Monday Memo 2/25/19

The Monday Memo

February 25th, 2019                                                                           PITT DPT STUDENTS

 

Challenging the Treatment of Lumbar Spinal Stenosis

Lumbar spinal stenosis (LSS) is defined as a narrowing of the spinal canal that results in compression of the nerves traveling down the lower back and into the legs. Lumbar spinal stenosis is often a degenerative condition that affects people later in life usually after the age of 65. Patients with LSS typically present with pain/symptoms below the buttocks, feel relief of pain/symptoms when seated, present with a wide base of support during gait, and have pain/difficulty walking.

Currently, the most common reason for surgery in older adults is LSS; however, there is very little evidence comparing surgery to non-surgical treatment, or of the efficacy of non-surgical interventions for LSS. Recently, a team comprised of members from the University of Pittsburgh looked to improve the evidence gap by publishing an article in the Journal of the American Medical Association that compared three non-surgical interventions for LSS.

The randomized control trial study specifically compared medical care, group-based exercise, and manual therapy with individual exercise. The non-surgical treatments were completed across 6 weeks. The main outcomes of the study were between-group differences at 2 months in self-reported symptoms and physical function and a measure of walking capacity.

Medical care involved 3 visits to a physician and typically the prescription of oral medications including any combination of nonnarcotic analgesics, anticonvulsants, and antidepressants. The medical care arm also gave physicians the option of prescribing epidural steroid injections if the patient was not responding to oral medications or presented with more severe neurological symptoms.

The group exercise arm participated in a supervised exercise class for older adults at 2 local Pittsburgh community centers. The study participants went to 2 exercise classes per week totaling to 12 classes.

The manual therapy and individual exercise group included treatment provided by a chiropractor or physical therapist. Treatment included light aerobic exercise on a stationary bicycle, lumbar distraction manual therapy, neurodynamics, hip, sacroiliac, and lumbar facet mobilizations, soft tissue mobilizations, and home exercise programs. The programs were individualized and stressed flexion-based exercises.

According to the study, the manual therapy and individualized exercise group showed greater improvement of symptoms and physical function compares to the medical care or the group exercise arm. At 6 months the study found that there were no differences between the groups. While this study did not directly compare non-surgical and surgical treatment for LSS it did demonstrate that patients experiencing lumbar spinal stenosis can make clinically and statistically meaningful improvements in walking capacity without the significant costs, risks, complications, and rehospitalizations associated with surgery.

 

-Janet Mitchell, SPT

 

References:

Schneider MJ, Ammendolia C, Murphy DR, et al. Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial. JAMA Netw Open.2019;2(1):e186828. doi:10.1001/jamanetworkopen.2018.6828

February 25, 2019 |

Monday Memo 2/18/2019

The Monday Memo

February 18th, 2019                                                                           PITT DPT STUDENTS

 

Battling the Gender Pay Gap in Physical Therapy

            The gender pay gap is alive and well in America. Despite women becoming the majority in the profession of physical therapy, women still get paid less than their male counterparts. According to data compiled in 2013 from the US Census Bureau, female PTs make 88% of what male PTs make. The APTA cited these statistics from the report:

Among the data related specifically to PTs:

  • Estimated full-time year-round number employed: 136,392
  • Male full-time year-round employed as PT: 49,118
  • Women full-time year-round employed as PT: 87,274
  • Median annual earnings: $72,260
  • Median annual earnings, men: $80,411
  • Median annual earnings, women: $70,509
  • Women’s earnings as a percentage of men’s earnings: 87.7%

There are a lot of misconceptions around the idea of why the gender pay gap exists. A few theories involve:

  • 1) The fact that women tend to choose lower paying jobs
  • 2) Women choose to work part-time
  • 3) Younger, more educated women do not experience a wage gap.

According to The Washington Post, these theories are not completely true:

 

Claim 1: Women choose lower paying jobs

Explanation: This is not always the case. In the 2017 analysis from The Washington Post, jobs with more women workers pay less than jobs with more men. The top 10 jobs with mostly men pay an hourly wage of about $17/hour, while the top 10 jobs with mostly women pay an average of about $16/hour. Also, women don’t hold as many supervisor, manager, or executive positions which would be higher paying jobs. It is not correct to say that this is a choice for women, as equal number of women and men have aspirations to hold higher positions. Men are chosen to hold these positions more often. This is often referred to as the “Leadership Gap”, and is seen in almost every profession, from politics to physical therapy.

 

Claim 2: Women choose to work part time

Explanation: This isn’t always a choice. With America being the only country in the developed world not legally mandating paid maternity leave and child care being extremely costly, a lot of women transition to part time or casual positions to be able to still work and take care of their young children. New mothers in Finland are entitled to three years of paid leave. Parents in Canada are entitled to 12-18 months of paid leave. America entitles new parents to absolutely no paid parental leave. Many employers offer up to three months of paid maternity leave, but there is no reason as to why fathers cannot receive parental leave as well.

 

Claim 3: The gender gap doesn’t apply to younger, more educated women

Explanation: While the gap is smaller for those younger than 35, it still exists. Women are now more likely than men to hold a bachelor’s degree, however, when compared to men in every age group with 3+ years of college, women are paid less across the entire continuum.

 

So, how do we battle this gender wage gap that still exists in America? We can do a few things, including being more educated about our rights. While the Equal Rights Amendment has not been ratified, there are laws that require people to be paid equally no matter what gender they are, such as the Equal Pay Act. Also, under Title VII of the Civil Rights Act, employers cannot pay women less than men for the same work and they cannot refuse to consider women for promotions based on the fact that they are women. Even though these are laws, employers are still getting away with paying men more.

To combat these inequalities, we can encourage people to be more transparent with their salaries and try to reverse the outdated stigma that discussion of salary with colleagues is taboo or inappropriate. The hiring process for men and women should be on a level playing field and women have the right to ask what men serving in the same role as them are earning to ensure they are being treated equally. We can also promote the utilization of workshops for women who would like to learn how to effectively negotiate salary. No matter what gender you may identify with, addressing the wage gap is an essential step in promoting equality for all workers. By increasing awareness of this disparity and encouraging action by men and women, we can work towards a professional environment that provides the most benefits for all.

 

-Kara Kaniecki, SPT

 

References:

G.V., X. (2017, October 26). Can We Talk About the Gender Pay Gap? Retrieved from The Washington Post.

Ingraham, C. (2018, February 5). The world’s richest countries guarantee mothers more than a year of paid maternity leave. The U.S. guarantees them nothing. . Retrieved from The Washington Post.

US Census: Median PT Earnings Nearly $10k Lower for Women than Men in 2013. (2015, March 17). Retrieved from APTA.

Washington Post: Female PTs Will Spend Last 4 Weeks of 2017 Working ‘For Free’. (2017, November 7). Retrieved from APTA.

February 18, 2019 |

Monday Memo 2/11/2019

The Monday Memo

February 11th, 2019                                                                           PITT DPT STUDENTS

 

The Role of Stabilizing Muscles

When most people go to the gym, they usually work out the “beach body” muscles: chest, arms, shoulders, and legs (only sometimes). Rarely do they focus on smaller muscles that are important for everyday functions such as walking, stairs or running. A lot of musculoskeletal hip pathologies stem from muscle imbalances due to years of compensation patterns.

I have worked out my entire life, but it wasn’t until my first orthopedic clinical rotation this semester that I realized how important the less commonly known muscles are. One that comes to my mind almost instantly is the gluteus medius. Ask an everyday patient, and they most likely will not know what this muscle is, let alone what it does. The gluteus medius is necessary to counter the hip adduction moment during gait/running.  Weakness in this muscle is evident almost instantly by valgus collapse, which in turn leads to various types of injuries and pain further down the kinetic chain at the knee and ankle. No one goes to the gym and has a “glute day” solely focused on working out their gluteals. But almost all the patients I have seen at my clinical have weakness in this muscle.

Another muscle that comes to mind is the transversus abdominis, which is necessary to stabilize the pelvis during hip movements. Limiting anterior or posterior pelvic rotation is essential during rehab to make sure you are targeting the muscles you want to target. For example, if your goal is to strengthen lower abdominals and you have a large anterior pelvic tilt, you will emphasize more hip flexors during exercises rather than core. During our initial session, we instruct our patients on a proper activation of their TA, and couple every subsequent exercise with TA activation in order to stabilize the pelvis.

In conclusion, rehab is similar to building a scaffold. You must start by laying a foundation with activating primary stabilization muscles before building up with more targeted strengthening. Emphasize form over reps at the gym because you will also target stabilizing muscles that don’t immediately come to mind. Every muscle serves a function and we should design our treatment plan based on that idea. After all, evolution would not leave a muscle that has no purpose.

 

-Sam Yip, SPT

February 11, 2019 |

Monday Memo 2/4/19

The Monday Memo

February 4th, 2019                                                                           PITT DPT STUDENTS

 

Communication with Patients who use a Communication Device

            Recent advances in assistive technology have transformed the way that people live, work, and communicate. For example, people who communicate verbally but have difficulty with fine motor tasks can utilize dictation (voice to text) software to send text messages or perform other functions on their phones and computers. On the other hand, a variety of communication devices exist that people with disabilities can use to produce an auditory message. These devices can be controlled with a touch screen and stylus, buttons, switches, and eye tracking/eye gaze technology. One company that produces these devices, Tobii Dynavox, is actually headquartered in the Southside of Pittsburgh.


For the past two years, I have worked as a personal care aide for a man named Mark who has Cerebral Palsy. Mark uses a Tobii Dynavox device that is mounted to his wheelchair to communicate verbally. He uses a switch that he controls with his head to create messages on his Dynavox. He also has a device that syncs his Dynavox and computer called an AccessIT. The AccessIT transfers messages from his Dynavox to the computer and permits him to control the computer mouse with buttons on his Dynavox, facilitating him while writing emails, typing essays, and posting on Facebook. Mark is pictured below when we went to the National Council on Independent Living Conference in Washington DC.

You can see Mark’s Dynavox mounted in front and the yellow switch located next to his head that he uses to control the screen.

During my time working with Mark, I have learned a lot about communication device etiquette and inappropriate behaviors when communicating with someone who uses a communication device. People are often hesitant to engage in conversation with someone who uses a communication device. However, these individuals have likely endured hours of training on their device and have it because they want to engage in conversation! Please don’t shy away from the opportunity if one presents itself. Additionally, when I am out with Mark, I often find people staring at me to answer questions that should be answered by Mark. If you are interacting with someone with a communication device, that is who your focus should be on. The aide or family member that is present will often know when to add to the conversation if it’s necessary. The last habit that I frequently observe is when people do not allow adequate time to allow Mark to respond. For example, they will ask him a question and as he is halfway through typing his response, they will ask a completely different question, forcing him to erase what he had previously written and start over. It is extremely important to be patient and allow the person time to formulate their responses! In a group situation, conversations are often fast paced. If you are working with someone who uses a device, it is okay to inform others that the person is working on a response. Therefore, the others present will remember to slow down and allow time for the person to contribute.

Lastly, I wanted to touch on some possible clinical situations that we may encounter as SPTs. When working with a person like Mark, whose communication device is mounted to his wheelchair, it is not always possible for the person to have access to their device during the therapy session. As PTs, we often transfer patients out of their wheelchairs onto mat tables or to stand and ambulate. In these situations, it is important to have a different method of communication. For example, Mark uses blinking to indicate answers to questions I ask him. He will blink once to indicate “no” and twice to indicate “yes.” If I transfer Mark out of his chair, I can ask him yes or no questions to ensure that his needs are met and he will blink in response. Some people may have a sheet of paper prepared that they can use to point to specific words. This method is good for situations when a person is in a certain position and cannot hold their device, like laying on a mat table.

Assistive technology has benefited the lives of many people and continues to grow as a field. With the increased prevalence of its usage, it is important to remember proper etiquette and how to be creative in situations when it may not be readily available to use. I am extremely grateful for my experiences with Mark and all that he has taught me. As always, Hail to Pitt!

 

-Niki Mikologic, SPT

 

**Mark’s name and picture have been shared with permission

 

 

February 4, 2019 |

Monday Memo 1/28/19

The Monday Memo

January 28, 2019                                                                          PITT DPT STUDENTS

 Think BIG

 

What is it?

 

Parkinson’s disease (PD) is a neurodegenerative disease that progressively reduces the number of dopamine-releasing neurons in the substantia nigra. Dopamine is an important component of the motor pathways within the basal ganglia. It functions to excite the pathway that facilitates movement and inhibit the pathway that slows or reduces movement. This loss of dopamine results in the commonly seen signs of PD, including the resting tremor, rigidity, bradykinesia, and postural instability. A true PD diagnosis requires at least two of these signs, in combination with a positive response to a trial of Levodopa.

 

Common Signs and Symptoms of PD

 

Along with the four primary signs previously mentioned, people presenting with PD may report decreased writing size or micrographia, voice changes, and difficulty initiating movements. Additionally, they may exhibit gait deviations including decreased or lack of arm swing, decreased foot clearance, decreased step length, as well as a festinating gait pattern.

 

Interventions

 

People with PD can benefit from a variety of modes of intervention, including cardiovascular endurance training, strength training, balance training, and task-specific functional training. Intensity is key. Studies have shown that high intensity training is superior to low intensity training for people with PD. There are a variety of high intensity exercise programs available to people with PD, including LSVT Big, PWR!, Rock Steady boxing, and Dance for PD.

 

LSVT BIG

 

LSVT BIG is a protocol driven, high intensity intervention specifically developed for people with PD. People with PD perceive their reduced movements to be of normal amplitude. This program focuses on encouraging what is perceived as high amplitude movement to facilitate normal amplitude movement. The program includes four parts, including a series of seven specific exercises incorporating large, purposeful movements, functional component tasks that are patient driven, gait training, and hierarchical task training based on patient needs and lifestyle. This program requires clinicians to be certified to provide it as an intervention to patients, however the concepts of large amplitude, high intensity movement can be applied to any task. Remember to Think BIG!

 

A special thank you to Dr. Dave Wert, PT,PhD and Jodi Krause, PT, DPT, NCS for their lectures on Parkinson’s Disease and the LSVT BIG protocol.

 

  • Katie Schuetz, SPT

 

For more info:

https://www.lsvtglobal.com/LSVTBig#treatmentExplainedSection

https://www.pwr4life.org/

https://www.rocksteadyboxing.org/

Welcome to the official Dance for PD® site

https://parkinson.org/

 

Reference:

 

Landers, M. R., Navalta, J. W., Murtishaw, A. S., Kinney, J. W., & Richardson, S. P. (2019). A High-Intensity Exercise Boot Camp for Persons With Parkinson Disease. Journal of Neurologic Physical Therapy, 43(1), 12-25. doi:10.1097/npt.0000000000000249

January 28, 2019 |