Hey team, sitting here in the office with snow falling, drinking a Booker’s and thinking about writing something.

Being a home health PT is awesome. The flexibility, the hours, every day looks different, getting to be out and see things every day. I really love it. But, it is different.

I have been trying to articulate how it is different (from outpatient) for a while and there are the obvious things you would think of: older patients, less differential diagnosis, more basic interventions, etc. But I think the thing that has been most pressing and honestly frustrating lately is the sheer amount of patients that are not good candidates for PT at all.

So any PT evaluation/ initial encounter the question “Am I the right person for the patient to be in front of?” is relevant but in outpatient the answer is almost always an easy yes. So any type of medical screening is quick and then you are off to the races.

Home health on the other hand is completely different. Sometimes the majority of initial interaction with the patient is spent trying to answer that question. And lately the answer has been no a lot of the time.

This is the hardest and most frustrating thing about home health to me. A lot of these patients have been examples of “kicking the can down the road” by medical providers upstream of home health and home health is where the can ends up.

In home health you have to have your medical screening and your “feelers” out way more than I ever realized because a large majority of these patients are not safe or ready for PT, even though they are sitting in front of you.

You just had images of a guy trying to pay for his coffee with a sock or vacuuming his front yard.

Most people would be offended by being called deranged. Being deranged, to normal people in society, means that you are a crazy person. So, obviously you don’t want to be called that.

But in the world of musculoskeletal medicine it means something entirely different and it usually is a great thing.

Let’s talk abou this.

A super smart PT named Robin McKenzie figured out after years and years of “tinkering” and being honest with himself that there is a whole category of aches and pains that no one had ever really defined. And it is the most common category of aches in pains that us humans have to deal with during our lives. He named this category the derangement.

So what the heck is it?

Derangement Syndrome is a clinical presentation which demonstrates Directional Preference in response to loading strategies and is typically associated with movement loss.

If you are confused right now, join the masses of PTs, chiropractors, orthopedic surgeons, med school students, PT school students, nurses and other health care people who have no clue that this even exists. But remember, this is the MOST common category of musculoskeletal pain.

I think it’s helpful to think about what a derangement is NOT sometimes. A derangement is not a part of your body, or even a specific pathology (like tear, or contusion for example) but it is a clinical presentation. A derangement can not (necessarily) be seen on x-ray or MRI. It is essential a description of what happens to your pain when you do certain things. Specific things.

You are probably still confused. And that is ok. The important thing to realize is that if I or another PT that thinks like Robin McKenzie say you have a derangement it is great news.

Derangements get better, and they get better fast usually.

How do you know if you have a derangement? Well, that’s where its probably helpful to see a PT who knows about this stuff, but here are some things to look for.

Example:

Let’s say your elbow hurts. If you bend it as far as it will go 10 times, does it feel better, no? Try the other way, straightening it as far as it will go 10 times. If it starts to make your pain go away or reduce as we McKenzie nerds would say, then you may have a derangement. The key here is the as far as it will go part. Be slow and listen to your body but try to move the joint as far as it will go.

If symptoms improve and last then you may have a derangement. It really can be that simple, if you know what to look for.

So next time you get called deranged by me don’t be offended, unless you are vacuuming your front yard.

This morning my kids were crazy people. There must be a full moon or something because they were more werewolves than people. Just crying a lot and fighting, generally being stressful. And it really was a stressful morning. A stressful stimulus.

My wife was more in the middle of it than I was, I was doing dishes and getting my work day started and all the sudden she came in at her wit’s end, teary-eyed. She said “I just can’t be in there [the playroom] anymore.” Next the two youngest ran out screaming “WHERE’S MOM!!!???”

It was just a lot.

After we calmed the storm and I left the house to start my day, I pondered the morning. Why did that go so badly? Why do things go badly sometimes? Why doesn’t God make life easy?

What’s this got to do with Adaptation?

Well, I have been thinking a lot about strength training lately. The stress to the body, or stimulus. The rest and adaptation that happens to heal and allow for more load next session. Without the stimulus there is no adaptation in the world of strength training. These thoughts are bouncing around my head as I ponder the difficulties of the morning and it hit me.

Maybe the stress, recover, adapt model is not just for physical change? Maybe this is how all change in life happens?

What if God, wanting to “strengthening us (our character, our patience, our joy, our reliance on him)” provides a stimulus, allows us to recover and facilitates the desired adaptation?

For a stimulus to be helpful in strength training it has to be “recoverable” or in other words, it cannot to be so stressful that excessive damage is done to the system. I think life is like this sometimes. I think the stresses of life can be excessive and can damage the system.

But like our bodies, small and calculated stimuli over time with proper recovery make those previously damaging stresses very doable or even easy.

In life there are equivalents to being hydrated, eating enough calories generally (and protein specifically) and sleeping enough. These are the factors that affect physical recovery. If these are dialed in, you will recover. In life, these things are more subtle. Maybe time with friends, time alone, laughing, going outside, watching a movie are the things that our emotional and spiritual selves need to rest and being in the Word is the “nutrition” that we need to recover from the stimuli around us.

These are new thoughts and half-baked ones but I feel that there are some principles at play. Maybe our characters are being strengthened and the hard times are actually intended to be useful stresses.

What is Freedom and why do I talk about it?

Good old Webster tells me “1 : the quality or state of being free: such as. a : the absence of necessity, coercion, or constraint in choice or action.”

This is pretty overarching so we will go with it. The absence of necessity, coercion or constraint in choice or action. There are a lot of areas of life that freedom is lived out, or sadly not lived out in. Financial freedom is one that comes to mind.

As a physical therapist, especially in home health, I get to see first hand everyday the glaring lack of freedom so many people live with. They are slaves to their previous bad choices, current predicaments, and often times poor health that is completely outside of their control. They aren’t free.

While some of these people are physically constrained in one way or another, whether it is simply getting tired more quickly than they wish, or they have non-weight bearing restrictions from a recent fracture, MANY are constrained by fear.

The fear of falling, the fear of a certain movement, the fear of getting sick, the fear of….fill in the blank. Many of these people aren’t free because they are thinking about a situation wrongly and they are enslaved by their fear.

You may be thinking, why is this physical therapist, strength/conditioning guy talking about this? Good question because I feel like we don’t talk about it enough. It shouldn’t be weird. The reason I am passionate about getting people strong and free is because oftentimes people in my profession/position are actually part of the problem.

 

Why are you afraid of going down your stairs? Well…I might fall

Why are you wearing that knee brace? Well…my doctor told me my knee is bone on bone and would give out.

Why are you afraid to lift your “dog” (insert 7 pound chihuahua)? Well….my physical therapist/chiro/trainer told me I have a slipped disc.

 

These are the conversations I am having with people all day long. These are smart people, many of them have been on this earth for 2-3 times as long as I have and they have been made to fear their bodies and their world.

This is the reason I want to inspire people to be free.

90% of this is not the load I select (10% is though…don’t under load people in home health)

90% of this is how I talk to these people.

People want to be free. It’s time to help them understand that they are robust (mentally and physically) or to use Webster’s words un-constrain them.

 

It has been a year already since I moved from a private practice outpatient clinic to a larger hospital system’s home health agency and I love it. This move was not easy for me because my previous job was incredible. Great people, fun environment, and very much a petri dish for my clinical practice. But I had to change. There’s a few reasons

1. Flexibility
2. Finances
3. Family
4. Broader clinical experience

Flexibility

My wife woke up sick one day and instead of leaving at 7 and wishing her luck or having to take off work. I checked my schedule planned to start seeing patients at noon and was still able to get home before 5, finished with patient care, just needing to polish up some notes. My kids’ daycare had a father’s day event from 10-12. As you may have guessed most father’s (paying for daycare) are working from 10-12 so there were not many there. I saw a patient before and then some patients after…simple as that. The flexibility of home health is truly wonderful. If you get your work done that everyone is happy.

 

Finances

Home health pays better. In some places much better. Simple put. There are also some benefits to working for a non-profit including the Public Service Loan Forgiveness Program, but that’s another post for another day.

 

Family

At the time of writing this I have a 4-year-old, a 2-year-old and a 7 month old. The previous 2 points also made sense for the family, but there is something else on this point. In school and when I first started practicing physical therapy was constantly on my mind. I was reading blogs, on Twitter, constantly learning and engaging with other PTs around the world, wanting to be known. And, while it was fun and probably made me a better PT it was ultimately unhealthy for me personally, spiritually and for the family. Home health has helped me put work in its place. A place where I still feel very passionate about what I do, and continue to strive to be great at it but 3 or 4 or 5th in life.

 

Broader clinical experience

Home health has given me exposure to much more than orthopedic/musculoskeletal pathologies….MUCH more. And with that my reasoning model and clinical decision-making has had to get bigger…MUCH bigger. For example, in the clinic I mostly assumed that the person was supposed to be getting physical therapy treatment, that their life was otherwise in relatively good shape and we just needed to fix the pain they were in. In home health sometimes physical therapy is the least of the persons concerns and because they are sitting in front of me it is my job to figure out what they need. Social work? OT? Placement in SNF or assisted living? Hospice? These are large-scale, whole person problems that take larger reasoning models than what tissue is the issue. It has made me a better PT.

 

I really enjoy being in home health and plan to do it for a while. If you have questions let me know.

I went to McKenzie (or the Mechanical Diagnosis and Therapy aka MDT) Part A: Lumbar Spine course the last weekend of July in St. Louis, so I have had some time to wrestle with and implement some the things I learned. Overall, the course was impressive, comprehensive, and very practical. I have been a fan of the method for a number of reasons for a while but I finally got some official teaching.

Overall Score: 4+/5

Practicality: 5/5

EBP: 5/5

Marketability: 3/5

Practicality:

The McKenzie course is geared towards teaching the information so that you can “use it on Monday.” The method itself is really easy to start implementing because it is a clinical reasoning framework more than a technique, which take time to develop into something that is useful and effective. Side note, when I took the IAOM shoulder course in 2016 that was one of my biggest complaints/frustrations. I felt like I needed months or even years of practice to “master” the techniques presented at the course, so really it wasn’t very helpful “on Monday.” The McKenzie part A course was the opposite. The framework is presented clearly and they brought it real patients for the instructor to treat so that “the method” is tested and on display for everyone.

 

EBP:

The low back pain literature and the low back pain world is a messy one. There is a lot of dogma, there are some gurus and there are a million different ways people treat it. It can be pretty daunting and frustrating. The good thing about MDT is that it somewhat tried and true, especially compared to some other treatment paradigms. Centralization is one of the more well documented findings in conservative musculoskeletal medicine and the MDT system has been around so long it just has a larger body of research behind it than most. MDT’s effectiveness in the lumbar spine is well documented (compared to other approaches), it incorporates patient’s values and individuality into the system and clinician experience is directed with the method to make more systematic/ logical decisions more quickly. However, the course presentation was not a literature review by any means. The focus of the course was on the system and how to implement it well, they gave you the resources to look at the evidence. Compared to the BFR course which seemed to be 80% defending the concepts from literature followed by 20% how to do it.

 

Marketability:

This is a tough one. I gave it a 3/5 because there are plenty of stories of physicians and patients seeking out MDT providers, it’s just not the norm. The fact that I have completed Part A means nothing to most people. Without going on too much of a rant I think my thoughts on this have changed over the last few years. MDT may not perk up the ears of the average consumer of physical therapy, chiropractic, massage, whatever BUT it does make me more effective at treating people with back pain. Being good at the service to provide is useful when marketing, especially if you can track your outcomes.

 

My 2 cents:

There are other systems out there, some of them are good. Most people (physical therapists) don’t use a system to organize their clinical decisions but just collective “tools” and put them in a toolbox over time. Imagine a toolbox that has 50 things in it but they are all piled on top of each other, no organization whatsoever. That is what most physical therapists are working with. MDT is the toolbox. It’s organized, simple, logical, effective, patient-centered, active, reliable, safe, well researched and applies to the whole body. To me that’s a win.

I already signed up for Part B: Cervical and Thoracic spine in October 2018…review to come.

 

This is a sensitive subject for most physical therapists and chiropractors. Depending on who you ask chiropractors are either magic workers that can pop the pain right out of things or they are quacks. In my experience there are very few people who fall between these two extremes.

Love them or hate them, I don’t really care. I’m not going to say that an entire profession is good or bad, that is never true. There are fantastic physical therapists and there are terrible ones, the same is true for dentists, physicians, nurses, and certainly chiropractors. I think as a whole the philosophy of chiropractors is different from mine, and I obviously think I’m great so I would tend to disagree with that philosophy. However, I don’t think that differences in philosophy are enough to call someone a quack…unless they actually are. If you want to know my thoughts on a specific provider based on accurate information that you can provide me I will happily give you that in private. 😉

Now to the question at hand, which is one I get often in one form or another Can I see a chiropractor while I’m seeing you? or should I keep going to my chiropractor? My answer to this is for the most part situational but in principle my answer is usually something along the lines of “It really isn’t good science for you to be trying too many things at once to try to make (fill in the pathology/symptoms) better. If you are seeing me, then going to a chiropractor, then getting a massage, then doing Tai chi, then taking a bath in Icy Hot and you come back to me hurting more I have no clue what to blame.” In my mind, it is best to bring as much clarity to someone’s pain/dysfunction/etc. as possible in order to help them efficiently and effectively. SO in short I don’t love when my patients are getting treatment from more than one place BUT this is situational. The main reason I would be ok with “co-treating” is to build a relationship with that provider.

Hope that answers that question.

 

Dear Patients,

Over the last year at Premiere PT we got to hang out. We got to know each other. We got to make fun of Sanders together. We grew together. And (I’d like to say) most of you got better and are back to doing what you love.

But I have to move on. I have taken a job in home health with Mercy in order to allow flexibility for our family as we bring a new little one into this world.

You have taught me more than I have taught you and I really appreciate it. I will keep serving this community just in a different way and a different set of people.

I want to personally thank you for the fun we’ve had and the opportunity to let me into your world at a time that you were feeling pretty low.

I’m still in NWA running, playing, parenting youths and being a spaz in general so feel free to reach out if you need anything at all. I will also be back to bother the crew at Premiere probably more than they want.

 

Sincerely,

Zack

My wife’s birthday is this weekend and my mom made her a cake. A chocolate cake. If you know anything about my mom it’s that she is basically the greatest chief of all time. You name it, she crushes it. Well, she absolutely crushed this chocolate cake. I just finished eating it, and I promise you it was the best chocolate cake on planet earth.

Maybe it was the chocolate cake being so good maybe it was just my ADD brain, but this experience of eating this cake got me thinking. How the heck is this chocolate cake so much better than a normal or even above average chocolate cake. There is something different. So I asked the chief herself. “Why is this so good?” This started a 10-minute breakdown of all the intricacies involved with every step of making the most dynamite chocolate cake in the history. It was jaw dropping. So many steps and each one had slight nuances and variables that needed to be perfect.

I have made chocolate cake before. It was out of a nice red box, I put some eggs in with some powder, I believe, haphazardly mixed it and then put it in a not fully pre-heated oven. Ultimately the same physical things went into that cake as my mom’s (that’s actually not true at all but run with it…sorry mom), but my cake was super dry and gross, and my mom’s made me want to eat until I required a wheelbarrow to exit the house.

The ingredients were the same but the technique was very different.

Upon reflecting on the greatest of the cake I came to the conclusion that technique matters. The little things add up. In cake making, they make a huge difference and I think the same is true for almost anything, including physical therapy.

There is a shift happening in the field of physical therapy both in the research and in certain circles away from highly technical manual therapy “tricks and techniques,” some would say that all those fancy techniques are nothing but a placebo. I think that’s a little bit of a stretch, but I do find myself leaning towards the “fancy techniques probably don’t matter so much team”….for now.

But

Technique matters a heck of a lot when making a cake and I think that the pendulum may be swinging a little too far in some circles of physical therapy. I think there is a difference (one that is very hard to detect in clinical research) between highly skilled (very technically saavy) PT and very basic PT. Like my cake vs. my mom’s. Some papers will say manual therapy works for this that or the other, some say it doesn’t but I think classifying an entire treatment method without taking the craftsmanship of the person delivering that treatment into account is missing something.

Manual therapy is just one explain. Teaching patients is another example, or exercise prescription…the list goes on and on. It is very difficult to truly measure and compare treatments because technique and nuance are very hard to account for.

In the world of conservative musculoskeletal medicine where lots of tiny effects make up big effects the nuances matter just like in making cake. Lots of little techniques at each step end up making a massive difference in the end product. 

Technique matters.