Let's take a look at other "controversial" pain therapies.  

Craniosacral Therapy (CST). Some have said has little scientific support, yet physical therapists continue to use this treatment. It has also been listed as an alternative medicine therapy in some of the literature. 

Modalities.  There are physical therapists and PTAs that fully support the use of every modality available and will seldom question the use of them.  But I have come across therapists who refuse to use them (except heat or ice) and apply a "hands-on" approach only with their patients. Who is right?

Chiropractors.  Some love them and some dislike their theories, but they do not seem to have difficulty finding patients that willingly go for pain relief. 

Is medicinal marijuana any more dangerous than Vicodin, methadone, cigarettes (how many therapists smoke) or even alcohol (how many therapists drink)? Or better yet, is using medicinal marijuana any more dangerous than using therapy techniques that are questionable in literature and practice?

A better debate might focus on whether the risks outweigh the benefits for any treatment that will relieve pain. 

JASON'S THERAPY

#1  Massage...........................$XX.00 (For first 15 minutes. $X.00 for each additional minute.)

#2 T.E.N.S............................$XX.00

#3 Ultrasound........................$XX.00

#4 Heat Pad

               Back.........................$XX.00

               Neck.........................$XX.00

              Arm/Leg.....................$XX.00

#5 Ice.................................$XX.00

Combo Special Every Tuesday

             Combine any two for one low price of $XX.00

Exercise Special Everyday

             One half hour session with two of the above $XXX.00

Of course we could alter it to offer iontophoresis, wound care, taping, etc.  Imagine the free market and competitive nature we could have trying to market ourselves.  Perhaps I could open a place across town from the busiest therapy office and offer a couple of my specials with coupons that offer a "Free Biofreeze massage With Purchase of Two Exercises".

Is the idea so far out there?  Hardly.  Clinics have run on cash only successfully.  When my place opens I will offer a lighted menu above the receptionist.  The receptionist will type the patients order into the computer, a therapist will call the patients number over the intercom system and bring the patient back into the gym or a room depending on what was ordered.

With direct access this may be possible.

Not too long ago I read about The Legacies Project--which is doing something similar, but on a larger scale. 

Jay Nelson and Jimmy Rhoades (www.nicework.tv/about.html) formally collaborated on the concept of collecting videotaped oral histories of residents in nursing homes by building it into school curricula. 

"Students are trained to enter nursing homes over multiple visits to videotape comprehensive oral histories of residents.  Then they're trained to add informational tags to the video, so that when oral histories are added to the project archive, it's fully keyword searchable," Mr. Nelson explained.

Jimmy Rhoades elaborated, "We want the archive to have the most value possible, so the entire project has Institutional Review Board Certification through the University of Michigan - Flint.  The lead researcher is project partner Dr. Heather Seipke, who is a Certified Gerontologist.  The students who do the interviews are actually trained to be Certified Research Assistants, which looks pretty good on a college application.  It also lets future historians who access the archive know that proper research protocols were followed when the stories were gathered."

Jimmy points out that participation of residents is voluntary and they can decline to answer any question or end an interview anytime. "So far the facilities, staff and participants have been not just cooperative, they've been really enthusiastic and gone above and beyond to make the project a success."

In early 2010 http://www.legaciesproject.org/ will be up and running with samples of their work and short stories. 

We did get a chance to travel off campus through the metro system (subway) and after a couple of confusing turns we ended up at the Smithsonian exit and did a lot of sightseeing in the nation's capitol. There were a lot of changes since I was a boy living there in the late 70s and early 80s. 

President Obama happened to visit NIH while we were there and initially I thought he wanted to speak to me about the comments I made about health care not too long ago in my blog. But alas, he didn't. 

Being part of a study has benefits in that we can help future generations in developing medications and treatment techniques that can assist the medical community as a whole. Having a cooperative family such as ours that is willing to do whatever it takes is certainly beneficial for future studies as well. 

So this got me to thinking. If you were asked to participate in a study that will not directly benefit you, would you do it so others may benefit from it?

I was excited one day that a patient had a wound we could treat, and I suggested to the MD that he should let us.  When the PT found out that I was the one who spoke with the MD, it was not a good day for me. 

I was told plainly to allow the PTs to make the suggestions in the future and my role was not in treatment implementation but to carry out the treatment that was designed by the PT. 

But, but, but...I am the one who put all the work in the wound care program and I can't even help try to implement it?  "NO!" was very clearly told to me.

I now understand why the PT pulled me aside and let me know who has the responsibility for the patient and why they wanted to be the one to determine whether the patient is appropriate for therapy or not.  At the time I did not.  But even today I tend to open my mouth a little wider than I should, and when that happens I fully expect the PT to be there to let me know who is in charge. 

A PT once described to me in terms I could understand about correcting and guiding the PT/PTA relationship.  The PT described it as a parent/child relationship.  The parent will need to guide and direct the child until there is enough confidence to allow the child to go further and further from home, but both should know when they have gone too far with freedom given and freedom taken.

So my question is how much freedom is given to the PTAs in your facility?

I discussed my role with a PT friend of mine recently and asked her about how much leeway she gives the assistants who work with her.  She told me even though she is friendly with them, she also likes to watch what they are doing to ensure patient safety and compliance to the plan of care.  She also said she would make corrections immediately if they were doing something unsafe. 

So I asked her if she ever allows a PTA to make a mistake to teach a lesson. "Yes" and "No" was the reply. "If it would not endanger patient safety it may teach a lesson in not going beyond what you know and should do." She went on to say, "I would rather do a quick correction than allow the PTA to get stuck in a position they should not even be in."

I asked another PT friend about the PTAs he works with. "I let them do their thing and I trust their judgment in patient care."  He went on to tell me about one PTA who would not follow the plan and always thought the patient should do other things instead of what is on the POC.  "So I had a sit down with him and explained our roles in the rehab department and the chain of command.  It didn't sit well with him, but I think he understood what he was supposed to do after that."

As leaders in the health care field, the PTs should have the confidence in the PTAs ability to make wise choices and follow the plan of care. Perhaps guidance and direction is needed more often than not. With the proper guidance, the PT and PTA will flourish (did I really use that word?) and with proper direction the relationship will fully develop into something that both can be proud of. 

As a PTA I have to rely on the PT for accurate and up to date information in order for me to perform my duties.

I have been to places where all the notes were up to date with the latest tests and accurate documentation and if one piece of information was missing the provider responsible for that patient got a talking to.  I have been to other places where I had a hard time finding the evaluations in the charts and progress notes were scarce due to the high turn over rate in patients and staff.

I have had PT's tell me verbally what they would like to do with the patients but then in the written POC it was different and my note appeared to be way off base as to what the PT decided to do once all the paperwork was completed.   My general policy is to completely trust the PT when they verbally tell me to do something with the patient. 

I may change that policy however.  As I do more research on documentation it is better to have everything written down so there is no confusion as to what should be done with the patient and both the PT and PTA are protected as to what activity the patient is able to participate in.  The PTA can carefully review the POC and goals and ask questions about them for clarification and if there are any contraindications they can ask the PT about it. 

The big concern is for the PTA.  What if in the middle of treatment someone from the state board would like to see the evaluation and plan of care of the patient to ensure compliance.  We technically should not be allowed to treat a patient until we have an evaluation, however I would check with the licensing board, but I am sure they would not want us to treat patients until a evaluation is completed and in the chart. 

Let me know, should PTA's treat a patient before the evaluation is written?

What is it that we want to be known for?

• Torturers?
• Educators?
• Innovators?
• Advocators?

All of the above? Or none at all?  If we see a patient once, and once only, what is it that we want them to take away from the visit?

Some of it will depend on diagnosis, but as a whole, we want the patient to recall what we did...

Do we want to be remembered as the therapist that will provide a home exercise program, or maybe one who provides a great massage with heat and TENS, or even a therapist that will impress upon the patients that we are really, really smart.

As I pondered this and looked around, the therapist I work with is definitely a talker and will be remembered as person you can "chat up" during the session.   I, on the other hand, usually skip the small talk and get down to business and put everyone to work immediately. 

I will torture first then educate the patients on why I do the things I do. Advocating for patients can be hard in that you may have to step on toes to get things accomplished and I have learned (the hard way) on diplomacy when it comes to being an advocate.  In fact, I am still learning this. 

I guess I am trying to figure out what the patients take away from a session of therapy.  I want them to learn something from the session and not think all I do is create more pain for them.     

I will have all the tools necessary (books, measuring devices, adaptive equipment, etc.), but will be unable to figure out what I'm supposed to do with all the information I have on hand. 

It's not about information overload, it's more about unraveling and categorizing the information into something tangible I can work with and then actually doing it.  There are times I am unsure as to what I should do next with a patient or which technique I should employ with them because of all the choices I have and theories that are around. 

When I sit down in our department and observe and assess a patient it may appear that I am doing nothing, but I am formulating a plan based on my knowledge at the time.  That knowledge can and has changed from morning to afternoon depending on which Website I have located and read during my lunch hour. 

I don't want to waste a patient's time during therapy, I want them to understand that they are with me to get better, stronger and back to their highest level possible in the shortest amount of time.  But for me to assist the patient, I have to understand the tools around me and apply them as effectively and efficiently as possible and I think that is where I get stuck.

Trying to get things done and developed programs in our department can be like a Chow-Lui Tree explaining the Bayesian Networks.  (The geeks like me will understand this)

I have attempted many times to do balance and stability programs and be consistent with the Berg or Tinetti but there is absolutely no carry over by the P.T. and since there is hardly ever a baseline to go from at eval and no goals to work towards that reflect a progression towards improvement I might give up trying to do this.  I have even explained reasons why we need to have a reliable test but the conversation seemed to go nowhere. 

I would be better off having the PT explain Ampere's Circuital Law (the integral form one, not the differential form) with Maxwells correction, than have a fall management program stay on track with appropriate goals that can reflect improvements. 

There are other programs that I would like to develop and interested in but need the backing of the PT so our department can do it.  If the PT is not interested in developing programs like wound care and falls/balance our department becomes stagnant as does our treatment techniques.   How can I light a fire under her to get her to become more motivated and want to improve and stay on task?

Anyone with an Alexandrian Solution?

A patient was evaled and goals were established for transfers and strengthening exercises. So I see the patient this last week and have her stand up with a FWW.  She took a step.  This was followed by several more steps on her own initiation and she eventually walked across the room.  I have seen patients do a one time walk and not do it again for the whole time they are on therapy, but his patient walked everyday as soon as she stood up.  

Unfortunately the PT was on vacation last week and was not able to establish any goal for gait.  

My thought processing with this patient was that the standing, the transfers, and the walking would fit into the goals that were established.  Since I walked (no gait) with the patient this fits into strengthening, right? And/or functional mobility.

And before anyone says anything, I checked the H and P, POC, eval, nursing and MD notes and there was not anything in there that excluded walking or weight bearing through bilateral lower extremities. 

This is a dilemma for me that I have yet to resolve or solve for myself.  If a patient stands and decides that they want to walk and no PT is available do I walk with them and discuss it with the PT later, or lose the rhythm of treatment and have the patient sit back down and wait until I find a PT that can assess the patient if no goal is established?

Getting up, weight bearing through the legs and walking is a natural sequence of events that we learn as children and it stays with us through our lives unless if we can't or absolutely don't want to.  Should I have allowed a person to do a natural sequence of events that was learned before I was born even though a PT did not assess it and establish a goal for it?

I pay for health insurance through my employer, I pay a deductable when I see the health provider, I pay the pharmacy for medications the insurance doesn't want to pay for, we incur costs for travel to specialists that are recommended by our primary MD, my young daughters are penalized with a mandatory waiting period for having pre-existing conditions, and I still get billed from the hospitals for blood work, x-rays and other tests the insurance didn't pay for. 

For a family like mine, regular employer insurance doesn't work and Medicaid isn't much better.  Usually one insurance is waiting for the other to pay first and as they point fingers at one another we have to field calls from the hospitals who want to be paid for their services. So guess who loses?

There are definite problems with the current system and we need to find a solution that is amicable for everyone. Here's what I would do first, Mr. President, are you listening?  

1. Free health insurance for children 0-18.
2. Eliminate waiting periods for pre-existing conditions.
3. Debt forgiveness for terminal illness.

Each of the three have obvious reasons why they are important and I am sure there are many other causes as to why insurance is so expensive and covers so little. 

I get frustrated when I give a patient HEPs and theraband with detailed instructions on its use only to be told they did not do them the whole weekend and stayed in bed to "rest." 

Then the next week the patients will say they want to leave and wonder what I am not doing for them so they can achieve this goal. I turn this around and ask the patients what they have been doing to ensure they will go home.  I will sometimes assist them in breaking down their day by the hour and figure out times they can do independent exercises.  This is usually frustrating on their part because it brings to light what they could have done but choose not to. 

I generally drop it there and encourage them to increase their participation with activity to their tolerance and get out of bed every day and wheel themselves down the hall independently. 

I remember reading in ADVANCE one time about a PT who took another perspective on this. She wrote that every time she instructs someone in exercises she reminds herself that it is probably the patients first time learning how to do them.  I must remind myself this and not get frustrated about it. 

I will try to be a good coach and a better therapist. 

I am not saying this because he e-mailed me back and gave me a great website to browse nor would I say this only because he is a PTA who does research about stroke rehab. I am saying he wrote a book families and clinicians can read and understand easily and I appreciate that. 

He did not advance me a copy with a fat check to endorse him either (although I am open to this). It took me about a week to read through the material and I thought "Wow." He is empowering families and survivors of strokes to ask pertinent questions about rehabilitation to their MDs and PTs. 

He is directing and encouraging survivors to take charge of their lives and act on what the therapists and MDs have directed.

Since reading his book, I have changed the focus of how I interact with stroke patients.  I use the term "you" more than "we" and I try to be up front with the families and the patients themselves to encourage them to take charge more. 

The book also mentions the insurance factor, which I have rarely seen written so clearly.  Basically it tells the patient their insurance will stop paying for rehabilitation if they do not progress and it encourages the patients to do as much rehabilitation as possible so they can progress. 

The book is encouraging to patients and it allows the care to be focused on what they can achieve rather than what they are not able to do. My copy went to work with me and I encouraged others to read through it.

I need someone that can understand my point of view but allows me the insight into another perspective.  I would like someone who can talk about Legos, Graeme Obree, Hannah Montana, 101^st Airborne, Spongebob, Sci-fi, children, psychiatric disorders, and the UFC. 

I also need them to assist me on focusing and honing in on my strengths to assist me in becoming better in all facets of my disorganized and dysfunctional life. 

My quest has yet to reveal someone I can trust in not judging me or my rash decisions and situations I help create. 

Perhaps I am reaching far too much. 

Maybe I am not looking hard enough.  I have met several potential people that I could have asked, but the more time I spent with them the more I realized they were not a good candidate for me. 

In the meantime I will continue to look and if there are any takers on becoming my mentor we can talk about it, just leave your e-mail address in the comment section.