There are two courses coming up in Houston and I would like to go both.  Both are one day offerings that fit my budget.  I'd really like to go.  Both sound like they would be beneficial.  One concerns radiology, something I became interested in after my class.  The other covers motor control theory, something helpful for treating neuro patients.  The problem is I'm not sure I'll get my money's worth.

CEUs were introduced as a way for therapists to keep current on skill and knowledge.  Currently 30 states have a mandatory amount of hours required for license renewal. Some of those states (I couldn't find the exact number) use a peer review process for approval.  Texas is one of those.  The idea behind peer review is that someone familiar with the topic will be a better judge of the quality of the course.  There are three problems with this system.  First, there are no objective quality control standards for any courses.  Second, there are no requirements that courses be updated on a regular basis. Third, peer review only works if adequate materials are submitted for the review.

The APTA has published standards for CEU offerings. They cover things such as: the instructor must be knowledgeable about the topic; the instructor must include evidence-based practice; there must be specific written learning outcomes; the course must be designed in response to an identified need; there must be a written record of who attends, and so forth.  None of the 11 standards really describes any quality control.  Taken at the bare minimum someone could go out and research something in which they have no experience, develop a course based on the research and then offer it as a CEU opportunity. 

Since I've been a therapist a number of years, I've noticed that many courses have been around a long time.  I took one recently on neuroanatomy that probably hadn't updated since the speaker developed it.  The handout was crowded and difficult to follow.  She had a lot of knowledge but I doubt anyone got much out of the course because of the poor presentation.  While all courses seem to have handouts, not all of the handouts are adequate.  I've spent so much time trying to write down what wasn't included that I missed things that were probably important.  Yes, I got my CEUs, but I didn't get my money's worth in information.

Another problem with courses is that awarding of the CEUs is based on attendance, not knowledge.  One of the APTA standards is that each course must have a way of evaluating a participant's learning.  I know people who wait until the last minute to take courses.  They take whatever is available and pay little or no attention to what is being taught.  I have a PTA friend who a few years ago waited until the night before he was due.  He bought a bunch of online courses and finished them in a marathon sitting.  He learned absolutely nothing but did have enough CEUs to renew his license.  What part of that improves skills or increases knowledge?

I'm a volunteer peer reviewer for Texas.  As a result, I see bits and pieces of what is submitted.  Texas has a form it requires each sponsor to fill out.  Some sponsors do a good job and include all pertinent information. Others, and these seem to be courses from one facility or a small setting, do the bare minimum.  I've seen several that were at least 10 pages long.  Nine of those pages were resumes of the presenter(s).  One actually described the course.  The only sort of review included is one of the course itself.  Okay, it's helpful to get feedback if I'm the course sponsor.  But what does location and room comfort really have to do with what I may have learned?  We've all filled these out.  The questions are pretty much standardized. 

Obviously the system needs an overhaul.  The idea is good. The implementation is a little lacking.  The end result is a potential participant debating whether the course is worth the time and money because there is inadequate information upon which to make the decision.  Nobody has money to waste.  No matter how much I enjoy courses, I want to actually learn something from going.  With the economy today I have to be picky.  Later this year the TPTA is sponsoring a CI certification course in Austin.  Austin is about 2 and half hours away.  If I go, I would have to drive up the night before and drive home afterwards.  The whole thing isn't that expensive, but now it's a question of which courses I would rather attend.  At least in that instance I know the quality of the course in advance.

There are several solutions.  Implementing them would slow down the CEU approval process and probably drive up the costs.  I would like to see courses reviewed every 3-5 years.  The renewal date would then be included on any literature advertising the course.  In peer review states the sponsors/presenters should submit a copy of the handout as well as required forms.  I can tell a lot more from a handout than a form.  The APTA needs to redefine or develop more specific criteria for courses.  Finally, and I know this is unpopular, each course needs a brief pre/post test. The instructors would be held accountable for the results.  If the courses are poor, the course doesn't get renewed.  Yeah, there are ways around that, but it's a start.

I think PTs always try to think of the best interests of their patients.  I would never deliberately recommend SNF over rehab if I thought the patient would benefit from rehab.  If the patient can't tolerate three hours of therapy daily, he is wasting both his insurance and precious recovery time.   He won't get any benefit from therapy if he is too tired to participate.  The same applies to my man with the quad cane.  He is able to walk with total assist of me to advance the leg and help him balance.  It would require extensive training to teach a family member to do that. Even then safety might still be an issue. The question became which is better: keeping him from walking or preventing a serious fall?

I divide my time between an acute stroke unit and inpatient rehab.  On the stroke unit I assess patients and make discharge recommendations such as SNF, rehab, home with home health or no needs.  The stroke physician, who is a neurologist, has the final say on disposition but usually listens to me.  The reason for that is simple.  A neurologist knows neurology while a PT knows recovery potential and realistic goals. On the rehab unit the PTs help decide if someone goes home as planned or requires placement.   Sometimes that means being the bad guy.  I'd rather be the bad guy with good intentions than recommending rehab for everyone just to keep the unit full.

No one becomes a PT in order to prevent patients from improving.  We become PTs to help people get better.  In the process many decisions are made.  All are made with the best intentions.  Sometimes I'm wrong.  Sometimes a patient does much better than I expected.  I like being wrong like that.  Sometimes a patient doesn't do as well as I hoped.  I was wrong because I wanted the patient to do well.  Anyone PT will agree patients are unpredictable.  No matter how hard we try the end result depends upon the patient.

It wasn't until I started working on the stroke unit that I realized how much responsibility I have for my patients.  The unit is small with high turnover.  Nonetheless, I think of every patient on that unit as being on my caseload and thus my responsibility.  Whenever I'm in doubt or unsure I make it a point to see the patient the next day to reassess my original impression.  I don't want to make a mistake about someone else's future. Life is much simpler on rehab.  Not only are the OTs and STs involved in the decisions, but we see the patients for more than one or two visits.  We have a lot more information to work with when discharge planning rounds come around. 

If I ever stop and really think about what I do each day I'm not sure I would be able to be as effective.  I try to be as objective as possible.  I base my decisions on my experience, knowledge and what I reasonably believe is possible.  I have to remind myself that I'm only involved in one part of the patient's recovery and my job is to make decisions to facilitate that.  I've never ask any of my co-workers how they interpret discharge planning.  I'm sure many would say it is another part of what we do.  As professionals it is our responsibility to make the decisions in the best interest of the patient.   I agree.  Sometimes, though, those decisions make me feel like the bad guy.

Once an individual survives into midlife it is likely that person will reach his or her life expectancy because most of the things that shorten life occur in the earlier years.  The problems we face as therapists with the geriatric population generally aren't related to age so much as the co-morbidities that accompany the aging process.  These can include problems arising from diabetes, HTN, debilitating arthritic pain, CVAs and vascular issues to name a few.  Patients don't come to therapy because they are old.  They come to therapy because a co-morbidity has impaired their functional status. 

The text pointed out that as therapists our role is to help delay the onset of the co-morbidities.  That would allow the elderly to have the same life expectancy but spend less of it in a state of debility.  This assumes that eventually everyone will fall victim to some sort of illness or disease process resulting in some state of dependence and/or a lesser quality of life.  It assumes that as therapists we can somehow cause our patients to make the necessary lifestyle changes to enable that to happen.  It also assumes everyone has the same potential to prolong morbidity free aging. 

I have a problem with all of that.  No one, PT or otherwise, can make another person make the healthy lifestyle changes necessary for that to happen.  Even then there is no guarantee something unforeseen such as cancer or a major trauma won't still occur.  There is no strong evidence out there that specifically links any of the preventive strategies discussed in text with actually preventing morbidities.  The best the book could do was anecdotal evidence. Granted an individual who has out of control DM or HTN is a stroke waiting to happen.  That doesn't mean I can do anything definitive about it. 

Many of my stroke patients have numerous other medical problems.  These people already have the co-morbidities the text is talking about preventing.  By the time I'm working with them it's a little late for prevention.  I think that's generally true everywhere.  The people with healthy lifestyles probably aren't going to need therapy for awhile.  It's the ones with the co-morbidities that need us the most. 

Therapy is about helping people overcome impairments no matter what age group they fall into.  If by helping someone recover from a stroke I'm delaying a morbidity, great.  The geriatric population is unique.  Aging changes how the body responds to the challenges it is exposed to.   Preventing debility and morbity is a wonderful goal, but it isn't the only focus of therapy.  When an elderly patient comes to me for therapy my job is to provide that therapy taking into consideration the circumstances arising from the aging process.    Some people are going to age better than others.  Those differences are what impacts therapy.  Certainly I can encourage lifestyle changes but I can't make them happen.

As I progress through this course, I hope to learn how aging affects the body and how those affects alter therapy.  My caseload will include both "healthy" and "unhealthy" geriatric patients.  I'm sure there will be more of the latter than the former.  Those are the ones I want to know more about.  This week's reading made me look at how I think about the aging process.  Since I'm nearing 50 this is becoming more important to me.  So, yes, I want to know about remaining healthy as I age.  I also want to know how to better treat those who've aged in poorer health.

One could argue that ethics are universal and based on common sense. Everyone should have an idea of what is ethical and what isn't.   Physical Therapists learn what is ethical during their training. They are taught to behave ethically. The same argument can be made for the Code of Conduct. PTs are taught that in school.  They know they must abide by it. The APTA also has a section describing professional behavior. It is based on the Codes of Ethics and Conduct. Until recently, when I researched it for class, I didn't know it existed.  I'm probably not the only one.

I accept the argument that PTs learn ethical behavior. I also accept that they learn how to conduct themselves for the most part. Obviously no one will harm a patient. When providing treatment a PT decides on the best available treatment.  Things start getting a little fuzzy when we get to appropriate charging, altruism and social issues.  In Texas we charge in 15 minute units based on the 8 minute rule.  Anything treatment greater than 8 minutes is counted as an additional unit.  I'm sure that gets fudged occasionally.  I'm also sure there are those who consistently round their units up to look more productive.  I worked with an OT who did. She would indicate she did 40+ units in an 8 hours day.  That's just not possible.

Altruism refers to putting the pt. first.  I can't count the number of PTs who put themselves first.  They schedule times based on their convenience not the pt's.  They do the same thing with everyone no matter what.  I worked with a PT who was salaried.  He never worked a full 8 hour day in the year I worked with him.  He arrived late.  Usually left early and always managed to get a full hour for lunch.  He never offered to help anyone.  He never took a patient that wasn't on "his floor".  He considered himself a good, patient oriented therapist.  He's not alone.  Granted things aren't black and white, but the majority of the time should fall in favor of the patient.

What I find sad is that the very therapists I'm describing wouldn't see the problem if they read those documents.  It wouldn't strike them that their behavior is unprofessional to say the least.  They're worse than those who refuse to accept evidence based practice.  At least those therapists are trying to do the best for the patient.   I admit I make mistakes sometimes.  Everyone does. The difference is I don't make those mistakes intentionally and always try to correct them in the future.

Professional behavior is becoming more and more important.  PTs want to be taken seriously.   Vision 2020 states the DPT is equivalent to an MD, DVT, etc.  The APTA has run into a lot of trouble trying to get that point across.  One reason is the lack of professional behavior by some therapists.  I work with many residents.  I see what gets beaten into their heads.  They are taught professional behavior and responsibility from the beginning.  Until PTs consistently demonstrate the same level of professionalism the DPT won't be taken as seriously.  There's a big difference between developing a friendly relationship with a patient and being unprofessional.  A therapist who is only concerned with how many units she can generate in one day isn't acting in a professional manner. Neither is a therapist who skips a beneficial treatment because he would actually have to put his hands on a patient. 

 We all know these people. Nothing will change until they realize their behaviors are unacceptable. I consider everyone I work with to be professional. If I saw something I didn't like they would list to my concern and possibly correct the behavior.  Someone who doesn't care will not listen to my opinion much less change a behavior. Since we can't change them we have to change the environment by modeling what is acceptable and what isn't. That might make a difference. It might not. What it will do is demonstrate professionalism on a larger scale so that others will take us seriously.

All three documents I mentioned can be found at http://www.apta.org/.  Go to the main page and type the document title in the search box.

In other words, we have a discharge nightmare. The only blood relative lives out of state and refuses to get involved.  She doesn't want to argue with her mother. It's obvious placement will be required. It's also obvious the patient will not agree to it.  What's less obvious, but just as important is the patient isn't capable of making that decision. Therein lies the problem.  The patient is able to make basic decisions about day-to-day matters. She can decide on her menu and what to wear. She is able to dial the phone. What she can't do is make a decision about discharge plans and no one has been able to definitely state why.

I did some research into the subject. According to several sources, the patient must be able to understand and describe her condition. She must be able to verbalize and clearly explain each option including the pros and cons of each.  Finally she must be able to verbalize a plan that accommodates her present needs and safety concerns. The only plan this patient will verbalize is going home as soon as possible. She won't entertain any other idea or suggestion. Since there are no other relatives, the facility is going to have to request guardianship be awarded to an independent third party. In the meantime, the patient will stay in the facility and receive therapy. Her participation is intermittent at best. Continued therapy may not increase her functional status enough to eliminate the problem.

The situation got me wondering how many other patients are in the same situation, but it isn't so obvious? The elderly can present challenging discharge circumstances. Patients with cognitive problems learn to mask them early on. I wonder how many have talked themselves out of the hospital and into a bad home situation. I wonder how many have convinced family that no assistance is needed when it really is. Many of those patients probably end up back in the hospital in worse shape than they were previously. 

I checked with some of my OT friends. They tell me there really isn't a cognitive test they do that would identify something like this. Even the MMSE is ineffective for this. I'm not sure what can be done because patients have the right to make their own health care decisions. I don't think anyone really wants to put someone in a facility unless absolutely necessary. I talk about discharge arrangements with my patients. I guess I'll now be thoroughly documenting those conversations. At least now I know what to ask and what responses to look for. 

That stopped me cold.  I have always believed that once the consent to treatment form is signed the patient has consented to be cared for.  The patient must be asked if therapy is desired because it can be refused.  I never even thought about in relation to every single treatment I provide.  If I want to do something new or a little different, I will explain it and make sure the patient is comfortable with what I want to do.  Sometimes a patient will only agree to walk in the room or doesn't want therapy at a specific time.  To me, those are examples of patient autonomy. 

Informed consent arose from unethical use of human subjects in medical experiments.  Over time it evolved into patient rights. Obtaining permission for each intervention makes sense when talking about invasive or risky procedures.  It doesn't make sense when talking about ROM exercises.  If I had stopped to think about it, I would have thought overall permission for therapy would be granted at the time of the evaluation when the POC was discussed.  I describe what I plan to do but not specifically how.  That's practically impossible with PT.  Patient status changes from day to day.  What was appropriate one day might not be the next.  As long as my patient progresses, I'm going to process therapy.  I can't predict exactly how that will occur.

I looked into it a little further.  There is still debate about what is considered informed consent.  For awhile the accepted standard was what another physician would reasonably say.  That doesn't really work because few people outside the medical field have that level of understanding of medical terminology.  Now the focus is on explaining in terms the patient can understand.  That's better, but it doesn't take into account who is doing the actual explaining.  A physician or experienced therapist who has done the intervention many times will present the information differently than an inexperienced new graduate or resident.  If the new graduate can't answer all the questions, is it still informed consent? 

This is even more significant in a place such as Houston where a large number of the population has a language barrier.  Frequently non-English speaking patients will agree rather than ask questions if they don't understand.  A good example is explaining weight bearing status to a non-English speaker who may be hard of hearing or slightly confused.  I've had Spanish-only patients get up and move around when they were in severe pain because they didn't know they had a choice.  I usually find out after I ask a Spanish-speaking therapist to find out if the patient is OK because the patient looks uncomfortable.  If I have to get specific consent to each treatment and there isn't a translator available that patient probably won't receive therapy.  It wouldn't be ethical. 

This is a huge gray area that I hadn't previous considered.  According to the APTA Code of Ethics and Standards of Care, our current practice is adequate.  Both of those documents bind the PT to do what is best for the patient while considering the patient's individual needs and desires.  That's good.  It will probably remain adequate since few people outside the therapy field are even aware of the differences in what we do.  There is also minimal risk to therapy and the evidence is still out in many cases on what is the best treatment. It would be a different story if the choice was between something very effective but a high fall risk and something less effective with no fall risk.

The things I read were published within the last few years.  The topic appears to be relatively new to discussion.  It may take on more significance as we move to direct access and Vision 2020.  Autonomous practice will require more disclosure and more specific consent.  Therapists in private practice will need to have some kind of consent to treat form to cover them legally.  This might not be anything right now but I don't think it will go away.

Heavier patients, on the other hand, are a problem. The more a patient weighs, the harder it is to mobilize that patient.  The truly obese ones require bariatric equipment to safely mobilize. That equipment isn't always available. My hospital rents the equipment when it's needed. It can be as many as two days before it arrives.   When patients are immobile any extra weigh usually becomes dead weight. Dragging the extra weight during transfers increases the risk of skin damage. A small skin tear can easily lead to a decubitis if the patient isn't able to shift weight.

Heavy patients require extra man power which is always at a premium. Treatments must be scheduled when assist is available. Missed treatment time is difficult to make up.  The risk of care giver injury is also increased.  Mechanical devices can significantly decrease the risk but don't eliminate it.  The unit I work on doesn't have such a device because the goal is for the patient to move himself. A max assist X 2 transfer is an injury waiting to happen if the patient slips or loses his balance. Getting hurt is something I worry about more and more. I'm getting old and probably weaker. It's not as easy as it was to move those bigger patients around.  I'm very careful but I can't keep from thinking what if.  Where is the line between patient benefit and therapist safety?

These aren't easy patients to work with.  Gone are the days when a medically complex patient was a 90 pound little old lady.  It's been awhile since I've seen one of those.  This is a trend that needs to be monitored. More acute patients don't automatically translate into more staff. More staff might be required but won't be available because of cost cutting measures. I've worked in units where nursing wouldn't get anyone up so it fell to therapy.  The evidence suggests early mobilization and OOB is related to better outcomes and shorted lengths of stay. The evidence doesn't indicate who should be responsible for doing it.

If this trend continues the future isn't pretty. There is a finite amount of work you can get from any one group of people. It doesn't matter how much work is assigned.  One therapist can only do so much. If every patient requires two people to mobilize that therapist will be doing more bed level treatments and getting fewer people up. If the patient has a trach the problems multiply. PTs are capable of treating these patients no matter what situation.    The limiting factor isn't knowledge or skill. If these are the patients of the future I hope the present day planners are looking ahead.

I knew there would be a problem almost immediately. She tried to rearrange her schedule with an abundance of orthopedic patients. It wasn't that she wanted to change the patients. It was that she came in after many of us had already started our day. Making changes would have been difficult for us. She was scheduled to fill in one day. When you fill in, you take what you're assigned. Later she tried to help me transfer a patient. He was a larger man with a dense hemiplegia. I'd been working with him for a few days and had a transfer technique that worked. As soon as she came into the room she wanted to do everything differently. I don't mind someone making suggestions. I do mind someone coming in and telling me how things should be done without asking me why I was doing them differently.

By lunch I'd decided to stay out of her way. She obviously had her own way of doing things that worked for her. She'd made it clear earlier she wasn't going to change. Then she brought up evidence-based practice. She was tired of hearing about it. She missed the days when you could do whatever you wanted. She didn't think she should have to do anything different. She'd been doing the same things for years and had good results. I can't even describe all the things that went through my head.

This woman is an example of one of the challenges facing PT as it moves toward 2020. She is stuck in the "old way" and is refusing to move forward. The DPT can be debated on end. Having treatment interventions supported by research makes sense. Medicine has been using evidence for years. Having evidence to support what we do is a necessary part of practice. With evidence we can defend interventions to third party payers, to other health care professionals and support our requests that patients receive continued therapy or defend why someone is ready for discharge.

After listening to her I realized how difficult it's going to be to move our profession forward. She couldn't even tell me what she meant when she said evidence. I can't imagine her doing a literature source for answers. In her world she has no reason to do things different. She believes her treatments have been successful. She is one person. Now multiply that by the number of PTs and PTAs out there who feel the same way. All the education in the world won't do a thing if those therapists don't buy into the vision of what we want to be. I'm beginning to think that Vision 2020 is going to be Vision 2030 because the only way those individuals will change is when they retire.

As I said, her presence was a learning experience for me. I saw firsthand what we're facing if we want direct access, autonomy and the like.  Now I have a better understanding of how someone on the other side of the issue sees things. I also understand why someone might think Vision 2020 isn't that important. Whenever she's back I'm going to talk to her. I won't try to change her mind. Instead I'll try to explain my thoughts and hope for understanding.

It turns out the chairperson of the committee that would hear the bill and recommend it for debate is a physician. The person behind her is also a physician. So far they have been turning a deaf ear to the problem. It's no better in the senate where the committee chairperson is married to a physician. That sounds a lot like conflict of interest to me but apparently it isn't. Neither chairperson has done anything with the bills. It isn't expected either will even make it to the floor for debate. There has been some debate. A compromise was offered. I will paraphrase what it said. They will allow PTs to treat patients without referral who they've seen in the last 2 years from the same physician for the same diagnosis provided the physician is notified the patient is seeking treatment. I don't see much compromise in that.

One reason this is happening is because there hasn't been much support forthcoming from the rest of us. The representatives and senators aren't getting tons of emails and faxes in support of the change. Every week some therapists travel to Austin (the state capitol) but have yet to see anyone plead our case. Now I'm asking myself if physical therapists, as a profession, really want to have direct access. It doesn't seem to be getting grass root support. There are some very dedicated people working on this but it will take more than that. But no one else seems to be making the effort. Why is that happening? As a rule, PTs aren't passive people. We're all busy, but sending emails don't take that long, especially if you already have the addresses. Maybe we, as a whole, just don't care.

I did a mini poll today at work. None of the PTs I spoke with had a clear idea of what direct access means. Everyone said practice without referral but no one could really describe what that means.  Some told me it only applies to those practicing in OP settings. That's true to a point. If you read Vision 2020, it sounds like they want direct access in all settings, hospitals, SNFs and OP clinics. I also discovered no one had thought about how patients would know what PTs do and when it's appropriate to seek our treatment. Accomplishing that will require a nationwide push of education and probably several years of effort.

I'm think there are two issues for this. On one hand, those that want direct access are willing to sit back and let someone else do the work. Simply saying I want direct access isn't enough. We can't sit back and let someone else get this done. It's going to take a group effort. The second issue is lack of understanding of what direct access is. I think these are the "old school" therapists who don't see the need to change a system that is working. On one hand, these PTs might agree direct access is a good thing but they haven't bought into the need to have it and probably never will. I know PTs that fall into this category. They're good therapists. They've kept up their skills. They just don't see the need to do anything differently. There is a subset of both of these groups composed of those who oppose the DPT.  To them you only need a DPT if you're going to have direct access. So if there isn't direct access, why have a DPT? I'm going to skip that can of worms this time.

If we want direct access now is the time to jump in with support. If you want it, send an email. Explain to others what direct access means and why it's important. Vision 2020 may be too optimistic but we have to start somewhere. This isn't going to happen quickly. Based on what I've heard when working in different locations, I think the APTA might be better off focusing on educating practicing therapists about what direct access means to them and eliciting their support. Then we should put the push on congress. I've come to this realization slowly. Now that I have, I will be sending emails when requested. I'll support the effort as much as I can. It isn't much, but it's a start.

I'm not picking on my co-workers.  They volunteered to help me with a project by listening to my presentation.  They had no idea what they were getting into.  Each of my classmates did the same thing with the same results.   If I combine everyone's results and generalize the conclusion is that very few current therapists are aware of how to read the literature and analyze what it says.  Let me clarify that statement.  I don't mean they are unable to read the article.   I mean they are unable to draw the pertinent information from the article and determine if that information is valid.  I was guilty of the same thing before I started taking classes.  If I found an interesting article, I read the introduction and the discussion.  I wanted to know what they did and the results.  Sometimes I skipped the actual article and only read the abstract.  Not any more; now I read the whole thing.

Those results aren't surprising.  Until recently, PT schools didn't teach how to interpret articles.  Now that we're moving toward evidence-based practice (EBP), reading and understanding the literature is more important.  There are many courses on EBP or courses that incorporate it into the topic.  I took one last week.  I learned what EBP is, why it's important and how to search for articles.  I didn't learn what to do with the article once I found it.  I don't think I've seen one class on reading the literature, only on using it.  That creates an interesting problem.  How can a PT use the literature if that PT doesn't know how to pull the information from it?  There's a lot more to using literature than reading the conclusion.

Even someone who wants the evidence will have trouble finding literature.  The APTA provides two magazines to its members. They cover a wide variety of topics specifically related to PT and are available both in print and online. The various sections also have a journal or newsletter which includes research more specific to the particular section.  All of these are only available to APTA members.  Section members are required to receive the journals. The APTA also provides Hooked on Evidence and Open Door to assist with finding evidence.  Unless someone is a member or has access to a university library, he or she will have little access to any literature.

There are other benefits from reading literature.  It keeps you up to date on new techniques and treatments.  It enables therapists to communicate more clearly with physicians.  A physician is going to pay more attention to someone with current knowledge who can cite literature to make a point.  Being able to speak knowledgably makes a better impression than speaking in generalities.  It's a lot easier to sell a new program or support a new piece of equipment with proof of effectiveness somewhere else.  More and more research is being devoted to comparing one treatment to another or combinations of treatments for best results.  Every time I've had to do a literature search or answer a question for a class, I've based it on a patient I was treating at the time.  I've learned things that have directly affected what I do in the clinic.  For instance, walking backwards is effective for gait training stroke patients.  Weight bearing on a hemiparetic limb doesn't increase muscle strength or standing balance.

In comes down to being able to read between the lines of the literature.   Not all literature is created equal.  It can be misleading.  Another topic I've looked at is body weight supported treadmill training. I   found articles both pro and con when compared to walking on land.  I've yet to form an opinion because none of the studies were well designed and didn't have a large enough sample size to get significant results.   Personally I want BWS treadmill training to be effective.  I've had good results with it.  I thought I'd find several articles in support, but was wrong. 

These are good examples of why PTs need to be reading the literature.   I was surprised by the results to those searches.  Reading literature doesn't require searching databases.  One well-written article will increase knowledge.   PTs will never embrace EBP until they learn how to read literature.  Even without EBP we should be reading more.  It's just as important to read for knowledge as it is for evidence.  Reading the intro and the conclusion is better than nothing.  Not every article I read is useful, but it is one more piece of information I might need someday.

Her statement surprised me because I've always treated that way. As much as possible I work on functional activities. It never occurred to me that other therapists did something different. From what I've seen we're all pretty function oriented. I'm sure many of us fall back on to strengthening when we don't know what else to do.  That doesn't happen too often. Granted she presented things that hadn't occurred to me.  I just don't think her statement is correct. If all we did was strengthen patients we'd have gyms full of unilateral body builders who aren't able to do anything else.

She made another point about how we, meaning PTs, forget about sensation when we're assessing gait or whatever else. That was a "doh" moment for me. Neurologically-impaired patients are going to have impaired sensation. If sensation isn't traveling up the spinal column adequately the brain is unable to properly control movements. A patient with a cerebellar stroke is a good example. They have good strength but are all over the place when they move. Her point is that we have to include sensation in our treatments or in its absence teach compensation techniques. 

From that statement on her bias came through.  Every gait, balance or transfer problem resulted from poor sensation.  She said coordination deficits don't arise from weakness but from impaired sensation.  Yes, sensation is a part of it, but coordination won't improve until the muscles are strong enough to complete the movements.  The woman knew a lot, but she lost me right there.  Nothing in PT is all or none.  Movement is a combination of multiple systems working together.  Ideally impairment of one can be compensated for by another.  There is more and more research supporting neuroplasticity as an explanation of why brain injury patients improve. 

I'm sure she had a good reason for saying that.  She certainly got me thinking.  I don't pay as much attention to sensation as I should.  I realize I need to incorporate things into my treatment that increase sensory feedback.  I need to use more visual cues.  Until this weekend I didn't realize how important sight was for altering perception.  I used mirrors for visual feedback.  Now I realize I need to incorporate vision into treatments including simulating visual distractions to help pts prepare for the real world.  My patients will be walking more on the nursing floors and less in the gym to help with that. 

All in all it was a good course. It got me thinking.  I came up with some new treatment ideas as well as new uses for old things.  I agree PTs need to focus on function.  I don't agree that sensation is the answer to everything.  I am more aware of its importance for transfers, ambulation and fall prevention.   I now have a better understanding of how CVA location is related to presentation.  I also have a better grasp on when improvement means making the best of what a patient has instead of trying to get more out of the patient.  The next few weeks are going to be interesting as I try out what I've learned.

It's a special feeling when everything clicks with a patient. Usually it's not as dramatic as my patient this morning. Often it's something small like figuring out why terminal knee extension is important for standing.  It can be even smaller like learning how to use the walker to decrease weight bearing on a painful limb. Whenever it happens it's always a feel-good moment for me. Being able to do something like that reminds me why I'm a PT.

I think we forget that sometimes. It's easy to get wrapped up in just getting through a schedule. There've been times when all I could focus on was what I was going to do in the next few minutes. My patients were making progress as I expected. I didn't have time to think about being innovative, much less do something different.  Patients got better because that was the whole point of therapy. It wasn't that I didn't care.  It was more I forgot the why part of what I was doing. I don't mean the why of figuring out someone can't gait because of hip extensor weakness. I mean the why that comes from a person needing help to get back to a previous life style.

We all need an occasional "ah" moment. My day got much better after that because I felt like I did something that made a difference. Patients need those moments, too. They're working a lot harder than we are. Having everything suddenly come together is a huge motivator, not to mention a prevention of depression.  Neuro patients must have periods of depression. One minute they're independently doing whatever they needed to do. The next they're in a hospital waiting for someone else to do almost everything for them. It has to feel good to accomplish something major. My patient was smiling the rest of the day.

Tomorrow is another day. I'll go back to work and start again. Hopefully my guy will do just as well in therapy with me. I'll be good to go as soon as I get there.  My inner therapist has been recharged. I did something good. I helped someone. Everyone needs an "ah" moment once in awhile to recharge.  What PTs do is special.  No other health professional can do what we do. That's important to remember as we struggle through a busy day. An occasional reminder goes a long way in remembering that.

There are many reasons why I'm seeing sicker patients.  The population is aging and living longer than previously.  Most of the patients I see are 70+ years old.  The fact that someone is that old is already a complication.  Having medical problems on top of that makes it worse.  People are also waiting longer to seek medical attention and so are sicker when they are finally admitted to the hospital.  Those people now require longer, more involved care than if they would have come in sooner.  Technology has improved so that doctors are able to save people who would have died a few years ago.  And, my personal favorite, many of these people are obese with poorly managed co-morbidities. 

I can treat these patients by myself, but I can't mobilize them by myself.  Bed level exercises can only accomplish so much. There comes a point when I have to sit someone up to progress them.  For that I need help.  If help isn't available, those patients don't sit up.  In the rehab department cost cutting means cutting out support and clerical staff.  It's not realistic to split one tech between four therapists and expect every patient to be seen and mobilized.  Even if I have help, that's no guarantee the patient will be treated.  Many times I arrive only to find the patient is unavailable or gone for a test.  I can come back later but my tech will be elsewhere.

PTs are caught in the middle.  Case loads become prioritized, often by who can be seen the easiest or which attending will scream the loudest.  Deciding who to see can come down to deciding between two higher-level patients that can be seen quickly or one lower-level patient that will take time.  The problem is exacerbated in departments where performance appraisal is based on productivity.  Patients who are heavy or otherwise difficult to move often get skipped.

This is an observation.  I don't have an answer.  It's not realistic to think departments are suddenly going to reverse direction and hire more support staff. If anything, there will be fewer support staff as facilities cut more corners to accommodate the higher salaries demanded by DPTs. Having fewer PTs and more PTAs may keep the overall salary costs down, but won't support additional support staff.  Meanwhile patients will continue to require extra man power that doesn't exist.  Certainly treatment frequencies can be decreased.  I've done that on occasion but never felt right about doing it.  It was pounded into my head during school that daily is best. I still haven't gotten past it.  Another option is co-treatment. The problem there is poor reimbursement for co-treatments. Most facilities don't want it to happen. Most therapists aren't able to compensate for the lost productivity in an 8-hour day.  I know I can't.

The problem is isolated to inpatient facilities.  I've worked in several SNFs with many multiple-man power patients. The SNFs I've been in recently had support personnel so it was a little bit easier. That's a double-edged sword. On one hand I can work with the patient. On the other, the patient doesn't have the endurance to participate in therapy. Outpatient clinics are beginning to feel this, too.  I've been in a few with labor intensive patients.  Most clinics are set up to accommodate those patients. If I have a patient with 02, a RW, min assist for gait and poor endurance, I need help to do it safely. 

Right now all we can do is wait and see what happens while we do the best we can with our patients.  Healthcare is on a crash course for disaster as it is.  This is one of the many problems we're facing. Hospitals and physicians are beginning to recognize the benefit of early mobilization on shortening stays. Maybe some bright money person will explain to them how having more rehab staff actually saves them money by shortening stays and preventing bed rest complications.  The evidence exists to support the rehab side of things. That's a start.

Many of the hospitals in Houston have gone to a paperless system.  The one I'm working at is among them.  The only thing written on paper in the chart is the physician orders and daily notes.  Everything else is on the computer, including all therapy notes.  Without computer access, I couldn't begin to treat a patient.  There was a steep learning curve when the hospital went live with the system.  Since that time, things have gotten much easier. Physicians are forced to dictate everything. That means everything is in the chart in a timely matter and legible. I have access to all radiological results and current lab values. I can look up therapy notes from previous admissions by merely clicking on a box. This is a major improvement from the previous system.

The age of computers isn't limited to hospitals.  I've worked in SNFs and OP clinics that are computerized.  A few years ago when I worked OP, the only thing computerized was billing and the schedule.  I think paper will practically be a thing of past there in a few years, if not sooner.  OP clinics have a lot to gain from going computerized.  Third-party payers won't be able to deny claims because they can't read notes.  They won't be able to nitpick about missing information if templates are used that have spaces and prompts for all necessary data, including basics like the pt's name, MD, diagnosis, POC, frequency, etc.  It's too bad the cost of installing the necessary hard- and software is so high.

PT schools are taking advantage of computers and the internet as well.  Many transitional DPT programs are 100 percent online. Both of the local schools here have part of the curriculum as online classes in addition to traditional classes. Exercise programs are available to generate written programs that can be translated into different languages.  That's really helpful here in Texas where half of the population doesn't speak or read English.  I've also seen programs that act as translators to help communicate with patients.

It's obvious physical therapy would be much different without computers.  I have a new appreciation for mine now that it is working again.  I'm sure there are many therapists out there who remember the day when we didn't have computers.  I'm also sure there are many newer graduates who can't remember a world without computers.  Until I sat down and though about it, I didn't realize what a difference computers made and how much we've come to rely on them.

Currently I have two patients I don't know what to do with.  Beyond the obvious, I'm not sure why they are on rehab.  In both cases the discharge plan and long-term goal of the admission are unrealistic.  One patient is s/p resection of a frontal lobe brain tumor.  On a good day frontal lobe brain injuries are a challenge to treat.  This gentleman has a long history of alcohol abuse and smoking.  His personality was difficulty premorbidly.   To further complicate matters he has a severe left side neglect.  He doesn't want to get out of bed.  He doesn't want to walk around.  Unless our therapy is walking to get coffee he doesn't want to work with me.   He becomes agitated whenever he is confronted with his situation.  He hasn't been violent, but aggressive behavior is characteristic of frontal lesions.  I keep an eye on him.

I've made little progress.  I don't think I'm going to get very far at all.  I understand that he needs therapy.  But he has to participate for us to accomplish anything.  I'm not sure what his admitting physician thinks we're going to accomplish.  His mobility problems aren't nearly as severe as his cognitive problems.  If he wants to get up and walk he can.  It isn't pretty but he can do it.  He will require 24/7 supervision when he leaves.  He won't be able to return to independent living so will be placed somewhere.  That will put him under 24/7 supervision.  Given these circumstances he seems to have obtained his highest functional level for gait.  Those same reasons are why he won't leave the unit before his anticipated DC date.  I don't know what to do with him.

The second patient is a R CVA with severe hemiplegia.  He is cognitively intact.  He is also an AKA on his uninvolved side.  He just received a new prosthesis (C-knee) prior to admission that he has never been trained to use.  He is max assist of 1 -2 for all mobility. Today he finally sat EOB with SBA against no challenge.  His rehab needs are fairly obvious. It's also obvious that it's going to take awhile to achieve any level of independence.  The problem is he lives alone and is insisting on returning there at DC.  He has some family that can assist him some of the time.  Unless he gets a huge surge of motor return on the right he won't be ready to be home alone at DC time.  No one but me seems to think this is a problem. 

I've been told the family will step up and help him. I've been told they'll increase his provider time.   He says he'll be able to do it at home.  How many times have I heard that?  What I want to know is how he'll go to the BR in the middle of the night when he can't even use his urinal using one hand.  The referring physician wants to wait until next week to make a decision because she believes he is going to improve.  I believe he is going to improve but not enough to be home alone for any length of time.  I wish his physician would share what she is thinking with me so I can plan my treatments accordingly.

All I can do is continue to work with these patients.  Maybe I'll be pleasantly surprised.  I'm hoping the stroke patient will figure things out for himself.  That doesn't address the issue of what is the expectation with these patients.   Therapy isn't a cure all.  We can only do so much.  It's one thing to admit patients telling them they're going to get rehab so they will hopefully go home.  It's another to think two weeks of therapy is going to fix everything.  I sometimes wonder if I'm looking too far down the road.  I look at these patients and think big picture.  Maybe I need to think small picture.  I could just let things work themselves out.   Even if I do that I still won't understand what we're trying to accomplish.