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Importance of Pro Bono Care

Luke Cancilla, SPT ’21

I made my decision to commit to enroll in the DPT Program at the University of Pittsburgh in December 2018. A few days after making this decision, I along with a group of fellow students from John Carroll University flew from Cleveland, Ohio to San Salvador, El Salvador to begin a ten day immersive experience with CRISPAZ – an organization dedicated to building bridges of solidarity between marginalized communities in El Salvador and communities across the world through mutual accompaniment[1]. Over the next week and a half, we learned from firsthand accounts about the Salvadoran Civil War of the 1980’s, current socioeconomic circumstances many Salvadorans face, and intimate migration experiences. Many Salvadorans shared stories about their lives, histories and hopes for the future. Towards the end of our experience, we travelled to Nogales along the US/Mexico Border to further learn and experience the realities that many migrants seeking a new life face. Throughout this experience of solidarity I had feelings of guilt, helplessness, and anger because of the challenges many of these human beings face. However, these same human beings that we lived with and talked to provided me with whole new meanings of hope, community, and humanity. These three values have driven my identity as a physical therapy student and are the foundation for what I strive to emulate as a clinician.

Since this experience, it has been those feelings of hope, community and humanity that have carried me through the long hours of studying and the stresses of PT school over the past few years. These continue to motivate my passion for physical therapy and my desire to join the physical therapists who reach out to all of our community. This experience of solidarity taught me the lesson that although no single person may be able to change the world completely, we all have the opportunity to change someone’s world and make small impacts to make our community more welcoming to all. Whether you are a teacher, accountant, or lawyer you can play your part. My part will be as a physical therapist.

During the 2020 fall semester clinical rotation, I have had the privilege of providing care at the Birmingham Free Clinic, a UPMC multidisciplinary pro bono clinic that provides care to the underinsured and uninsured of Pittsburgh regardless of their immigration status and socioeconomic standing. This clinic reaches into the shadows of our city and calls out to those too often overlooked by the American healthcare system in order to provide the care that many of our neighbors are in need of. By providing physical therapy care at this clinic, we have been able to help people walk pain free, babysit their relatives without limitations, and return to doing the things in their lives that bring them the most joy. Through this pro bono clinic, we have been able to help human beings in a way that all should have the opportunity to be helped. The Birmingham Free Clinic provides holistic healthcare to those who need it the most with a true sense of hope, community, and humanity.

Luckily, the Birmingham Free Clinic is not alone in providing pro bono physical therapy services to people who would otherwise be overlooked or do not have the means to receive this type of care. Throughout the United States, physical therapy programs have started their own student-run pro bono clinics to bridge the gap to all those who need our services[2] in their communities. Pro bono care continues to gain traction within our professional governing bodies with the American Physical Therapy Association (APTA) ensuring that “pro bono services are consistent with our profession’s values and vision” [3]. Across the world, organizations such as Move Together are working to “increase access to quality rehabilitation medicine around the corner and around the world” by shaping leaders in physical therapy and establishing sustainable clinics and programs throughout the world[4].

Throughout this semester providing care at the Birmingham Free Clinic in Pittsburgh and continuously learning about fellow physical therapists’ involvement in pro bono services, it continues to fill me with pride and hope. It fills me with pride to be in a profession that recognizes the role it can play in expanding access to care. It also gives me hope that as a profession, we can continue expanding access to care for all those who need our services, both locally and globally. The Birmingham Free Clinic is just a drop in the ocean and there is certainly a need to further expand our outreach into the communities that we serve, ensuring that no one is overlooked. By spending this past semester at the Birmingham Free Clinic, I have been able to experience PT services that exemplifying the meaning of hope, community and humanity in a way I haven’t experienced in physical therapy before. This clinic realizes that although it doesn’t change the entire world, the healthcare it provides can change someone’s world. This is a realization that all physical therapy clinics and clinicians should emulate.

[1] CRISPAZ Delegations – El Salvador e-Encounter. (n.d.). Retrieved October 23, 2020, from https://www.crispaz.org/

[2]The Pro Bono Network. (n.d.). Retrieved October 23, 2020, from http://theprobononetwork.com/

[3] Pro Bono Physical Therapy Services. (n.d.). Retrieved October 23, 2020, from https://www.apta.org/your-practice/practice-models-and-settings/pro-bono

[4] Healthy Movement. Healthy Communities. (n.d.). Retrieved October 23, 2020, from https://www.movetogether.org/

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Spotlight on Women’s Rehab and Men’s Health

There is physical therapy for that?!

Sarah Kremer, SPT ’21

I think that is a fairly common reaction when it comes to the area of women’s rehab and men’s health (WRMH) physical therapy (or women’s health for short). This area of physical therapy is one of the more unique ones, and one that I have particularly grown to have a lot of passion for.  I could probably write a book on the different diagnoses that this area of PT can treat, but I am going to try and highlight the most common patient populations that WRMH physical therapists see. 

Pelvic floor dysfunction is one of the most commonly seen diagnoses in this subset of physical therapy. All of the so called “taboo” subjects like urinary and fecal incontinence, urgency, constipation, prolapse, pelvic floor spasm, sexual dysfunction are issues the physical therapy can treat! The underlying cause of a lot of these conditions may be pelvic muscle dysfunction and can be resolved with pelvic floor physical therapy paired with lots of education. These patients often benefit from both hip and core strengthening, as weakness in these areas can play a significant role in pelvic floor dysfunction.  Something imperative to note, is the importance of communication and establishing a very trusting patient-therapist relationship when treating pelvic floor dysfunction. It goes without saying that this is a sensitive and personal area of the body. It is crucial that the patient feels comfortable voicing any questions, concerns or discomforts they may feel during their treatment.

Breast cancer patients. Breast cancer is a diagnosis that unfortunately hits close to home for a lot of us, as it is the second most common cancer among women in the United States according to the CDC.[1]  The treatment that these patients undergo such as surgery (most commonly being lumpectomy, single/double mastectomy), radiation and chemotherapy can immensely alter these patient’s physical health. After a patient undergoes a mastectomy or lumpectomy along with radiation, the skin where the breast tissue was removed can become very tight and fibrotic. This condition will very likely be painful and limit their upper extremity range of motion (ROM).  Following lymph node removal, these patients may experience a condition called axillary webbing, which will also greatly restrict their upper extremity ROM (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5178020/ gives a thorough overview of this condition). The goal of physical therapy is to use techniques such as instrument assisted soft tissue massage (IASTM), passive range of motion and strengthening exercises to break down the fibrosis, axillary webbing and scar tissue to improve overall ROM. 

If breast cancer spreads, the first place it typically will go to is the surrounding lymph nodes. After lymph node removal, these patients are at high risk of developing lymphedema.  Teaching these patient’s preventative techniques, particularly manual lymph drainage (MLD) and having them fitted for compression garments can assist in prevention of lymphedema according to the Clinical Practice Guideline from the Academy of Oncologic Physical Therapy of APTA.[2]  If the lymphedema is unable to be prevented, these patients will benefit from complete decongestive therapy (CDT). CDT is a technique that women’s health PT’s will likely be certified in and includes bandaging, compression garments, MLD and skin care. Lymphedema patients are at much higher risk for skin infections so education about skin care on the first visit is crucial.  Ensuring the skin is moisturized at all times will prevent any cracks/breaks in the skin that would allow bacteria or fungus to enter.  Bandaging is an important part of lymphedema treatment and includes the use of short-stretch bandages to reduce swelling and prevent fluid accumulation.[3]Unfortunately, supplies for bandaging can become extremely expensive for patients and they are not covered by insurance.  I have seen patients in the clinic who are unable to properly manage their lymphedema due to financial restrictions. Here is a link to the Lymphedema Act, in which you can contact your local legislators about the importance of insurance (particularly Medicare) coverage of compression supplies for these patients.

Head and neck cancer patients are also a part of the population that WRMH commonly sees. These patients may also struggle with lymphedema due to damage to the lymph nodes from radiation. So in some cases, they will need CDT and MLD techniques to manage their lymphedema or reduce their risk of developing it.  Another common issue that these patients come in with is extreme tightness and fibrosis from the radiation on the skin around their sternocleidomastoid (SCM), thyroid cartilage, scalenes and submandibular region.  These patients greatly benefit from manual techniques such as IASTM, thyroid/hyoid mobilizations and passive stretching to decrease tightness and increase overall ROM.  In many cases, the cancer and treatment will have caused issues with swallowing and/or speech, and many patients have to rely on feeding tubes as their main form of nutrition secondary to their issues with swallowing. The techniques utilized in PT can help to break down scar tissue/restrictions and hopefully assist these patients with their overall swallowing  and speaking abilities. This population has a high risk of aspiration when eating/drinking so it is absolutely crucial to decrease the risk of this occurrence.  These patients also greatly benefit from posture correction techniques due to the common presentation of forward head posture, due to tight anterior neck structures.

Finally, post partum patients are another very common subset of patients that come into women’s health PT.  Giving birth is a wonderful miracle of life but can be extremely physically taxing for the mom and cause lasting musculoskeletal issues. A common postpartum issue that women experience is a condition called diastasis recti abdominis (DRA), which is defined as a separation of the rectus abdominis muscle of more than 2 cm at one or more points of the linea alba.[4] Women can experience this during their pregnancy and also directly after giving birth due to delivery related trauma.  The combination of hormones released during pregnancy and the stress of the growing fetus on the abdominal wall results in this separation. Luckily, physical therapy can help with this condition. Focusing on deep core strengthening (especially the transversus abdominal muscle), pelvic/sacroiliac joint alignment and posture are all key components of treating DRA. Additionally, women commonly experience pelvic floor weakness/dysfunction and prolapse after delivering. Physical therapy can focus on strengthening and coordinating the pelvic floor muscles which will consequently help to address prolapse symptoms. In May of 2018, the American College of Obstetricians and Gynecologists (ACOG) embraced the concept of the “fourth trimester.[5] This concept addresses the importance of ongoing care for the mother and baby in the weeks following birth, especially physical therapy for the mother.  Advocating that physical therapy should be a standard of care for women postpartum will greatly increase the resources women will have available to them to improve their overall health and well-being.

This specialty area of physical therapy clearly has quite a diverse patient population and can treat many musculoskeletal issues affecting one’s day to day life.  Through my time in my WRMH clinical rotation thus far, I have experienced first hand how much this area of physical therapy improves patient outcomes and helps them achieve their own personal goals.

[1] Breast Cancer Statistics. (2020, June 08). Retrieved October 18, 2020, from https://www.cdc.gov/cancer/breast/statistics/index.htm

[2] Davies, C., Levenhagen, K., Ryans, K., Perdomo, M., & Gilchrist, L. (2020, July 19). Interventions for Breast Cancer-Related Lymphedema: Clinical Practice Guideline From the Academy of Oncologic Physical Therapy of APTA. Retrieved October 18, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7412854/

[3] Why Bandage? (n.d.). Retrieved October 18, 2020, from https://www.lymphcareusa.com/patient/therapy-solutions/compression-therapy/bandages.html

[4] Thabet, A., & Alshehri, M. (2019, March 1). Efficacy of deep core stability exercise program in postpartum women with diastasis recti abdominis: A randomised controlled trial. Retrieved October 18, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454249/

[5]OB-GYN Group Embraces ‘Fourth Trimester’ Concept, Acknowledges Role of Phys… (2018, July 11). Retrieved October 18, 2020, from https://www.apta.org/news/2018/07/11/ob-gyn-group-embraces-fourth-trimester-concept-acknowledges-role-of-physical-therapy-in-postpartum-care

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The Value of Interdisciplinary Care

Kimberly Berkovich, SPT

If you ask anyone in the field of Physical Therapy what they like about the profession or why they chose it as a career path, you will likely hear something to the effect of “I want to help people move better and optimize their function” or “I want to increase the quality of life my patients experience.”  One of the first lessons we receive in Physical Therapy school is the importance of treating the whole person and not just simply the diagnosis he or she presents with. This involves looking beyond the pathology and considering who our patients are fundamentally, what their day-to-day life looks like, what goals they have that are important to them, and what kind of activities and responsibilities they hope to return to. Understanding who our patients are helps us provide a more tailored treatment approach to achieve more meaningful goals. However, what people may not realize is that for many of our patients, Physical Therapy is just one piece of a larger healthcare puzzle. It is often through collaboration with our medical professional colleagues that we are able to provide the most holistic, comprehensive care.

Historically, medical care has been siloed, and when one specialist is not aware of what another specialist is doing with a patient, duplicate work or contradictory instructions may result. This can lead to confusion and frustration on the part of the patient, and quality of care suffers. Recently, there has been a push in healthcare to implement a more interdisciplinary approach to combat these issues.

Interdisciplinary care, as defined by the Victoria State Government, is an approach where individuals from various disciplines work together with a common purpose to “set goals, make decisions, and share resources and responsibilities.” [1] The disciplines involved in this approach can include any or all of the following: physicians, nurses, pharmacists, dieticians, occupational therapists, speech language pathologists, psychologists, social workers, neurologists, and more. The medical team, along with the patient and the patient’s family members or social support group, create a plan of care to best serve the patient.

This collaborative treatment effort is becoming increasingly utilized, and with good reason. Interdisciplinary care has been shown to reduce length of hospital stay and has been linked to improved patient outcomes and overall satisfaction of care, which is especially important in the midst of Covid-19. [1] Each discipline is specially trained to treat a unique aspect of a patient’s clinical picture, and in combination with one another, ensures that all of the patient’s medical needs are accounted for.

The best place to observe this in action is in an Inpatient Rehabilitation setting. In this setting, patients receive > 3 hours a day of intensive therapy that includes Physical, Occupational, and/or Speech Therapy, and 24-hour medical care is provided by an attending physician and nurse. Psychologists, pharmacists, and case managers are typically involved as well. The healthcare team meets at the beginning of each patient’s rehab stay to establish goals and a target discharge date, as well as to discuss any perceived barriers and how to address them. Later in the patient’s stay, another meeting is held to determine discharge criteria and the patient’s needs post-discharge. It is encouraging and heart-warming to witness this comraderie and observe how each discipline contributes their wealth of knowledge to optimize each patient’s health.

In the inpatient rehab setting, physical therapists are one of the first healthcare specialists to get patients moving after an acute life-altering event, such as a stroke, traumatic brain injury, or spinal cord injury. We have the opportunity to build relationships and rapport with these patients and witness firsthand the benefits from the interdisciplinary care they are receiving. There is something special about the moment when your previously nonverbal patient is able to communicate verbally with you thanks to the time spent with their Speech Therapist or the first time you see a patient brush their hair independently as a result of working with an Occupational Therapist. The most rewarding part about interdisciplinary care is celebrating a patient meeting all of his or her goals and getting discharged, knowing that each discipline played a part in the patient’s success.

As the U.S. population ages and the world continues to battle a global pandemic, it would be beneficial to see interdisciplinary car extended beyond hospital settings and incorporated into more outpatient practices. Hopefully we can see a bridging of the various disciplines in both the inpatient and outpatient setting going forward to provide patient-centered treatment and high-quality patient care for those who may benefit from a more holistic, comprehensive approach.

1. Department of Human Services 2008, Health independence programs guidelines, State Government, Melbourne.

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Monday Memo Oct 5, 2020: The Importance of Return to Sport (RTS) testing in ACL Rehabilitation

Phil Forsythe, SPT ’21

Week two of the NFL came and went filled with injuries in one of the worst weekends for players and fantasy football owners alike. For Saquon Barkley of the New York Giants and Nick Bosa of the San Francisco 49ers’, their 2020 campaigns came to a halt with one of the worst injuries a professional athlete can suffer: torn ACLs.  In a review of Orthopaedic Surgeries effect on athletes’ careers in the NFL, the average rehabilitation period for ACLRs was 378.1 days or just over a year [1]. These are some of the most elite athletes in the country with some of the best professional surgeons, physical therapists, and strength and conditioning specialists, and yet, it still takes them on average a year to return to the field.

That raises an important question: how good are the outcomes for physical therapists treating high school and college athletes in the outpatient orthopaedic setting? Not great. In a 2014 study looking at the incidence of a second ACL injury two years after return to sport in 78 patients, they reported a second ACL injury rate of 29.5% with 20.5% occurring on the contralateral ACL [2]. Surgeons and physical therapists alike have made progress on recognizing some of the most important factors from the literature to reduce reinjury rates including symmetrical quadricep indices and time until return to sport. In general, it appears that every month RTS is delayed up to the ninth, the likelihood for reinjury is reduced by 51% compared to the previous month (3).

Every new graduate in the outpatient orthopaedic setting will eventually see the referral to evaluate and treat a post-operative ACL patient. Alongside that referral they will receive a protocol outlining the goals for range of motion, strength, jogging, jumping, running, cutting/pivoting, and finally return to sport. The problem with only adhering to your protocol is you are trying to eliminate the personal aspect from your athlete’s rehab. The protocol should serve as your guide, but it should never paralyze your ability to assess what your athlete is showing you on the day to day basis. Every athlete should earn the right to the next stage of their rehab until they are ready to step back onto that field. Otherwise, you are potentially doing them a disservice. At Pitt, one of the mantras we get taught is to test early and test often. While that doesn’t mean you start doing hopping tests before they are jogging, one of your goals should be to assess strength of the quadriceps compared to the uninvolved side before the patient earns the right to progress in their rehab. Communicating early with the surgeon to align recommendations with objective goals ensures there is no miscommunication during checkup visits.

What is the next step when nine months passes by, and your athlete feels that they are ready to start playing again? As physical therapists, we need options that will accurately assess the demands of their sport and provide an evaluation that clears an athlete for play. Researchers are still working on the most optimal battery of return to sport tests, but they have shown that meeting a comprehensive RTS criterion can significantly reduce reinjury rates in athletes who passed versus athletes who failed [3].

Here’s an example of the battery used in the Delaware-Oslo ACL cohort study (>90% symmetry for all tests is considered a pass) [3].

1. Quadriceps Strength Testing: Isokinetic Concentric (Biodex) – The Biodex is considered the gold standard for testing quadriceps muscle strength, but it is also extremely cost prohibitive for typical outpatient settings. A handheld dynamometer can produce a more cost-effective assessment, and even 1-rep maximum testing on the leg press is better than no strength assessment. Quadriceps symmetry is extremely important; this needs to be tested before you should be comfortable letting a patient return to sport.

2. Four Single Legged Hop Tests – There are many different options for single legged hop tests: single leg hop for distance, triple crossover hop, triple hop, 6 meter timed hop, lateral and medial single leg hops. Symmetry between involved and uninvolved in terms of distance or time is what you are measuring.

3. Two Objective Outcome Scores – KOS-ADLS and Global Rating Scale. These outcomes tell a lot about how the patient perceives their knee and overall function. Another great outcome score would be the ACL-RSI; this outcome gives a quick measure of the patient’s fears about returning to sport and the specific mechanism of injury for their knee [4].

RTS testing is an integral element to ensuring that you are providing the best possible opportunity to prevent a second ACL injury. While there are additional considerations on whether athletes should progress through a tapered return to live, full contact sport, RTS testing is the bare minimum we need to be doing as clinicians before signing off on our end.

Nine months minimum is one of the longest rehabilitation times in physical therapy. By making your RTS decision objective and measurable, you could prevent that athlete’s return to physical therapy for a second injury.

1. Mai HT, Alvarez AP, Freshman RD, et al. The NFL Orthopaedic Surgery Outcomes Database (NO-SOD): The Effect of Common Orthopaedic Procedures on Football Careers. The American Journal of Sports Medicine. 2016;44(9):2255-2262.

2. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. Am J Sports Med. 2014 Jul;42(7):1567-73

3. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016 Jul;50(13):804-8.

4. Webster KE, Feller JA. Development and Validation of a Short Version of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale. Orthop J Sports Med. 2018 Apr 4;6(4)

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Monday Memo 04/27/2020

The Monday Memo

April 27th, 2020                                                                       PITT DPT STUDENTS

The Bioethics of a Pandemic: Navigating the Moral Challenges of a Global Health Crisis

This public health crisis we’re all facing right now has forced everyone to ask impossibly difficult questions of themselves and others. COVID-19 has impacted nearly life in our nation and worldwide. Undeniably, a lot has been lost: physical connection, employment, a shared sense of health security, and most devastatingly, human lives. In this time, I’ve learned (with help from others) that very few good things come from comparing someone else’s suffering to your own. Sharing the burden of suffering… now that’s a different story. We are ALL going through things that are incredibly taxing right now. Consider it like this: we are all in the same boat, but not in the same storm.

If you couldn’t already tell how much self-reflection this quarantine has sparked, it’s a new level over here – and I have been thinking a lot about ethics. To begin the conversation on bioethics, I want to make the distinction between the two terms, ethics and morality. Although exact definitions are disputed, ethics is generally thought to be the practical, guiding principles of “right and wrong” conduct that is distinguished by certain communities, while morality is the principles of “right and wrong” based on a more subjective, individual code of beliefs. That said, “bioethics” or “healthcare ethics” is a branch of applied ethics studying the implications of the philosophical, social and legal issues arising in medicine and life sciences.

             As if these concepts and practices weren’t difficult enough in “normal times”, add a pandemic to the mix?! I have been mulling over all the different topics of concern in bioethics right now, and I won’t lie, it is a bit overwhelming. Here are a few pressing ones on my mind (certainly not all-inclusive):

  • Allocation of scarce resources – most pressingly: ventilators/medical equipment, PPE, food, and monetary support.
  • End of life decisions, especially for those without a pre-determined preference. (shout out to Atul Gawande’s wonderful book, Being Mortal.)
  • Balancing individual (patient-centered care) and community health (patient care guided by public health emergencies). This includes clinicians following triage protocols that may cause them moral distress, since they have had to change their usual practice.
  • Ethical issues surrounding human vaccine trials and expedited research.
  • Wellness vulnerability of undocumented or low-wage immigrants, as well as people that are impoverished or homeless.
  • Damaging impact of spreading misinformation, which can lead some to respond in a way that puts themselves/others at an increased health risk.

I don’t mean for this to stir up fears (or even more anxiety) on top of what we are all already feeling. These conversations are difficult, but necessary. I often find myself exhausted from the 24/7 pandemic coverage and have to ration my intake of news. Taking inventory of my emotional capacity is one aspect of self-respect that I’ve engrained into my own moral code. Something I’m constantly struggling to follow. And not for everyone. But whether or not we watch ALL the news or only some, we should acknowledge that there is definitely an obligation to stay informed for the sake of our collective health. This leaves us with a tricky balancing act – watching for safety and not watching for sanity. Some tips: pick a few reputable sources, check in with them in a way that honors your emotional capacity, and then step back.

PT school has given me the tools to begin these conversations around bioethics, but I certainly can’t do it alone. By having these exchanges with others (as you’re able), we can build up our own moral toolkit. Taking a piece here and there from the people we admire. Take lessons now from the brave work of our PT colleagues in hospitals across the nation, who are acting out the highest form of APTA’s “altruism” value. Now it’s our turn to practice APTA’s “social responsibility” value by staying home! There is no easy answer for these modern bioethical questions, (a lot of them answered by the classic “it depends” PT school answer). But as I like to think…. In the words of Pittsburgh’s dear Mr. Rogers: “Anything that is human is mentionable, and anything that is mentionable can be more manageable.”

-Hannah Davis, SPT