spend our future careers in as licensed PTs.
I don't leave tutorial with a list of readings to do or textbooks to reference; I leave class with learning issues. These are concepts that we discover or are guided to as students to address during the current case file.
The semester in orthopedics might be things like joint position error testing of the cervical spine, electromyography testing of carpal tunnel syndrome, rehabilitation protocol for ACL reconstruction, and workers' compensation guidelines for treating low back pain. We choose how we approach the topics and then we bring what each of us have learned and discuss it together.
Tutorial isn't the only class time we have either. We have 15-18 hours of clinical labs and a scattering of lectures each week; all are adjuncts to the tutorial environment with a total of 38-40 contact hours a week.
Most schools have a case file component, but everything we do is through the lens of our current case file. Clinical lab, anatomy lab, off-campus experiences, and minimal lectures all orbit tutorial. Although there are only 6 hours a week of the tutorial learning environment, each of us spend countless hours a week outside of these classes preparing for each session, and it's the lynchpin of our didactic journey.
Despite the vastly different learning experiences, the rates of graduation, first-time passing of the board exam, and employment within 6 months of graduation parallel the norms as described in CAPTE aggregate program data.
You might say we voluntarily attend a school that requires tons more work for the same output, and you'd be right. However, this is how I learn best. Being an active member of your education correlates with greater memory in the long-term.
In addition, the PBL style of learning empowers and encourages us as autodidacts, self-teachers.
We choose which sources to use and are well practiced at finding answers to the questions we establish.
These precious skills nurture our growing confidence and clinical independence, as we venture further and further out of the tutorial room and into the clinic itself.
PBL isn't the only way to go, it was just the only and most preferred way for me. The lecture style may be great for you, but it also may be the only thing that you've ever been exposed to. No one ever told me that I had another option; I found it by accident, but I couldn't imagine physical therapy school any other way.
Nicole Seward, SPT, is a current student at Clarkson University. You can connect with Nicole via email.
The Wanderlust PTs
"Don't do it." Those words escaped the mouths of many of my doubters.
Not sure if it was the toddler mentality that took over—like when your parents told you not to touch something and you did it anyway—or just that I had been dreaming of it for over a year.
My friends who started as traveling physical therapists (PT) raved about their ability to experience new places and settings, meet new people, grow professionally, and pay off student loans.
So my mind was already set. I was going to become a travel PT.
On the other hand, Jess, my girlfriend at the time, was not convinced. She feared the unknown, feared missing home, friends, and family, and was not eager to step out of her comfort zone.
I made a deal with her, "Let's just try it for 13 weeks and if we don't like it we can come home." She agreed.
That was 8 years ago.
Since then, we've learned valuable information about the ins and outs of being a traveling PT.
We love what we do and the lifestyle we've created, and we quickly realized that we needed to share what we learned with others who want to pursue this type of lifestyle too.
In 2016, we established WanderlustPTs to help and serve as a resource for aspiring traveling PTs as well as to connect them with us.
If you too want to experience multiple settings and places, work among variety-skilled clinicians, grow professionally and personally, pay off student loan debt, and find balance between work and play, we invite you to join us at APTA's National Student Conclave in Providence, Rhode Island, October 11-13, 2018, to learn how we've done it and how you, too, can do it successfully.
In the meantime, follow our current 8-week cross-country road trip in our DIY campervan on Instagram and Facebook. Cheers!
Gabe Renzi, PT, DPT, and Jessica Renzi, PT, DPT, are cofounders of WanderlustPTs. You can connect with them on Instagram and Facebook.
Nutrition and Physical Therapy: A Powerful Combination
Estimated Reading Time: 5 minutes
Here is a situation you are bound to encounter all too often as a physical therapist (PT).
A patients comes to you seeking pain relief.
She is 50 years old. She works a 9:00 am–5:00 pm job, is very overweight, and is diagnosed with bilateral knee osteoarthritis and is mildly depressed.
She has pain when going up and down the stairs and with increasing ambulation. She notices that she is gaining weight and losing physical function. She's suffering and looking to you for help.
Where do you begin?
We know that exercise and movement is a vital part of the care plan, but is there something else you could do to help this patient live a vital, active life, and improve overall quality of life?
As future 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.
I full-heartedly believe that by providing evidence-based nutrition counseling you will be ahead of the curve in our profession and improve patient outcomes. Here are 5 ways to integrate nutrition into your physical therapist practice.
Explore the Evidence
As a doctoral trained practitioner, you have access to many evidence-based resources, and nutrition is a hot topic and for good reason.
Poor nutrition is a factor that adversely influences the health of many conditions commonly encountered in physical therapist practice.
A systematic review and meta-analysis in the 2017 European Journal of Nutrition found that a Mediterranean-style eating pattern exerts a protective effect on the risk of cardiovascular disease, and is associated with smaller gains in BMI and waist circumference.
Nutritional interventions are alone useful tools to improve overall health outcomes in patients, and specifically reduce inflammation. Low-grade inflammation and oxidative stress underlie chronic osteoarthritis.
Furthermore, there is substantial evidence to suggest that a healthy pattern of eating may decrease the risk of depression, whereas a Western-style diet increases the risk. Review the patient history above and notice the evidence on how nutrition can support this patient's recovery and comorbidities.
Experience the Difference
Remember when you first learned about lumbar stabilization exercises or plyometrics?
I bet you tried them out on yourself before prescribing them for a patient.
It can be just as fun to explore how a change in nutrition affects your own health.
A good exercise is to pick an evidence-based diet and for 30 days explore how it changes the way you feel and function.
My favorites are the Mediterranean diet, the Okinawan diet, and the DASH diet. All 3 have ample evidence for weight loss, lowering cardiometabolic risk factors and reducing inflammatory markers.
Not ready to shift your entire diet? How can you make one simple change to your diet? Start small by eliminating added sugar from your diet and sweetened beverages, such as soda or the spiced pumpkin Frappuccino.
Evaluate Your Readiness
Now that you're familiar with some of the evidence and have noticed how nutrition impacts your own health, is it time to jump in head first? Maybe.
Just as patients have a certain readiness for change, practitioners go through the same stages of willingness when adopting a new skill.
Nutrition is part of the professional scope of physical therapist practice, but you desire more training before intervening. You can first take a course to boost your knowledge and confidence.
Physical therapists have a deep understanding of the basic nutritional biochemistry, and a 2012 meta-analysis in the Journal of Physiotherapy Theory and Practice found that physical therapists can effectively counsel patients with regard to lifestyle-related interventions, including nutrition.
Evaluate Your Patient's Readiness
Okay, now that you've tried it and reviewed the evidence, it's time to assess the readiness of your patient.
Be prepared with a few key questions that you can ask during the evaluation. Collecting information provides a bird's-eye view of your patient's current nutritional habits, if they require a nutrition intervention and if they are ready to change their eating habits.
A skilled intake informed by strong motivational interviewing skills will strengthen the patient's personal motivation for and commitment to a specific nutrition goal.
Eat the Pain Away
Once you acquire the knowledge and your patient is ready, there are a few things needed first.
Patients will have questions about what to eat and what to avoid. They will have questions about the advantages and disadvantages of different diets, the timing of meals, nutritional supplements, and how to order from a restaurant menu. You may have to track their blood glucose levels.
As you develop and build your nutrition practice, you'll stock your arsenal with different meal plans, food plates, shopping lists, and recommendations for how your patient can stock their pantry, fill their grocery cart, and order off a menu. Remember, education is the foundation of every good nutrition intervention.
Moving Forward Combining Nutrition and Physical Therapy
Patients with poor nutrition habits may notice a decrease in pain within as little as 4 days.
You will note a decrease of inflammation, a decrease of edema, an improved metabolic profile, a decrease of nociception, and improvements in function.
When you combine nutrition with therapeutic exercise it is a powerful combination that sets your patient up for success and teaches them a valuable health skill. This combination of skills also prepares you for the future of integrative and lifestyle medicine.
To hear more about nutrition in physical therapist practice join Joe in Providence, Rhode Island, October 11-13, 2018, at APTA's National Student Conclave.
Joe Tatta, PT, DPT, is a physical therapist and board-certified nutrition specialist. He is an author, host of the Healing Pain Podcast, and founder of the Integrative Pain Science Institute, where he teaches physical therapists how to use functional nutrition and lifestyle medicine. Learn more by visiting http://www.integrativepainscienceinstitute.com.
Why Be Selfish When Inherently We Are Selfless?
Estimated Reading Time: 4 minutes
The gift that keeps on giving, that is exactly what we have as physical therapists and students.
Whether it's the tools in our toolbox, the expertise given to the health care team, the knowledge we can provide, and the help we can give within our communities and to our patients, we as a profession have a lot to offer.
Now, if you're a professional or a student who is just getting by each day, accomplishing the tasks that need to be done and nothing more, well, in my opinion that's a missed opportunity. You have the ability, knowledge, and expertise—it's on you to share it.
It's not about us
"What's in it for me?" is a natural human reaction. However, when it comes to our profession and treating patients we should set aside our own doubts or excuses that may hinder us from sharing our gifts of knowledge, insight, and tools with the world.
We must change our mind-set from selfish to selfless. In all reality, keeping our knowledge within the confines of the classroom, clinic, or hospital is selfish to the majority of the public and the health care community who don't know what physical therapy can do and who will benefit from our expertise.
We can all remember a time when a patient reminded us why we love this profession. It may have been a young patient with ACL injuries who we helped return to sport, a patient who is older and needed to be the caretaker for their spouse, or a patient with an amputated limb who thought their life was over. Whomever that patient was to us, they will always hold a special place in our hearts and we will always remember that feeling of being the blessing they needed.
Now, what if we take those 1 or 2 patients and multiply them by 100 or even 1,000 of potential people who don't yet know how physical therapy can change their lives. How many other patients are out there hoping and praying for the blessing that each one of us can provide.
According to the Bureau of Labor Statistics, there are more than 200,000 physical therapists (PTs) employed in the United States. If each of these PTs can reach just 5 more patients throughout the lifetime of their career, physical therapy as a whole can change over 1 million lives. That's incredible to even imagine.
Oftentimes, we discuss how we can change the perception of physical therapy for the public and through legislation. If 1 million more people were exposed by our unselfish gift of physical therapy, many of the current professional burdens and obstacles felt could be a distant memory.
How to share
The following is a passage from a PT in Motion News article titled, Study: Primary Care Physician PT Referral Rates Dropped 50% Between 2003 and 2014:
In an article published in the Journal of General Internal Medicine authors analyzed 12 years of primary care physician (PCP) data from the National Ambulatory Medical Care Survey. The survey includes patient and visit characteristics, physician diagnosis, services, and tests ordered, including physical therapy. Authors included APTA members Janet K. Freburger, PT, PhD, and Samannaaz Khoja, PT, PhD.
For all musculoskeletal-related visits, the rate of referral to a PT dropped by 50%, from 94.4 per 1,000 visits, to just 42.9.
Physician referrals are on the decline. Therefore, we have no choice but to step out of our comfort zone and be selfless for the sake of the public and our profession.
In the past, the main avenue to expose ourselves to patients was to first pass through the toll booth of the physician. Although now that direct access has arrived, we as physical therapists and future PTs have a toll-free way to share our skills of health and wellness that keep on giving.
What's your gift?
So at this point you may be wondering what your gift is other than your professional expertise? And how do you share it other than to practice and engage in our profession?
Well, let me share my example of this.
As a student, I was lucky enough to work with other students in receiving advice and guidance on how to navigate the pre-PT process (eg, PTCAS, prerequisites, interview prep). Once I was accepted into my physical therapy program I felt like this same advice, insight, and shared experience should be spread to the masses. Long story short, an alumni of my program and I cofounded Pre-PT Grind (PPG), an online platform for prospective PT and PTA students.
We're about a year into the conception of PPG, but we feel humbled in our journey to assist others in their quest to join our great profession.
That's my story, though. Others have expertise in communications and marketing, social media strategies, public speaking, presenting, or have a desire to serve their communities through pop-up clinics or pro bono work.
Wherever your strengths and expertise lie, I challenge you to get out in your community, work with your legislators, or even mentor PT and PTA students. It's only when we share our gifts that our profession will thrive and we can showcase our desire to make our profession and expertise well-known.
Casey Coleman, PT, DPT, is a #FreshPT and cofounder of Pre-PT Grind. You can connect with him on Twitter at @preptgrind.
Our Profession: Thriving With the Help of Young Leaders
Are you a student who is just happy to be finishing school and never thought you had the time or capability to get involved in your state physical therapy association?
I can speak from experience in saying that I was one of those students, and despite my professors in physical therapy school telling me not to wait to get involved, I did.
I was graduating from the University of Pittsburgh and leaving a city that I had lived in for the first 25 years of my life, moving to take my first job in Avon, Connecticut.
I had a hard time adjusting to a new state, being a #FreshPT, making friends, and adjusting to life as a New Englander. Being a new professional juggling a full clinical caseload and trying to improve my skills was tough enough, and I didn't think that I had anything to offer the Connecticut Physical Therapy Association. What I learned through my path was that I had way more to offer than I realized, that my opinion matters, and that people like me were needed within our state association.
During our panel discussion at National Student Conclave in Providence, Rhode Island, you will have the opportunity to hear the stories of 4 APTA chapter presidents, how they got involved, and ask them questions you never thought that you would get the opportunity to ask.
How you can get involved if you're not interested in a leadership position? What attributes do we look for in students or new professionals that help you identify them as a leader? How about the struggles that we have faced and experienced during our path to leadership?
If you would have asked me if I ever thought I'd be a chapter president within my professional association when graduating from school, the answer would have been a firm "no!"
So how did that change and who influenced us? Whether you realize it or not, all of us are leaders each and every day.
We lead in our homes, communities, and our patients look to us for direction and guidance. Why can't we do this for our association as well?
We look forward to meeting you at APTA's National Student Conclave and can't wait for the great dialogue and discussion! I will be joined in the panel discussion by Matt Hyland, APTA vice president, Jason Harvey, Rhode Island Physical Therapy Association president, Heather Jennings, Massachusetts Physical Therapy Association president, and Mark Mailloux, New Hampshire Physical Therapy Association president.
Michael Gans, PT, DPT, is a board-certified orthopaedic clinical specialist and a fellow of the American Academy of Orthopaedic Manual Physical Therapists. He is program director of orthopaedic residency at the Physical Therapy & Sports Medicine Centers, and president of the Connecticut Physical Therapy Association. You can find him on Twitter at @Gans_DPT.
Jason Harvey PT, MSPT, is co-owner and chief operations officer of Elite Physical Therapy, Inc, an outpatient orthopedic private practice, with 10 locations throughout Rhode Island and southeastern Massachusetts. He is president of the Rhode Island Chapter of the American Physical Therapy Association. You can email him at email@example.com.
Matt Hyland, PT, PhD, MPA, is vice president of the American Physical Therapy Association. He is co-owner and president of Rye Physical Therapy & Rehabilitation, an independent outpatient physical therapist practice. You can find him on Twitter at @VP_Hyland.
Heather Jennings, PT, DPT, is a board-certified neurologic clinical specialist at the Department of Veterans Affairs Hospital in Boston, and is program coordinator of the VA Boston Neurologic Residency program. She is president of the American Physical Therapy Association of Massachusetts. Connect with her on Twitter at @heathjenningsPT.
Mark Mailloux, PT, MBA, is a board-certified orthopaedic clinical specialist and director of outpatient rehabilitation services at Portsmouth Regional Hospital in Portsmouth, New Hampshire. He is president of the New Hampshire Chapter of the American Physical Therapy Association.