Direct Access to Physical therapy: Helping you and Helping Healthcare

Tags

advocacy, APTA, direct access, healthcare, injury, physical therapy, prevention, PT advocacy, rapid city, rehab, shoulder injury, south dakota

It is Thursday evening and you are playing softball. After fielding a ball you throw to first base and feel an intense pain on the front of your shoulder. This is not a new pain but it feels worse than usual. Despite your usual treatment regimen that night (Ibupfrofen and ice), you wake up with a sore, hot shoulder. It is time to get this thing fixed. Afterall you have a tournament next weekend. If you live in California there is no way you are getting started with Physical Therapy before next week. With all the state laws and insurance company hoops to jump through it becomes difficult to get started on your recovery. But in South Dakota and many other states, you can get started that day!

Direct Access: Free to use your own judgement to seek out the appropriate medical professional without being told by another one to do so.

Why is Direct Access to Physical Therapy so important?

1) When you get injured, you want to get started as soon as possible. Direct Access eliminates the wait time to get into the specialist doctor or a costly trip to urgent care.

2) Going directly to Physical Therapy may cut down on healthcare costs (unnecessary imaging, medications, extra copays). These hoops to jump through keep patients from seeking treatment or from getting better faster. Don’t worry. Physical Therapists are trained in medical screening. If you need an x-ray, medications or if Physical Therapy is not appropriate, we will refer you on. The last thing we want is to do is treat someone who has a red flag (non-musculoskeletal pathology not warranting PT).  That is why it is called a red flag. Stop!
Here are some examples of theses hoops patients must jump through in various states/insurance types:
1) You can be evaluated by a PT but can’t receive treatment utility you get a MD referral.
2) You can receive treatment by a PT for 21 days but after that you need a referral.  How often do you completely recover from an injury in 3 weeks?
3) Many states and insurance companies require a signed plan of care by an MD prior to proceeding with care.
*These examples only delay care and provide extra work from all parties. More hoops to jump through make people reluctant to use insurance at all.

Why Physical Therapy?

1) We don’t get you better. We help you get yourself better.

Sure, we are going to use modalities (fancy machines to help you feel less pain and more relaxed) and have you relax on the table for a bit (for massage, joint stretching and other passive techniques). But, this is just a jumpstart or a reset to the system. Once the system is reset we will help you re-enforce the changes. The rest of the work is done by you. We are going to educate you and train you to do what is best during your rehab and going forth.

2) We want to make sure it lasts.

Guess what? You didn’t throw your arm out JUST because your shoulder is weak. There are probably 5 other factors contributing to your recurrent shoulder pain. Ergonomics, posture, exercise habits, sleeping habits, diet, throwing technique…these are just a few things we can identify during your treatment for acute shoulder pain.  Then we can help you prevent another occurrence. We love our patients but, really, we don’t want to see you forever.

Part of “making sure it lasts” is taking you to the next level of fitness. Everyone has body image or fitness goals. We can get you started on working towards those goals during the rehab process.

3) We have an eclectic approach.

We do manual therapy. We do exercise. We use machines. We use tape and braces. We know if you don’t do your homework (home exercise program) and will make you do it in the clinic before we do the passive treatments. The benefit of being eclectic is that we do what is most important for you all the time, not just what you expect us to do.

So next time you are sidelined by a nagging reoccurring injury, get on the horn and call a PT. We will get you started on recovery immediately… IF YOUR STATE HAS DIRECT ACCESS.

*Many states have been labeled direct access but patients DO NOT have clear access (“hoops” described above).  See below in Direct Access spelled out state by state. There is lot of current advocacy related to clear direct Physical Therapy access in these states. Please help support this effort.

References and More Information

American Physical Therapy Association info on Direct Access

Direct Access Spelled out State by State

Clout for Direct Access to Physical Therapy

Tips for Lifelong Shoulder Wellness – Part 1: The Cause

Tags

GHJ, labral tear, law of repetative motion, overuse, physical therapy, pull ups, push ups, RCT, reverse total shoulder, rotator cuff tear, RTSR, shoulder exercises, shoulder injury, shoulder instability, shoulder pain, thoracic mobility, tissue tolerance, total shoulder replacement, TSR, upper crossed syndrome, yoga downdogs

The Shoulder – a simple ball and socket joint that becomes very complicated when pathology strikes.  Compared to treating the spine, the shoulder has lot fewer and modifiable variables that can prevent chronic issues.  To simplify:  when I say the shoulder, I will be talking about the glenohumeral joint (GHJ) – where the humerus meets the scapula (upper arm to shoulder blade).  We are talking about pathology at the GHJ, but without mobility and stability from its partners (thoracic spine, cervical spine, scapulothoracic, acromioclavicular or the sternoclavicular joints) the shoulder will not function optimally.  Most patients I see in the clinic that present with chronic pathology around the GHJ could have been prevented.

Common Pathologies

1)  Labral tear

2)  Rotator cuff tear

3)  Instability (capsular)

4)  Biceps tear

The list above are the common irreversible conditions that can all be prevented from entering the symptomatic threshold and with proper training, posture, and management of injury.  If not managed correctly long term disability due to pain or loss of function result.  This leads to and includes inability to perform you favorite recreational activities, and surgery that may not end in optimal satisfaction.  If you look at baseball pitchers, 79% have abnormal shoulder MRI’s.  Most do not have shoulder pain.  This is because they train their body correctly to maintain good shoulder health for long careers.  Inefficient supporting structures, poor mobility and stability lead to that symptomatic threshold –> pathology.  Painters, on the other hand, typically do not train for their profession.  This is why often they end up with pathological rotator cuff tears over the years

Law of Repetative Motion

I = NF/AR or

Insult of injury = Number of reps  x Force or tension  /  Amplitude of reps X  Relaxation between bouts

In other words, too many movements or too forceful of movements with not enough rest in between is a recipe for overuse pathology.  The key for shoulder longevity is to find the balance between tissue tolerance and tissue loading.

Depending on the degree of damage in the pathologies above, surgery may be warranted.  What most people fail to understand is that the dysfunction in the structures around the GHJ are usually the culprits.  So if you repair something at the shoulder surgically, you are doing all that pain and hard rehab work injustice.  The problem is bound to return in the future.  Also, the surrounding dysfunctional structures are the ones that can be less painfully changed for better shoulder use.  These structures should be addressed in therapy the first time you have a painful episode or notice poor mobility.

As a Physical Therapist I see a lot of reversal of functioning between structures.  The thoracic spine (between the shoulder blades) is meant to be a mover.  The shoulder blades are meant to be stabilizers.  In today’s desk occupied sedentary lifestyle, the function becomes reversed and the thoracic spine becomes stiff (lacks extension and rotation) and the shoulder blades lack stability (muscle control).  Unfortunately the GHJ takes the brunt and is damaged during attempts at “exercising.”

Too many yoga downdogs, recreational softball or tennis, push-ups, pull-ups, P90X, Crossfit… before the shoulder has enough mobility and stability can lead to much worse problems then the 4 listed above:

5)  Joint changes and osteoarthritis

Total Shoulder Replacement

 

The big daddy:  total shoulder replacement (or reverse total shoulder replacement) is becoming more common of a treatment option for those who have gone through early trauma / injury that was not managed properly at the time.  This is the surgery you get because you are no longer able to stand the pain or the mobility is so bad you cannot perform simple daily activities like washing your hair or using the toilet.  The point I want to make in this blog is that, hopefully, total shoulder replacement can be avoided.  Although having a TSR can dramatically reduce pain and disability , the shoulder is far from being “new”.  Expectations after a TSR are to improve motion to slightly overhead (120-140 degrees flexion) and just behind the back for activities such as toileting.  There is no returning to tennis or freestyle swimming after these surgeries.

So, why do people get to the point of having to have a TSR?  As I say to many patients:  “overuse or underuse” and poor injury management early in life.  If you ever pushed through an injury or completely ignored an injury as you waited for it to “heal, ” you have mismanaged your shoulder health.

Reverse Total Shoulder Replacement

For patients who primarily have arthritis in the joint (wear and tear) and have a good functioning rotator cuff, Total Shoulder Replacement is sufficient (pictured right).  As you can see it resembles a normal ball and socket joint like where the upper arm meet the shoulder blade.  If the rotator cuff is too damaged to salvage, a Reverse Total Shoulder Replacement (RTSR) is performed (pictured left).  Notice how the ball and socket have been reversed to allow for improved lever arms allowing the humerus to elevate for overhead movement.  Common procedure is to use the latissimus dorsi (not a rotator cuff muscle) graft to offset the mechanics of the deltoid during overhead reaching.  It gets the job done, but limits the variability of movement over shoulder height = rotation.

How do you avoid a shoulder joint replacement?

a)  Rehab your shoulder WELL the first time it is injured — >  get your full range of motion back in the GHJ and if needed address your spine limitations.

b)  Do you shoulder exercises forever — > maybe not 6x/week but at least a couple of days / week.  Figure out how to incorporate your rehab exercises into your fitness program to save time.

c)  Address your ergonomics or work habits –>  Everyone is aware that we are becoming more sedentary as technology drives our business.  Make sure you set up your desk optimal posture and arrange your day so get enough activity for maintainance good scapulothoracic mobility and stability.  Avoid upper crossed syndrome.

Resources

Shoulder Anatomy and Exam

Total Shoulder specialists

Total Shoulder stats

Joint Replacement Background

Optimal Shoulder Performance Lecture by Mike Reinold