How to be a physio extremist.

How to be a physio extremist. [applies to EBP-fanatics AND physio astrologers alike]

a. BE ABSOLUTIST. Take a side and commit to it regardless of individuals involved, evidence, or circumstance.

b. FAVOR TRIBALISM. Make Physical Therapy Great Again. Only you & your friends can do it right. Everyone else is completely wrong.

c. LOOK DOWN ON OTHERS. Use words that diminish viewpoints and approaches that disagree with yours. For example, a drastic reductionist perspective is that all “Manual Therapy” is the same. Even worse, use words to demean any “Manual Therapy” such as “tickle, rub, push, poke, prod” and the like. Equally ridiculous is the reduction of the biopsychosocial model to “talk the pain out of the person”.

d. BE SENSATIONALISTIC. Get the attention you know you deserve… because you’re worth it. Use extremist headlines because you know you’re a rebel. Show your rebelliousness to the world!

e. POLISH THE PEDESTAL. Use language that is inconsistent across domains: research vocabulary and clinical practice. Even better, start using arcane and unfamiliar phrases to convey simple ideas. It makes you look so very smart.

f. CLAIM THE ETHICAL HIGH GROUND. Always bring up any and all potential ethical faults to take the conversation away from the central topic of conversation. In fact, bring up your ethical concerns the same way a vegan would, and expect the other side to see things your way. One popular word in the world of Twitter-PT is “nocebo”. It’s the equivalent of dropping “Hitler” into any conversation: an immediate conversation dilutor that re-routes the conversation away from the main topic. You are a connoisseur of conversation killers.

g. LET SELF-PRESERVATION BE YOUR GUIDING LIGHT. A crowd of similar beliefs & opinions offer warm comfort – who cares if those beliefs &/ opinions are weaponized?! Stay warm in your crowd. Never mind the existence of the other crowds who may hold different perspectives than yours – they are wrong. They always have been, and always will be. Enjoy the warmth of your echo chamber.

h. EVIDENCE SCHMEVIDENCE. Arm yourself with a quiver of research papers that you can quote/link in your Twitter arguments… I mean “discussions”. After all, arguing is supposedly nothing but constructive & positive… right? So, why not come prepared. Come prepared to win, not to learn. While you’re at it, feel free to take 1 of 2 opposing sides; either you are a qualified physio who functions in a world of religiously peer-reviewed and statistically approved physical therapy where nothing you do in the clinic is without the complete blessing of the research gods, OR you choose to believe that all research is inherently flawed from beginning to end… and you no longer hold any faith in the existence of math. Go ahead, choose your side and guard it with every fiber of your being whether you’re ultimately right or wrong. And by all means, never ever look up the word falsifiability.

i. ABOVE ALL, FORGET THE MAIN THING: THE PATIENTS. It’s about you being right, not about you being right for the patient in front of you.

Now that you’ve chosen your side, remember: there is no middle ground in the world of an extremist. You’re either with “us” or against “us”.

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Approaching multiple climaxes in PT.

What are the odds that we are reaching multiple climaxes in the world of PT? Student loans, declining reimbursement, more PT students graduating every year, combined with a weak professional moat and big data all point toward a significant shift in the industry.

Add venture capital into this already volatile mix, and there’s now more fuel to combust. The entry and increase in PT venture money is somewhat surprising given the trends in industry reimbursement dynamics. Not only does it expose physio’s to unseen financial risk, but it also fuels an insidious race to a commoditization of our profession.

In an effort to battle this ongoing commoditization, some adventurous physio’s are branching into niches that weren’t on the radar 15-20 years ago. PT business models are adapting into new environments focusing on specific clienteles based on their needs, as well as the ever-growing number of physio’s specialties. 

Catering to these changing dynamics, some physio’s have even built enterprises with the intent to educate other physio’s. As a result, the realm of Continuing Education has transformed into an immense mess of a financial boon.

PT ain’t what PT was. The internal dynamics are shifting, and have been shifting more intensely for the last decade.

I wonder when it will reach critical mass. Even more so, I wonder what’s on the other side of this critical mass.

When do you think this’ll happen?

What shifts in the industry have you noticed? What shifts are you expecting in the near & far future?

How are you adapting? What prophylactic measures are you taking?

How is it affecting You?

I’d love to know.

Our Inner Tribesman (or Tribeswoman!)

It’s hard to challenge what have become your core beliefs. You’ve made a stance in the past and don’t want to look like someone who wasn’t right from the start.

Good news: most of the greats weren’t right from the start. The adapted themselves and their ideas to the world around them. They let go of crowded thinking and mob mentality to forge a future only they could foresee.

Tribalism puts blinders on your ability to adapt. You feel caught in the spirit of the times, cementing a sense of certainty, and discounting the costs & consequences of being wrong. We do this by ignoring signs, ignoring opposing evidence, continuing to invest in sunk costs, and downplaying any counter-arguments with cries of biases and clever belittlement.

Let go of your inner tribesman. It hampers your adaptability & hijacks your future. 

Our hidden biases betray our true incentives. Uncover your hidden biases; the ones that you dare not admit to the world. Ask yourself: “what is something I believe that most of my tribe would have strong disagreements with?” Why do you have these differences? Are you trying to feel the warmth of an agreeable crowd or are you thinking for yourself? [hint: neither option is ideal. You ought to be serving something greater than yourself. If not, then you may be lying to yourself about your hidden biases and true incentives.]

Find your hidden fears. What negative impacts would you suffer if you were wrong? Explore these fears. Test these fears of being wrong. These fears are very likely tribal & misguided… weighed down by the distant and recent past.

Don’t pin yourself to the past. Don’t hang your hopes on a confirming future. Free yourself from tribalism and allow yourself to adapt to the changing terrain of the present.

The Physical-Therapy-Education Bubble-Market

Recommended Reading: November 2016 edition of the Journal of The American Physical Therapy Association. It refers to something I’ve been warning about for the last 5 years: there’s a coming inflection point in our industry that could be triggered by a number of things. One of them is the intersection of declining Insurance Payments and increasing costs of Physical Therapy programs across the US.

The University of Saint Augustine (USA) was recently sold to Laureate International Universities. Laureate – the world’s biggest for-profit educational outfit – intends to transition into a Public Corporation (for ~$1 billion) and list on the NASDAQ. You can read the Initial Publics Offering (IPO) here. Laureate’s IPO comes with enough controversy to orchestrate a rocky IPO. The current cost of attendance at USA’s Florida campus is ~12.5k per semester. For comparison it was about $6k 10 years ago.

Has the cost of anything else (maybe, other than your health insurance premium) increased 100% in the last 10 years?

Have Insurance Payments increased? Both of us know the answer. Insurance payments continue to drop across the board. Some insurance pay so little that PT’s actually lose money by treating folks insured by these particular companies.

There are more PT’s graduating in the US now than ever before.The number of PT programs have expanded across the US. In fact, from 2000 to 2016 there has been a ~25% increase in the number of PT programs. Presumably, this is intended to not only fill the supposed demand for more Physical Therapists, but also because it is lucrative business. The total cost of these programs range from $60k to $188k. There are also more applicants than ever before. And, why not? Based on the Bureau of Labor Statistics, the demand is expected to grow at 34% per year.

Combine the growing number of PT’s with down-trending Insurance Payments and imagine what you get?

Is it any surprise that salaries for Physical Therapists have (on average) dropped 2.3% in 2015. This is something that I’ve been expecting for the last 5 years. From a completely objective perspective, this is to be expected. Graduates schools are money-making machines. Guess who isn’t making as much money? You guessed it, the graduates.

Yes, the average salary of PT graduates sounds great, but what about those pesky loans? Potential graduates are considering the impact of rising costs of PT programs more & more. The number of law school graduates at lower now than they were 10 years ago. Could this happen to PT? If it could, then what would drive this trend?

Lower insurance payments has already pushed hospitals to hire more Physical Therapy Assistants than Physical Therapists. PT’s do patient evaluations, and PTA’s carry out treatments. I don’t imagine this trend slowing down any time soon.

Student Loan Debt is by-no-means limited to PT Graduates. In aggregate student loans are reaching climactic proportions. The last time something increased at such a persistent trend was the cost of housing in the 2000’s. We all know how that ended: the harshest economic melt-down since the depression.

This time the amount of money involved is significantly higher. Here’s a graphic pulled from tuition.io:

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What pricked the housing bubble? Things started going south when the number of defaults exceeded expectations. So, where are we in terms of Student Loan payment delinquency? Well, it’s not very pretty. The number of Student Loan delinquencies has now eclipsed the number of Credit Card delinquencies.

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Here’s what makes these delinquencies insidiously worse: student loans cannot be cleared in a bankruptcy. That’s right. What was the “best loan to have” can quickly transition into the worst loan ever. The bubble is set to pop. The question is when.

WHAT ARE YOU TO DO??

First, let’s get the obvious out of the way: Explore Income-Based Repayment Loan Forgiveness Programs. Do your research online. Then, talk to at least 5 different individuals about your options and the best course of action for you.

Now the stuff that takes a bit of elbow grease…

You have something truly priceless: YOU. That’s right, your best investment is in yourself. Let’s make this a bit more actionable.

  1. If you are a recently graduated PT, then I strongly encourage you to consider entering a residency/fellowship program to sharpen your clinical skills.
  2. Ensure that you experiencing personal growth on a consistent basis. If the week went by without any change in your thoughts, perspectives, understandings, or performances, then you are doing yourself a disservice. Get better. Now. The most successful individuals have an insatiable curiosity for something. Uncover your curiosity. Explore it as completely as possible. Read everything you can on the topic. Talk to and network with anyone that feeds this insatiable curiosity. I was (and am still) very interested in sharpening my Manual Therapy skills. I also have a couple other curiosities that I’m fostering and exploring right now.
  3. Make sure that you work for someone you admire. This is especially important in your early professional years. Nothing beats having a strong mentor who guides you in a direction that will likely skirt the pain of monotony and stunted professional growth.

If you are working for a company, then make yourself indispensable.

  1. Learn the company’s ecosystem inside and out. What drives the company and it’s leaders? How can you add fuel to their drive?
  2. Volunteer your time and efforts to take on additional responsibility. This has the dual benefits of learning a new role and embedding yourself in the execution of these roles. So, when they need someone to fill a similar role guess who they’ll turn to? You.
  3. Put yourself in the owner’s shoes. Look at the entire clinical operation from the perspective of an owner. Make decisions (as little as they may be) as if you are the owner. Got an idea to help the clinic owner spend more time away from the clinic without worrying about the day-to-day clinical/administrative routines? Lay it out for him to adopt. Time is valuable to everyone. Be the individual who makes it clear that you are the one who is saving the company and it’s administrators time and money.
  4. Once you’ve managed to pull-off steps 1-3 you’ll have the leverage to increase your paycheck or even better: get on a path to generate your own income.

 

CEU Review: DN-1 & DN-2

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I recently attended DN-1 & DN-2 by the Spinal Manipulation. The courses were fantastic experiences and have provided me with new means of addressing a variety of conditions in the clinic. Both courses surprised me on two fronts:

1. The Research. I wasn’t expecting so much time spent on discussing the research and how it guided their approach. The amount of research presented simply blew me away. Research is research regardless of which geographical region of the world it was done and in which professional journal it was published. And so, they pulled research from all over the planet and thought a decent variety of disciplines. This was strangely refreshing. The lectures were quite heavy on the current relevant research; and, it was presented fairly in that both positive and negatives were mentioned. I don’t know about the nuances & specifics of these studies, but the fact that they exist and haven’t been explored in other courses is very interesting.

2. Pain Science Lectures. Yes, I know what you’re thinking…it’s a dry needling course and they’re presenting lectures on pain science? Oh, yes they did. The phenomenal lectures on pain science as it relates to Dry Needling also caught me completely off-guard….in a very good way! I gotta admit: pain science talks in both courses were in-depth on biochemical and mechanical levels as related to dry needling. It was fantastic and convincingly presented. Very convincing. Tommy presented a very detailed & balanced lecture, and Ray bled passion during his lecture.

Now onto specific critiques on the courses themselves, as well as recommendations for future attendees.

The Negatives.

About 40% of the manual was summaries of research reports. While this provides a nice foundation of research on which to base Dry Needling treatments, it could easily be converted into a PDF to be emailed and downloadable to course attendees. Another issue with the current manual (DN-1 2016) is that it didn’t always correlate with the material presented. In other words, material was presented that wasn’t in our course notes, and there was no way to obtain an updated manual. Why? Apparently the new manual wasn’t yet approved for publishing. It would be fantastic to make this information accessible to 2016 course attendees (with a reduced price) when it is available. Maybe you could save paper and simply email/download it in PDF form; printed manual could be an extra charge.

The manual had a couple more short-comings. 1) There was very limited space to take notes. 2) The semi-standard protocols weren’t to be found; however, there is ample instruction on palpation, needle placement, and needle technique. It would’ve been nice to have drawings/pictures of the protocols alongside written instructions for future reference within the manual itself.

When it came to lab time, there was often ran into extremes of either excessive or short practice periods. This was the first Dry Needling course for a number of attendees, and spending a little longer on basic needling practice would’ve been more beneficial. Then again, maybe I was just too slow to get comfortable before moving on to labs 2 or 3. DN-2 did a much better job of managing lab time.

Finally, there should’ve been more time spent on the technicals of employing Dry Needling in the clinic – things like how to bill insurance for it, how it’s incorporated into a cash practice, orchestration of Dry Needling into the Plan of Care to address questions of stretch after/before or skip exercising entirely. All these items should be addressed up front and as clearly as possible. I had these questions addressed in DN-2 by asking the instructor during lab time. Be sure to ask this question to multiple folks – instructors & other DN practitioners.

Some Tips & Recommendations.

Take lots of pics from a variety of angles – at least 2 different angles. This will allow you to get a better appreciation of needle placement when you’re practicing it on your friends, family, and coworkers after the course.

If you’re a visual learner like me, then it might be a smart idea to sketch out the lab demo with all the insertion markings. It might also be useful to re-create this on your own after the course is over. This way you feel more confident about inserting the needles, and know exactly what you’re doing before you start poking your friends, coworkers, and/or family members.

Let’s stick with the lab demo for a bit longer. As I mentioned earlier, the course manual provides very little room to take adequate notes. So, it’s a really good idea to jot down instructions/sketches during the lab demo into either a separate notebook or sheets of paper. Using a clipboard with unruled sheets of paper works best for me. This allows freedom to sketch and jot down info as it suits my visuals without the constraints of ruled pages.

Consider reviewing the relevant anatomical regions prior to taking the course. Here’s how I would’ve done it: cover the insertions of major/important muscles and their innervation, trace major nerves (for DN-1 think brachial plexus), and, finally, roughly familiarize yourself with the “spaces” (for example, the quadrangular space) that are created by the framing muscles and/or other structures – no need to be very meticulous about this, just consider the obvious ones.

Finally, bring some cash. They tend to supply needles like your grandmother would supply dinner items: better too much than too little. This allows you the opportunity to purchase some needles right after the course and start practicing right away. $50 worth of needles should be a nice start.

The Positives.

Their conceptual application of combining spinal manipulation and dry needling certainly peaked my interest. It made me want to explore these “segmental effects” deeper on my own prior to taking a spinal manipulation course. I really appreciate the work behind creating these protocols (much of which was lifted directly from research articles).

Both instructors were knowledgeable, presented the material well, AND presented it fairly. They pointed out studies that showed both sides of the argument. Their perspectives on utilization of the literature was refreshing and made me open my eyes a bit more toward how some (many?) folks view the literature through tainted lenses while wearing blinders. 

This course provided me with incorporable content and manual intervention options that can dove-tail nicely with my current clinical framework. While I don’t think wearing the “osteopractor” label is in my future, the concepts were intriguing and definitely warrant more of my curiosity.

Final Take.

I came away from this course with much more appreciation of an intervention that I had ignored just 4 years earlier. Dry Needling seems to have the potential to address multiple fronts at once: save my hands, access structures that are difficult to reach/treat with manual palpation, provide another route to address chronic pains, and provide me with another differentiator with which to market my services for the benefit of my future clients. Good content. Engaging instructors. Worth the time.

Mea Culpa

2016 exploded onto the scene, and there’s no looking back. A couple milestones await for me in the next few months. One of them is a Physical Therapy Class Reunion. No, I’m not going to mention how many years have passed, but let it suffice to know that I’m more excited about our profession now than ever.

Emotion and Experience were vital components to my growth as a Physical Therapist thus far, and they will likely continue to play their vital role for the foreseeable future. Emotion and Experience are also vital components of our growth as human beings. Perhaps the Environment we grew though, and will continue to grow in/through, is an equally (or more) significant determinant in our Emotional and Experiential growth.

Either way, here are some thoughts that are crossing my mind in this period of critical change. I hope you find them as useful as I do.


Don’t shy away from asking yourself “What the fuck am I doing with myself?” Don’t shy away because there’s no wrong answer to this question. The reality is a very small percentage of you (no, it’s probably not you) are following a life-plan penciled perfectly in high school. Asking yourself this question is more about self-correcting than proselytizing. It’s a series of continual adjustments based on your long term vision.

Entertain yourself. It’s more fun than you can imagine.

Don’t shy away from intentionally disappointing someone if you know that there’s a high probability that the bread is about to fall jelly-side down. This doesn’t mean you have to be memorably offensive. Saying “no” effectively without crushing relationships is a skill worth developing.

Don’t worry about what people think of you. This simple life-hack will free your mind more than almost anything. Also, it clears your lens on life by allowing you to see how clever or transparent people truly are. You’ll be tempted to gain and keep the recognition of those smart people you think you identify with. The reality is you’re probably fooling yourself into building a self-image that is ultimately painfully unsustainable.

If you aren’t any closer to your desired lifestyle this year than the last year, then hop on that horse and make it happen. It’s incredible how 1 year turns into 3, and before you know it you’ve been treading water…at best. This simple fact will continue to boggle your mind in real-time and in retrospect. Some smart guy once said: “The best way to predict the future is to invent it.” He might be right.

Health is wealth. Yup, the oldies were right. Health truly is wealth.

Consider the impact of all the non-renewable resources in your life. “Time” deserves to be very high on that list.

One of the few constants other than Time is Change. Don’t be afraid to change. It’s going to happen anyway, so why not take the wheel rather than handing it off to people you don’t really know – employers and their management teams, especially their management teams. Don’t be afraid to take the wheel and change lanes.

Sleep. Sleep because feeling well-rested is a glorious feeling.

Don’t “grow up”. I’m still not sure what that term means, but avoid it as much as possible. The “grown-ups” tell me it’s overrated.

Be nice. The world is getting smaller every year…which means Karmic paybacks happen quicker and/or with greater intensity today than yesterday.

Simplicity is priceless. If you can’t explain what you’re doing to a 12 year old, then you’re carrying around unnecessary baggage. Lighten the load, and clear your plate down to the bare essentials. At the very least, simplicity makes it easier to smile.

You can’t outrun your fork.

And, if you’re riddled with indecision, then apply the Regret Minimization Framework.

As many of you are well aware, I enjoy reading books. Early March 2016 saw the first edition of my Quarterly Readings Newsletter. It is an update on some of the more interesting reads of the 3 months preceding publication of the email Newsletter. Email me with “I love to read!” in the subject line, and I will add you to the email list. 

Twitter Interview!

I decided to close out 2015 with an interview with questions from twitter.

Check it out!


@therapyinsiders: Which Bourne movie was your favorite and why?

This is a tough one. I really enjoyed all three – yes, I’m excluding the one with Jeremy Renner. I’ll choose my favorite Bourne flick based on 2 things: villains and motorcycle scenes. And the winner is… The Bourne Ultimatum! Desh was the perfect roleplaying villain. I loved his fight scenes which seemed like a mix of Wing Chun Kung Fu and Capoeira. The motorcycle scenes were incredible! Watching Bourne ride through Tangier at a fast clip while negotiating daunting street obstacles in narrow alleys was thing of beauty.

@MattBobman: Biggest professional regret and/or failure?

I should’ve casted a wider net in my first few years as a PT. While I was lucky enough to have a role and gain experience on both sides of the business, I could have developed a wider view and started developing a Framework of thinking and action much earlier than I did. Here’s what I would recommend:

Experiment enthusiastically with different approaches of treatments.

Connect with a wide variety of professionals within driving distance and through social media.

Take more risks in terms of: creating new products, developing new platforms, re-inventing yourself.

Read a kaleidoscopic selection of books and authors. And, follow Jeff Bezos’ “Regret Minimization Framework.”

This is a great question! Jeff Goldblum – not because I look like him, but because he plays some interesting roles and for some reason his personality resonates with me. Anyway, check out his Top 10 Moments:

Anonymous: When are you going to Haiti with STANDHaiti?

Hopefully some time in 2016. In the meantime, check out STAND’s 2015 Re-cap and this inspiring story.

Doesn’t matter. Just get moving in anyway that you enjoy – play sports, lift heavy things, dance, run, yoga, climb things, conquer things… If I were forced to pick team or exercise, then I’d say go with whichever fits your personality the best.

@DrBenFung: If you could change one thing about the person that annoys you the most, what would it be?

This is a tricky one, and here’s why. If you find someone that annoying, then odds are this person means something important to you. Maybe s/he is someone you want to hold onto and have agree with you. Maybe s/he is someone you want to impress. Maybe you believe changing him/her will make your professional or personal life complete. Here’s what I think: maybe you should work on yourself & your environment before you think about think about changing someone. Changing someone is often a futile effort. Changing yourself is a much more powerful endeavor with compounding returns over time. Book Recommendation: The Education of a Value Investor by Guy Spier.

@Eric_in_AmERICa: If you could put a billboard anywhere in the world where would it be and what would it say?

https://twitter.com/Cinema_Air/status/682608338383683584

@rupalPT: what is your pride and joy?

Spending time with my family & friends and providing as much value to the world as I can are my prides & joys.

https://twitter.com/TheAwesome_PT/status/682663763305082880

Careful whom you marry.

Explore wider and faster. Do not ignore your instincts. Learn widely from outside the field of Physical Therapy. You need a framework – work hard at developing a foundational framework on which you can build further. And, don’t fear failure. Just make sure you learn from it. You might get more out of my interview with Dalin.

Hello. My name is Indigo Montoya…

Thank you everyone! And, best wishes for a fantastic 2016!

Connect with me @Cinema_Air

Book Review: You Can Run Pain Free! by Brad Beer

I had the pleasure of interviewing Brad Beer last year. It was a fantastic interview – I learned a ton.

Not too long after the interview Brad published a book titled “You can run pain free!” For full disclosure, Brad provided me with a copy of his book for review – Thank You!

My verdict: It’s worth your time.

Physiotherapists and other clinicians will benefit from Brad’s pragmatic blend of research and reality. The book also provides the general public with a solid background of how to evaluate themselves, progress their running, and communicate better with their Physiotherapist when needed.

5 REASONS THIS BOOK IS WORTH YOUR TIME

IT PROVIDES A GUIDING FRAMEWORK. This framework puts the novice runner into a better first step, and can give him/her a more nuanced view on efficient and pain-free running than the average new runner. Many weekend and seasonal runners can also benefit from this book for the same reason: they are now equipped with tools for faster and pain-free running.

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PSYCHOSOCIAL PERSPECTIVES. Brad does a very nice job integrating the psychology of running injuries and their impact on returning from injuries. His views on this are beneficial to both runners, as well as Physiotherapists who work with runners. Here’s one of my favorite passages on this topic.

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METAPHORS & COMMUNICATIONS. It is becoming ever-more clear that the way we (Physio’s) communicate with our patients has a direct impact on their recovery. Brad uses a variety of metaphors in his book to steer the runner into a healthier mindset that allows him/her to believe in their own potential. This alone is worth the read for clinicians and runners in general. His concept of “Frame Weight” is one of many clever expressions peppered through the book.

MORE THAN THEORETICAL. While Brad cites published literature throughout his text, he manages to integrate the lessons he has gleaned from his personal and professional empirical distillations. A nice example of this is his perspective on overtraining.

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OPPORTUNITY TO LEVERAGE BRAD”S EXPERIENCE. Brad experienced a knee injury that eventually underwent surgical repair and was told that his running days were behind him. Well, time has proved those words false. Brad completed the NYC Marathon in 2015!

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How did he do it? What did he learn through his years since his knee injury? What can you learn from his experiences? You Can Run Pain Free! is a synopsis of what he has learned and applied over the years. It’s more than an academic exercise, it’s a pragmatic text based on his personal & professional experiences.

Here’s a quick blurb Brad posted just prior to his book launch.

You can pick up You Can Run Pain Free! here.

@Cinema_Air

Two Braces & A Conversation

The following patient story by @DrDunawayDPT recounts an extraordinary experience from @STANDHaiti. It’s a quick read that reminded me of how lucky I am, and how valuable our service is to those in need.

Familiarize yourself with Justin by reading my 2-part Interview with him here & here. You can find a recap of the Fall 2015 STANDHaiti trip here.

Are you a Physical Therapist wanting to participate in this unique opportunity? Then check out their website for more info: http://www.standhaitiproject.org/.

Here’s Justin.


This is not a story of superior physical therapy prowess, amazing diagnostic problem solving, or out of this world rockstar manual therapy skills. This is a story of a case so incredibly simple and fairly terribly tragic, with a mildly uplifting finish. In a system with adequate care and resources, this patient would have received emergency care, surgery, and physical therapy, getting him back on his feet with minimal to no enduring consequences. Even in the most poverty stricken areas in the United States, he would have received the care he needed to return to function. Instead, this case takes place in the incredibly impoverished streets of Port-de-Paix, Haiti, where aside from our teams periodic two week trips, there is no care or resources for the injured and poor.

While in Haiti, Morgan and I have very little time to actually treat patients. Our days are consumed with the daunting and stressful task of “keeping the wheels turning”. However, we love patient care and need to take breaks to recharge and zero out, AKA treat patients. It was the third day of our trip before I could break away from logistics detail and get my hands on a patient… and I was “jonesing” to do so. I grabbed a table, a translator, and the next chart in the stack and was ready to get to work. As I read the chart that said “knee trouble” and then saw a man carry a 17 year old boy to my table, I realized immediately that, in this case, that means “I can’t walk any more”. My first reaction was: my first patient all week and there will be nothing I can do for him. I started shifting from excitement to sadness.

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After a very sad subjective and some graphic photos printed on computer paper, this is what I learned. The boy was brutally attacked in early July, beaten and drug through the streets. The assailant then took out a knife and very deliberately severed both the boy’s patellar tendons and left him in the street. His goal was to take away the boy’s ability to walk… and he succeeded. In the US, someone would have found the boy within a few hours of the attack. They would have called an ambulance and he would have been admitted to the emergency room. Despite living in poverty, he would most likely have Medicaid and would have received emergency surgery, reattaching his patellar tendons, and mostly have been sent to physical therapy. Over the next few months, he would have regained strength, relearned to control his knees, and returned to function. He would have returned to being a teenage boy: running, playing sports, regaining his life… but that’s here in the US.

Back to Haiti. The patient was carried to my table, just as he was carried everywhere. He hadn’t stood up since his injury in July. Once a normal teenager, he has now become a burden on his friends and family, a member who cannot contribute in any way. An objective exam revealed two patellas that, in sitting with knees flexed to 90 degrees, sat somewhere in the distal 3rd of the femur. He demonstrated strong hamstrings/glutes and had maintained some ability to activate his quads, but lacked the ability to extend either knee more than a few degrees. The patient also exhibited fear of standing, depression, and other psychological symptoms from the traumatic experience. The patient expressed interest in surgery, but in this area, those services are non-existent.

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Seeing that he had hip/hamstring strength and some ability to activate his quads, I attempted to have him stand. He and I both quickly realized that with some assistance for knee control (locking into extension), he could stand and balance. If I manually controlled his knees from buckling during flexion, and helped him hold his knee in extension when striding, he could walk. After a quick consult with Morgan, we decided that a pair of hinged knee braces with adjustable flexion/extension locks might just do the trick. We were able to find and fit him with these successfully. We allowed the knees to move from 0-60 degrees, added a little training and fear avoidance education, and really just told the boy “you can walk, trust your legs, practice… you will fall and then you will get up… you will be just fine”…

He took a few steps… and then a few more. He walked through the clinic, slowly and clumsily at first, and then faster and with more confidence. We walked up and down the stairs, then out on to the back patio… where he cried. These were his first steps since June, his first steps since he had given in to the thought that he would never walk again. He has a long way to go and will never be 100%, probably never get his surgery, and will always have some major dysfunction, but now he can walk. There is no brilliant PT work in this case, no medical miracle or amazing surgery, just two braces and a conversation.


Connect with Dr. Justin Dunaway & STANDHaiti via twitter: @DrDunawayDPT & @STANDHaiti

Find me: @Cinema_Air

STANDHaiti Report: Fall 2015 recap & Upcoming Opportunities

Here’s an update on STAND Haiti’s Fall 2015 trip by Dr. Justin Dunaway. Find out more about Justin and STAND Haiti by clicking on the blue links you just read.

FYI – the next trip is scheduled for Jan 22 to Feb 7, 2016.

Enjoy!


wk1 team

There’s nothing like a hurricane to give you perspective. You would think that torrential rains, mud-sloshed roads, and wind gusts up to 60 mph would keep people at home. As it turns out, the care we provide in Port-de-Paix, Haiti is so valuable that the elements themselves did not prevent people from seeking care from STAND clinicians!

Over the two weeks that STAND had its clinic doors open, we treated over 1,350 patients. People came to have back pain addressed, post stroke drop foot assisted, and spinal cord injury therapy plans created! New prosthetics were built for amputees, patients’ infections and maladies were addressed by our medical staff, both kids and adults received appropriate orthoses and assistive devices, and people left with less pain and more hope!

Additionally, during STAND’s time in Port-de-Paix, we created jobs for 41 locals, gave medical screenings and care for school children, and provided clinical education hours for a local nursing school. Our teams of physical therapists, prosthetists, orthotists, and nurses worked selflessly to make a difference in each patient’s life. Hailing from fifteen states across the US (plus one amazing prosthetist from Leogane, Haiti), STAND’s fall team made the magic happen on levels we could never have imagined!

Wk 2 team

In the end, it was our ground crew in Haiti that made this all possible. Without the hardwork and dedication of Lifaite, Gomez, and all of our support staff in Port-de-Paix, this extent of success would have been difficult even to imagine.

With every cog turning and each team member working to decrease our patients’ pain and disability, STAND’s fall trip of 2015 will be one for the books! We cannot thank each member of our STAND family enough for making this trip more than just a success, for making it a memorable beginning to our growing work in Haiti.

Stay tuned! Excerpts, patient stories, and therapists’ reflections are on their way!

If you’re interested in joining the STAND family our next trip is Jan 22- Feb 7th and you can volunteer for 1 or 2 weeks, then please contact us at JDunaway@Stand4Haiti.org or MDenny@Stand4Haiti.org.

Morgan and Justin

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