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PT and the City

2014 New Year's Resolutions
by Lisa Mueller

It's hard to believe it's 2014 already. I officially graduated from physical therapy school five years ago! Wow. Seems like it was yesterday. It also seems like I'm talking like my mom or grandma when I use phrases like "seems like yesterday," but so be it. Now's the time each year when I review my resolutions from the previous year and set goals for the upcoming year, although I'm slightly hesitant this year because I know I didn't achieve the ones I set last year. Either way, let's review!

  • Read one book per month -- partially completed. I read six books this year, which was an improvement from 2012 but not quite my goal. I'll take it, though. I did enjoy this resolution, talking with friends to pick out my next book and reading book reviews online. I hope to continue reading more in 2014 as well.
  • Regular participation in department journal club -- major fail. I believe I participated in four of the 11 journal clubs in 2013. I have excuses, such as traveling and other meetings scheduled during the journal club, but I could (and should) have made this a priority.
  • Take a CE course of the thoracic spine -- partially completed. I'm signed up for a thoracic outlet course in two weeks. I also took some other CE courses at the APTA conference in June.
  • Don't delete all my own stuff -- successful!

For 2014, I have the following resolutions to focus on:

  • Spend one hour each week cleaning out my email. The number of messages in my email takes my focus away from other important tasks if I can't find what I need or fail to follow up on an item because the message got lost in the shuffle. In order for me to succeed professionally, I need to be able to make my email communication more efficient, which includes regular management of the volume of emails.
  • Exercise regularly, with a goal of twice per week. This sounds so incredibly cliché and hypocritical, coming from a physical therapist, but I need to be honest with myself (and my readers). Exercise should be my best habit and a top priority each week but it hasn't been this year. Traveling for work and taking on new responsibilities resulted in me focusing on other things, and I need to make exercise a regular part of 2014.

What about you? What are your goals for 2014? Share them below!

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This Is a Test
by Lisa Mueller

Several of my family members are in the process of transferring old photographs, 35mm slides and film negatives into digital format. A project I encouraged my mom to complete for many years was one of the best Christmas gifts I received this year, as I can now click through hundreds of my childhood photos on my computer. (You may recall a previous blog where I wrote about winning a photography contest. Photography is one of my favorite hobbies). Now, there is still nothing like the old photo albums they came from but it's nice to have the photographs organized and more easily shareable.

One of my relatives took in a stack of slides to be transferred to a CD and told the staff at the photo shop, quite frankly, "This is a test." The small stack of 30 slides was a sample of more than 4,000 slides, which could all be transferred to digital copies if the test run went well. The sales clerk wrote on the package, "Test for possible larger order." We were all excited to see how the slides would turn out in a digital version -- images we had only seen on a small slide viewer could now be seen on any computer!

Over Christmas we popped the disc into the computer and clicked through the images of our priceless memories. Some images were wonderful; just as crystal clear and colorful as we had remembered. But, some were not great. Some had dirt on the digital copy because the slide hadn't been cleaned completely. Some images were crooked because they hadn't been lined up straight prior to being scanned. We were all a little disappointed because we were so hopeful the "test run" would be flawless.

What would happen if a patient of physical therapy told his therapist, "This is a test?" How would it feel to be tested? What if a patient's experience and outcomes determined if he would return? This is probably a theme prevalent in the minds of private practice therapists since referrals and loyal patients help sustain their businesses, but for some therapists, the idea isn't as strong. Would you practice differently if you knew you were being tested? Should every patient be treated as a "test?" Should there be a difference between a "regular patient" and a "test run," or should we be practicing our best with every appointment, every time?

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Holiday Breaks
by Lisa Mueller

Well, it's officially the holiday season. I spent last weekend wrapping all of my presents (three total hours), adding ribbon with name tags (two additional hours) and applying stamps and stickers to some of the packages (one hour). This weekend I hope to bake a batch of cookies that would fit in well with the five inches of snow that fell last night (and would also help me avoid shoveling the driveway).

Because Christmas falls on a Wednesday this year, I was able to take most of the week off but only needed to use two vacation days since my clinic is closed Christmas Eve and Christmas Day. The same pattern applies to the following week with New Year's Eve and New Year's Day. As I've been scheduling my patients for their follow-up appointments, I realized that although the time off is nice, it's also difficult for patients to receive the therapy they need when the clinic is closed.

What happens to your clinic over the holidays? Are you able to take time off to spend with your family and friends, or are the needs of your patients the priority? Is there a way to compromise? I remember working on Christmas at the hospital in acute care and many patients and families were always surprised to see physical therapists working on the holiday. I can understand their perspective since many times physical therapy is not "critical" for acute-care patients. However, I'm always grateful when our services are needed and wouldn't want to lose an opportunity to educate patients on the benefits of physical therapy.

There are some times when I struggle taking time off from work because I don't want my patients to have a gap in their care, and other periods when I'm not as concerned because I need the break. It's important to take time for ourselves throughout the year.

Here's to wishing you and yours a safe, peaceful and blessed holiday season.

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How Can I Help?
by Lisa Mueller

One of the reasons I like being a physical therapist is that I'm able to help others. I like teaching patients and families new things that will (hopefully) improve their quality of life. I enjoy helping patients reduce pain and seeing their faces light up when they're able to complete functional movements with ease. When I can't offer much help to my patients, I'm somewhat comforted with offering alternatives and coordinating care for my patient with other providers -- so I know they are least have options.

An acquaintance of mine was recently diagnosed with ALS and has lost a lot of function in the past three months. For the first time, I really don't know how to help. I haven't seen any imaging results to know the severity of the pathology, but I know enough about the disease and the change in my friend to know the impact ALS has had this far.

There have been times during treatments when one of my patients might become overwhelmed with his physical or mental disabilities, or the prognosis of his disease, and become quite emotional. Physical therapy can many times highlight a patient's deficits (in order to assist the patient in improving), although in some cases it is the therapist's duty to emphasize the progress, and rightfully so.

The situation is that, I've become accustomed to speaking with patients from the perspective of a physical therapist, but not very often as a familiar friend. I don't know what my role is or needs to be. Although I know my friend well, this new diagnosis brings unfamiliar friendship territory. I'm not sure if my friend needs me to be a physical therapist -- interpreting some medical advice, recalling past experiences and emphasizing that miracles do happen. Or perhaps my friend needs some empathy, someone to vent to about the frustrations of a new diagnosis. Maybe both.

In either case, this experience (so far) has made me grateful yet again for the knowledge I have about the nuances of the healthcare system and the blessing of good health.

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Thankful!
by Lisa Mueller

Every year I look forward to this time of year the most, and this year is no different. I have a lot to be thankful for. Writing those things down and publishing them on my blog makes it so much more real. So, as my faithful readers are anxiously waiting for my annual thankful blog... wait no more! This year I'm thankful for:

1. My health! Working in a medical setting reminds me daily how lucky I am to not have any pain, injuries or disease.

2. Spending time with my family and friends -- I was able to go on two trips this year with my family and I appreciated the time to relax, unplug and make happy memories.

3. My career! I took on a new role this year as a supervisor and am glad to have the opportunity to grow my skills and learn more about the different roles in the physical therapy field.

4. Reliable transportation. My car is gaining miles every year, and I'm always thankful when it starts every morning so I don't have to finance a new vehicle or invest time in finding a new car.

5. Friendly people! I've traveled a lot this year and am so thankful for those who helped me during my adventures -- whether it was giving me directions, suggesting restaurants or teaching me about the culture of the area, thank you!

6. Time. I told my mom earlier this month that when I was in college, time seemed to drag by. Semesters seemed like years. Now it seems like I blink and months go by. I'm grateful for each day I have.

Here's to wishing you, your family and friends a wonderful Thanksgiving day. May the rest of 2013 be an enjoyable one!

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Is It Really Accessible?
by Lisa Mueller

I traveled for work a few weeks ago and stayed at a nice hotel for the week I was there. Anytime I stay at a hotel with a pool, I feel like I've won the jackpot. After a long day of work, I can come "home" to not only a clean room (thank you, cleaning crew for all that you do!), but I can also float in the pool and feel my stress levels diminish with my weightlessness.

This trip was a little unique in that I was put in a wheelchair-accessible room. I walked in and thought there had been a mistake with my reservation. The room was huge! The bed had a ton of space around it and the bathroom door was wider. I felt like a giant! I wasn't accustomed to such a large space when traveling. I usually struggle to find a spot for my suitcase and separate spots for my clean and dirty laundry.

As I spent the week there, I started to think from the perspective of a person in a wheelchair and reflected on education I provided my previous patients in regard to their mobility. I identified a few areas that could have been challenging for a patient. For one, there was no transfer bar next to the toilet. There was a transfer bar in the shower, but no shower bench/chair, just a larger shower stall (not a bathtub). The power switch on all the lamps was at the base with a push-pin-like size, which even I struggled with my thumb one morning to successfully operate.

While each patient's abilities are unique, I don't think a "typical" patient needing a wheelchair would have been able to utilize the lamps or toilet without some supervision or assist. Nor could he have reached items on the tall shelves in the closet (iron, or extra pillows).

I've been lucky enough to be involved with the construction of new clinics and I've always been impressed with the contractors' knowledge of American Disability Act (ADA) requirements for a facility. This traveling experience will certainly make me think even more from the perspective of the patient!

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The Anterolateral Ligament
by Lisa Mueller

Last week, healthcare news was focused on the discovery of a new ligament of the knee by two surgeons in Belgium, coined the anterolateral ligament (ALL). The ALL connects on the anterior lateral portion of the tibia proximally to the posterior lateral femur. ABC News reported that articles dating back to 1879 included discussion on the anterior knee connective tissue, although it was unnamed until last week.

Rewind to my blog post from last week, where I wrote "the origins and insertions of muscles haven't changed much"... and now I find myself in the face of some strong evidence indicating the opposite. Yes, even in 2013 we are still finding new areas of anatomy! The ALL may now be connected to more research of knee stability and ACL injuries, and that's only the beginning.

I heard about this news story on Friday from some of my colleagues, and even as I sit here on Sunday typing this post, many of the health news websites I read (Wall Street Journal Health, CNN Health, Google News with keyword health) already have the story shifting toward the bottom of the page with newer stories prepped on top.

The timing of the ALL news coinciding with my blog from last week was a professional "aha" for me to not be so confident in what I think I know. There are always new developments in health, medicine and physical therapy and we must be advocates to find the supporting research. Things I learned in school may no longer be effective treatments for physical therapy but that cannot be discovered until the research is completed. The real challenge is in holding all physical therapists accountable to assist with the research.

What do you think? Will the ALL be the focus of upcoming research? Are you surprised anatomy is still being discovered?

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When is Research Outdated?
by Lisa Mueller

A comment on my blog last week got me to thinking about the length of time that research is valid for use. The topic was brought up after I mentioned that I have an article from 2007 that I often use with patients, and a reader suggested newer research was likely available. 

During my clinical experience at the Mayo Clinic, I remember doing a small project on the validity and reliability of the Homan's sign for a thrombophlebitis (venous thrombosis). I had a hard time finding any research articles newer than 1985. My clinical instructor told me that sometimes newer research isn't available because once a topic is proven, the research won't be repeated.

So if the research in 1985 showed the Homan's sign to have a certain reliability and validity, it wasn't likely that a group of researchers would repeat the same study. They may, perhaps, conduct a similar research study to evolve the research into a different direction, but likely not with the exact same parameters. If I had an article from 1905 that encouraged eating healthy foods and exercising regularly, I'd probably still provide it to patients regardless of the date, because the content is still relevant.

Some topics in medicine are constantly changing with advances in technology, such as pharmacy, modalities, and genetics. Other areas are more consistent. The origin and insertions of muscles haven't changed much, to my knowledge. Calculus books don't need to be updated as often as say, tax books, which change every year with different adjustments to the laws and budgets of the government. 

Now that I'm typing these ideas out, I wonder if the APTA has any position on this, or what the Twitter-world would say... do you have any thoughts? If physical therapy research is older, can it still be used? If you find an article from 2001 (I can barely believe that was 12 years ago already), would you use it, or does some of the information need to be disregarded due to the time gap?

I'm excited to hear what you have to say on this topic!

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Do Patients Use Evidence?
by Lisa Mueller

Some of the research articles I've read recently have been about running, including the biomechanics of running and associated absorbed forces. Two years ago, I took a weekend CE course specifically about running. I'm interested in the progression from gait patterns to running patterns, and as a runner I hoped the information I learned would carry over into better patient care.

A recurring theme in these courses and articles has been the comparison of a "traditional" heel strike to an anterior landing at initial impact. So, over the past few months I've altered my running pattern to see if I could feel any difference between the two. Would I feel less LE impact if I changed to an anterior landing? Would my stride be longer with a heel strike? A few times I've actually laughed at myself as I've flipped between the two patterns because it resulted in me almost skipping when my coordination couldn't keep up!

As I've thought about these things and played around with my running pattern, I've wondered if patients of physical therapy do the same thing. Do you share recent research articles, or things you've learned at CE courses with your patients? Do you show them the articles, or handouts from the class?

There's one article from 2007 that I keep a copy of at my desk relating hip weakness to knee pain. I share it with a lot of my patients with knee injuries. Most patients really appreciate the information, and it almost seems to "inspire" them to consider all the factors contributing to their diagnoses.

I think the challenge I encounter most is having time to find research articles for patients. I have a hard time finding time to read them for myself, much less for my entire patient load! So, I've made a small goal for myself to find one article a week that pertains to my current patients and share it with them. Hopefully I can find an article with a simple takeaway message that my patients can understand, and one that isn't too lengthy.

What do you think? How does evidence-based practice transfer from physical therapists to the patients they care for?

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What Do YOU Want?
by Lisa Mueller

I received a postcard in the mail last week from a local hospital that said "What changes would you like to see in the healthcare we provide?" with a large space for a response to return. I thought this was very interesting -- what a great way to engage potential clients into finding solutions to provide better care! I know mailing surveys typically bring a low return rate for receiving feedback, but I really appreciated the effort of the hospital to be proactive during this time of nationwide healthcare changes.

I thought for a while about what I would write on the card. I know the feedback I hear from colleagues is that we need more time with patients, and tools (typically software) to be able to do our jobs. We need to have better access to research, and we need to be able to document and communicate our findings to a patient's other healthcare providers. But in those cases, I'm thinking about this from a provider standpoint, not a patient's perspective. What do I want as a patient?

So, what did I write? I think I would want to see the following things:

● I want more face time with my physician. I don't want to give my entire history to a medical assistant only for the physician to quickly review it and leave the room within 5 minutes.

● I want a better review of all of my health issues when I visit my physician. Too many times, I feel like the physician is just focusing in on my sore throat or new mole, when I have an entire body with many systems that could benefit from attention.

● Better information about, and access to, my benefits. Who do I call to ask how much an MRI will cost me? I think this information is difficult for patients to find and understand, and by the time a bill comes, it might be too late.

What do you think? What feedback would you give your doctor, or hospital system to provide you with better care? How do you think the Affordable Care Act will fit in this time of change?

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Engaged?
by Lisa Mueller

When I was younger, I would hear the word "engagement" and get excited for bridal showers, bachelorette parties and weddings! I love weddings. I'm always looking forward to hearing a good engagement story and brides talk about their weddings. Now, however, I hear the word "engagement" and I think about my career. Am I engaged in my role? Are my teammates engaged in their work?

I've taken engagement surveys before, and my engagement was usually decided by how flexible my job or supervisor was. Was I able to adapt my schedule when needed? Were their times when I had the flexibility to treat a patient with a plan of care I thought was necessary? I also really liked when the setting I worked in allowed for a lot of collaboration with other disciplines -- I was constantly learning from other people! In my new role as a supervisor, I'm learning that engagement is different for everyone. People are motivated by different factors, and there are different factors that make a person more happy in her job compared to others.

The more experience I have as a physical therapist, the more I'm realizing that some areas of my job can't be controlled, while others can be. A therapist's schedule could be adaptable; for example, therapists have the ability to come in a little earlier or later depending on the type of setting. Therapists are generally not able to work from home, however, as patients need to be seen at the healthcare facility.

Do you know what makes you the happiest in your current position? Is it the hours? The pay? The type of patients you work with? Is it your leadership? Is it your commute? Work/life balance?

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Best State to Practice
by Lisa Mueller

I just finished reading the October issue of PT in Motion, the APTA's publication I receive each month with a copy of the Physical Therapy Journal. The writers of PT in Motion ranked all states and the District of Columbia based on six specific criteria:

● Quality of life (for PTs and the general population)

● Literacy rates

● Employment rates

● Business friendliness

● Technology/innovation ranking

● APTA engagement

I was surprised to see literacy rates as a measurement in this survey. I can't imagine myself saying, "I really like practicing physical therapy in Wisconsin because of our literacy rates," but I can imagine considering job rates (probably the most) and the other criteria. I would be interested to see which states support and publish the most research, but I'm not sure if that's a measureable component. I was very proud to see Wisconsin listed twice in the rankings, but I'm guessing that was an error!

I took a survey toward the end of my physical therapy schooling (about five years ago) that ranked the top 25 places I should live based on my preferences. I know it included the availability of indoor/outdoor activities, population size, climate and a few other factors. My top locations were (I saved the email): Anchorage, Alaska; Missoula, Mont.; Fort Collins, Colo.; and Provo-Orem, Utah. According to the APTA article, Utah, Colorado and Minnesota are the top states to practice as a physical therapist... so if you compare those two lists, it looks like I should re-locate to either Utah or Colorado! I'll have to see what my husband thinks.

Reading this article and reflecting on my own "top places to live" reminds me of the differences I've witnessed in PT practice while traveling for student clinicals and more recently for my job. ADLs I wouldn't have thought to ask a patient are common tasks in some areas of the nation, and things I consider to be common (negotiating stairs to a basement) aren't relevant in other areas!

Have you read the APTA's article? What do you think? Are there better states to practice PT compared to others?

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Federal Shutdown
by Lisa Mueller

I'm trying to keep up with all of the news regarding the government shutdown, but it's been somewhat difficult for me to understand. News stories use a lot of federal vocabulary and I'm still processing some of the headlines before I can even move into the content. "The Government Shutdown" and "Washington Braces for Prolonged Government Shutdown" -- how can that even be possible? The events are impacting our nation at an alarming extent so it was important for me to translate the news and determine how I would be professionally and personally impacted. Here's what I've figured out so far:

The Affordable Care Act was passed in 2009 by Congress. It was signed into law on March 23, 2010. On June 28, 2012, the Supreme Court decided to uphold the law. Even researching just those dates was news to me. I didn't realize the ACA had become a law, and I didn't realize it happened nearly three-and-a-half years ago! Fast forward to last week: On Sept. 20, Republicans voted to deny money for the health law. Several votes on various funding, tax repeals, and modifications to the healthcare law occurred over the next few days. On Oct. 1, the government's new fiscal year began but with no spending legislation in place, partial federal shutdown commenced. Oct. 1 was also the planned effective date for individuals and small business to buy health benefit plans in an "insurance marketplace."

In short, per The Washington Post: "There are wide swaths of the federal government that need to be funded each year in order to operate. If Congress can't agree on how to fund them, they have to close down. And, right now, Congress can't agree on how to fund them."

It's amazing to me how these events have extended far beyond the boundaries of the healthcare law. Many national parks, historic sites and museums are closed, while social security applications are delayed due to the lack of funding and therefore, staffing. I'm probably not the most enthusiastic supporter of the government or federal news, but I'm certainly learning not to take their role for granted.

Has there ever been a major strike among physical therapists? Have you ever been restricted from work like many federal employees are currently experiencing? What do you think? Are you surprised at how government parties disagreeing over a healthcare law has developed into a federal shutdown?

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Functional Measurements
by Lisa Mueller

At the PT 2013 conference earlier this summer, one of the speakers encouraged physical therapy programs to transition away from education on passive modalities and objective measurements such as range of motion or manual muscle testing to instead focus on functional limitations and progress towards functional goals.

I've thought a lot about this idea since hearing it and gone through a few "phases" of acceptance. At first, I was in complete agreement. In most of my patient experiences, I've been able to track a patient's progress with gross strength and range-of-motion measurements compared to the exact goniometer alignment and measurement of a patient's range I learned about in school. There are times with a post-operative patient when that quantitative data is needed, but in most cases I focus on the functional impairments. I use passive modalities mostly for pain control, but have found most effective treatments using exercise and manual techniques. So overall, I was happy to hear that other practitioners held a similar opinion to my own and expressed it at the conference.

The second part, as I'm experiencing now nearly three months after hearing this proposal, is my curiosity about how these changes will be implemented. Passive modalities have been a part of physical therapy curriculums for decades. How can we transition away from that? My thought is that teaching content like modalities is either an all or none topic; is there any gray area to teaching only part of the material?

I give a lot of credit to the people involved with establishing the content for physical therapy programs. It cannot be an easy task to sort through the latest research while also balancing that with traditional practice techniques. I can't imagine being the person to say, "Okay, we aren't going to teach anything about ultrasound this year" because it seems like such a "basic" to being a physical therapist. I'm sure other content was phased out in PT programs during the years before I was a student, and I know educational programs in the future will continue to focus on the most relevant components of being a physical therapist.

What do you think? Is it important to continue teaching students about passive modalities, range of motion and manual muscle testing? Have you experienced changes in PT program curriculum during your years of practice? If you are an experienced clinician, are you ever surprised by what students are learning?

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Breaking it Down
by Lisa Mueller

I was lucky enough to attend another leadership skills course last week and learned a lot of good content. It was fun to be able to step aside from my regular work, listen to the experiences of other colleagues and practice skills I'll need in my new supervisor role.

One of the activities I completed was a skills assessment, or a "card sort." I was given a pile of cards and had to stack them into three groupings: cards that described me most of the time, some of the time, and rarely. The cards had qualities listed such as listening, confronting direct reports, composure, approachability etc. There had to be an equal number of cards in each pile, too! I completed my pile and asked two of my colleagues to complete a sort for me as well (for me to understand how I'm perceived).

The next task was to take the cards/qualities that rarely described myself and find two to improve. This part was hard for me. I picked two qualities I wanted to work on: sizing people up (being able to assess the strengths/weaknesses in others) and conflict resolution. I knew working on those qualities would ultimately make me work better, but I couldn't imagine fixing them. How do you get better at conflict resolution, by finding more conflict? It seemed like an overwhelming task.

We were then given a worksheet that allowed for space to identify mentors, experiences, independent research and other activities to promote growth in those areas of weakness. I had an "aha" moment -- it finally made sense to me. By writing out the number of steps that would give me some "practice," I was able to take something that seemed so overwhelming and make it manageable. The final part of the exercise was to find ways to leverage our strengths to help others.

Aristotle once said, "We are what we repeatedly do. Excellence, then, is not an act, but a habit." Here's where I can see that quote ring true. I'm not going to become any better at conflict resolution or sizing people up until I make the tasks more manageable and practice them consistently.

This shouldn't have surprised me as much as it did because this kind of framework is exactly what we give to patients. A patient one-week following a total knee replacement can't imagine running or playing tennis again, but when the goals and tasks are broken down into smaller pieces, they become achievable. What do you think? Have you ever needed to work on improving yourself in a way that seemed impossible?

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