3 Lessons from my Car Mechanic.

I recently took my car into the shop for an alignment issue. Dan, the front office guy who has known me for years, greeted me. I gave him as much detailed information as I could so that he could effectively address the issue with my car. He said it would take a couple hours, gave me a rough estimate, and offered to drive me to a coffee shop or back to work so that I wouldn’t have to wait there. The shop is fairly comfortable and equipped with wifi, so I stuck around. When he motioned me over toward the desk about 2 hours later, Dan broken into a truly magical conversation that captured me as a customer. This is about that conversation.

First, in the initial greeting Dan was excited as ever to see me, and was familiar with our details, including history of our prior visits. This was remarkable considering I only see him 1-2 times per year for minor jobs. My guess is that he takes meticulous notes on his computer,  it either way – by memory or by computer notes – I was impressed by his mentioning of our previous visits.

Second, and most importantly, the words he mentioned when he motioned me back to the desk transported my experience in the mechanics shop to somewhere else… some place that made me feel like this guy has been paying attention to me since I first came to his shop. Here’s as approximation of what he said:

You know, I think you’re pretty good at your job, but I think you’re going to be much better. I can tell that you’re starting to pay attention to details more than before, and I’m sure it translates into your work as well.

What do you mean?

You gave me a pretty detailed and informative report of how the car was performing at highway speeds. It’s something you’ve never done so well in the past.

Ok, so this guy took my current experiencd, placed it within the larger arc of all my prior visits, and extracted an empowering theme with which he completely shocked me… and it makes me want to keep returning. This guy is actually paying attention to his customers as Human Beings, not simply customer #3842 with an alignment problem.

Third, he made a deeper emotional connection as we walked by a beautiful Audi:

Isn’t she pretty?

Yeah, looks nice…

Well, I wouldn’t buy it. It’s got problem after problem. Talk to me before you buy your next car. I’ll tell you what you shouldn’t be buying. And, I’ll tell you what to look for in the prospective car. This one is terrible…

Did this guy just offer me his time & experise (for free?) to help me make a smarter purchase on my next car?? He knows that it isn’t fun to keep bring your car in for major repairs/fixes. Of course he could make more money by me bringing in a terrible purchase for regular fixing, but he opted to help me get a car that wouldn’t require as much (if any) repairs or upgrades. With that, he said goodbye as I walked to my car with keys in hand.

  1. He remembered my history.
  2. He noticed positive big picture change in me and brought it to my attention. This made me feel really impressed by him.
  3. He offered something outside of the norm from a mechanic’s shop… for free, and most likely at the loss of potentially more income.

Customer service won me over, again.

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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”.

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 Diagnosis Trap

Beware believing or giving a definite diagnoses. 

It might ossify your approach & (by default) your treatments.

Ossified Diagnoses : Everyone Loses.

Adaptive Diagnoses : Everyone Smartens.

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:

tuitionio

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.

STUDENT-LOANS-VS-CREDIT-CARDS_0.jpg

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.

 

Fund #GetPT1st Now!

Many of us have enjoyed the benefits of the efforts of Sean Hagey in coalescing the profession behind #GetPT1st. Some folks were a bit skeptical about it in the beginning, but their skepticism faded as #GetPT1st stayed focused on its message and continued to deliver content that you, I, and our fellow PT’s have shared with colleagues, friends, and family.

Here’s the crazy part: Sean managed to rally the profession while working his regular job and devoting extra hours (and finances!) to the #GetPT1st campaign…his “pet project”!

Let’s rally behind Sean. Check out his video and donate by clicking here.

Who could have predicted #GetPT1st 5 years ago? Certainly not me. #GetPT1st turned into a powerful medium to spread the value and power of physical therapy, and I strongly encourage you to take part in the movement.

What’s not to like? Do it for your patients, do it for your profession. This might just be the most fulfilling money you’ve spent is some time.

Join me in supporting Sean by funding #GetPT1st here.

 

Interview with Ramona Horton

Ramona Horton, MPT is a pelvic physical therapist who teaches for Herman & Wallace Pelvis Rehabilitation Institute. She is passionate about the impact of visceral and fascial components as they relate to functional activities.

If you share my curiosity about the impact of viscera on your patient’s function, then you’ll enjoy this interview as much as I did.

Connect with Ramona on twitter @PelvicViscera. Enjoy!

Let’s start this off at the beginning of your day. What do you usually have for breakfast?

During the week always the same thing, a small serving of mixed raw nuts.  I am a protein gal the nuts manage to fill me up and give me a good slow burn until lunch time.

What led you into the wonderful world of Physical Therapy?

My own knee surgery at the age of 16 combined with the fact that a career in the medical field was the only thing that attracted me.  I was contemplating the nursing field, and took a job as a CNA in order to get exposure to health care, rehab just became the obvious choice. 

How did you get interested in Pelvic Dysfunction? And, how did this lead into your passion for Visceral Mobilization?

My PT training was through the Army-Baylor program, I was all in for orthopedics and sports medicine until October of 1990.  I gave birth to my second child, an adorable but behemoth  9lb 9oz baby boy.  His delivery, a VBAC (vaginal birth after cesarean) was very traumatic on my pelvis, I sustained pudendal nerve injury and muscular avulsion.  When I queried the attending OB-GYN about my complete lack of bladder control his response <insert righteous indignation here> and I quote “do a thousand kegels a day, and when you’re 40 and want a hysterectomy, we’ll fix your bladder then.”    As for the desire to study visceral mobilization, that reflects back to my PT training through the US Army which was 30 years ago, when the MPT was just getting started.  It was an accelerated program to say the least, we received a master’s in physical therapy with 15 months of schooling.  Given the very limited time line, which included affiliations and thesis, the emphasis in our training was on critical thinking and problem solving, not memorization and protocols which in 1985 was not the norm.  I can still hear the words of our instructors “You have to figure it out, I am not going to give you a cook book”.  

Following my initial training in the field of pelvic dysfunction 1993, as I started treating patients I had a problem, I could not wrap my head around how I was to effectively treat bowel and bladder dysfunction….without treating the bowel and bladder?  I knew that there was more to this anatomy than just pelvic floor muscles and the abdominal wall, but at the time that is what was being treated.  Once I started learning VM principles and applying the techniques to my patients I saw a vast improvement in my outcomes.  I realized that the visceral fascia is a huge missing link in this field and that somewhere along the line the physical therapy community forgot one simple fact.  We are not hollow, the visceral structures attach to the somatic frame through ligaments and connective tissue and have an influence on the biomechanics of said frame.  

Why is the adoption rate of Visceral Mobilization so low amongst Physical Therapists who aren’t pelvic specialists?

Most likely several reasons, first they do not deal with dysfunctions that have visceral structures involved the way pelvic health therapist do.  The second being a paucity of higher levels of evidence on the effectiveness of VM for musculoskeletal conditions.  The third and most difficult issue to deal with is the broad based claims that VM can be an effective treatment for issues ranging from acute trauma to emotional problems.  One website called VM “bloodless surgery”.   The problem simply is when anyone purports their technique to be a virtual panacea for all that ails mankind, without adequate evidence to back up the claims, the clinical world raises its collective antennae.  These critical remarks are coming from a practitioner, published author and educator in the VM field. The reality of evidence based medicine is talk is cheap, research is not.

Could you share an anecdote/story of the effects Visceral Mobilization in clinical practice?

A male patient many years ago that was experiencing constant right flank pain that made physical activity almost impossible and the pain increased during urination.  He had been evaluated by the chief of the urology department at the medical school and was sent to me for biofeedback with a diagnosis of pelvic floor dysfunction and bladder-sphincter dyssynergia based on urodynamic testing.  His symptoms began 3 years earlier while experiencing hematuria, most likely due to a kidney stone but that had not been confirmed.  His exam revealed clear cut muscular guarding with tissue changes in his right psoas, quadratus and gross restriction of the renal fascia.  I went rogue, and did not initiate the biofeedback, instead treating his restricted renal fascia which encompasses the ureter.  He returned for his first follow up about a week later reporting that 3 days following PT evaluation and initial treatment, while urinating he experienced a strong sensation in the area that I had been working felt a rush and had immediate resolution of all pain.  The best part is what he told me next “trust me, this was not a placebo effect because I thought you were a quack”  reporting that he was quite irritated that I had not initiated the biofeedback as his urologist had requested and he was planning on cancelling his follow up appointments and going to another therapist.  He was so pleased with the outcome, that he wrote a letter to the CEO of the hospital about his experience, encouraging them to assist in furthering my field of study.  

You’ve just traveled back in time and are sitting face-to-face with your 25 year old self. What advice would you give yourself?

Learn to get over it

Fascial Mobilization has been another touchy topic for some Physical Therapists. Why do you believe Fascial Mobilization is such an important aspect of clinical practice?

Most importantly because fascia is ubiquitous, it is EVERYWHERE throughout the body and it contains a vast neurological network to include nociceptors, mechanoreceptors and proprioceptors just to name a few.  The fascia was that stuff that we all dissected out of the way in anatomy lab so we could learn the assigned structures that soon would have a pin with a number stuck in it that we needed to know for a lab practical.  We need to move beyond the “myofascia” and understand that the fascial system has multiple layers in the body starting at the panniculus which blends with the skin, the investing fascia surrounding muscles and forming septae, the visceral fascia which is by far the most complex and the deepest layer of fascia, the dura surrounding the central nervous system.  All fascial structures, regardless of layer or location have their origin in the mesoderm of early embryologic development.    

Why do you think there are more cases of Endometriosis today than 10+ years ago? Given the hormonal component (estrogen dominance) involved, how do you counsel your patients on what you can do for them, and what they can do for themselves?

I am pretty straight with these patients about their options as far as hormone suppression goes, surgery, pain control and fertility. I also advise them to take a very good look at their household and eliminating endocrine disruptor chemicals in their environment.   

Favorite books & authors? (these don’t have to be PT-related, but they certainly could be…)

I am hooked on The Outlander Series by Diana Gabaldon

Tell us about your relationship with Herman & Wallace. How did this start? And, what are the biggest challenges to creating a course?

I did my initial pelvic dysfunction training with Kathy Wallace and Holly Herman in 1993.  While  attending a course on pudendal neuralgia in Seattle in 2007 Kathy Wallace was there as well.  We got talking about our practices and as the topic of VM came up, when she learned of my level of education on the subject, she asked me to consider writing a course for H&W.  

For me, the biggest challenge is trying to decide what information to leave out.  I am terrible about trying to cram in way too much content, too many techniques and too many clinical pearls in a limited amount of time.  Students can only absorb so much, and I have a tendency to overwhelm them with information.

If you could have dinner with any famous individual who is no longer with us, then whom would you choose? Why?

Sorry, I can’t pick one.  For me, the great dinner would be with Jesus, Mohammed, Gandhi and the Buddha and I would ask them how they feel about mankind killing each other in their name and how we can make it stop.

Ramona, thanks for this great interview!

Connect with Ramona Horton on twitter @PelvicViscera

Hope you got as much out of this interview as I did.

Cinema

P.S. – 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. 

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