Dr Peter’s blog

Benign Paroxysmal Positional Vertigo – BPPV So what does this mean? It seems like a tongue twister if nothing else. It‘s easier to say and remember as an abbreviation. This vestibular condition falls under a larger category most would generalize as Dizziness.

The definitions, signs, and symptoms of dizziness will no doubt expand:

1)  Presyncope - such as might occur with a sense of fainting from ischemia (lack of blood flow/supply to the brain)

2)  Disequilibrium - (cervico-genic, neurogenic), a sense of the legs giving way, going to fall.

3) Other - sense of not feeling oriented, floating, and anxiety (may be accompanied with a fear factor or head fuzziness and wanting to sit or lay down).

4)  BPPV - a true vertigo where things seem to be spinning/rotating and one “knows” they are going to suddenly fall down (in an acute sudden overwhelming episode) or a (lighter sense of disequilibrium) when one can hold on to a wall or heavy furniture to “stabilize balance”.

Once movement has ceased for 5-10 seconds however, it will pass until the head is turned again. This is not to be confused with Meniers’s Disease also involving vestibular structures but actual patho-physiology not really known and the episodes are much longer in duration (greater than 10 seconds – often hours).Of course medication can result in “BPPV like” symptoms. True BPPV can be treated by Occupational and Physical Therapists (and other professionals, including unlicensed non-professionals; family members or by self administration, such as a Brandt-Daroff maneuver).

Briefly there is evidence of CaCo3 (calcium carbonate) crystals getting loose from an “inner ear” structure, the utricle, and lodging/floating in the posterior semi-circular canal (the canal system sensing turning or rotation motion). Through an apparent obstruction of normal endolymph flow, otolith hair structures can not adequately feed back to the brain a validated head position in space. The “brain” not knowing “where its head is”, then does what it knows best, stops one in his/her tracks by getting them to sit down, lay down, or fall down.

So if you experience repeated episodes of the above BBPV definition, where episodes end within about 10 seconds of becoming still (immobile – freezing in place), you could see an expert, such as an OT or PT, for a BPPV assessment before taking pills to clear it up; there’s plenty of time to take the medication later if therapy doesn’t help.

Health Data management.

I was reading an article on one of the sites to which I subscribe, and was asked my opinion about mandatory pay for performance (P4P) initiative, subsequently being renamed (euphemized) for physicians as PQRI (physician quality reporting initiative) concept/program: Medicare Link.

In that vein of thought, Medicare already plans to have in place October 1, 2008 a policy of not paying for hospital related mistakes and patient injuries (such as hospital/nursing home acquired infections, fractured hips, gastric intubations during anesthesia, postoperative complications, etc) “. Medicare currently is in its first voluntary PQRI (some aspects of which, in the areas of falls/disequilibrium also apply to physical therapists and occupational therapists) phase July 1, 2007 - December 31, 2007. In theory, it is like a lot of good ideas; on paper it would make anyone question why it hasn’t always been required.

Such rating concepts (the Better Business Bureau has ratings for local businesses, school districts have “report cards”, US News and World report publishes an annual listing of “Best of XXX” categories, etc) have been and are being developed by state and federal agencies specifically focused on health care delivery and outcomes. It of course has nuances premised as report card information which the government thinks will improve health care delivery and reduce costs. New York state’s Attorney General, Andrew Cuomo, however, threatened to sue health insurance companies like Horizon if they implemented their plans; half-baked and nefarious because they are based on old as well as inaccurate data: Nursing homes, hospitals, and physician offices are the first to be “targeted”. 

My reply (my opinion based on 35 years of keeping current):

We’re far off from valid standardization of P4P or PQRI rating systems. Insurance carriers can’t even properly identify member benefits let alone how members respond to rendered care. Insurance carriers can’t even (or won’t even) keep the same insured members long enough to have a longitudinal data base to assess outcomes.

There is no standard for assessment over enough criteria to warrant P4P / PQRI tools such as might be applied based for example on such criteria as Cost or number of visits/treatment sessions /patient’s term of care; accurate pathology identification for definitive diagnosis and co-morbidities influence; validity of providers administration or application of various patient health status information indexes or tools; valid environmental/ethnic/racial correlations of applied assessment tools, etc, etc, etc, do not yet exist.

Even “standard” pain and functional tool questionnaires are difficult to inter-rate/intra-rate in a single clinic. Sure a miniscule number of clinicians can be “taught” to standardize a single clinic but significant broad application ethics aren’t even on the horizon.

In fact survey after survey demonstrates a large majority (75% - 85%) of physicians aren’t even close to adopting IT as a routine practice option (on-line consultations, internet prescriptions, release of patient data to any agency that could intrude on the physician-patient confidential relationship, or use of electronic medical record keeping. Notice all those hand written charts in the vertical files (often behind the receptionist desk) with all those colorful tabs???

In fact what to call IT patient files is not yet itself standardized. Are they EMR’s (electronic medical records), EHR’s (electronic health records), or PHR’s (personal health records), add your own naming phrase. Where will these records be stored or accessed? In hospital consortiums, insurance company data bases, RHIO’s (regional health information organizations), physician offices, HIE’s (health information exchanges), in a chip under your skin, Google, Yahoo, Microsoft’s Health Vault, or some other repository system/concept.  

In today’s health climate the medical providers are too disgruntled, too concerned about HIPAA, to wary of the above proof there is no standardization, not being given the time to learn  and relearn the technology of it, or just plain skeptical, to even consider buying into any performance protocol. The culture isn’t there for P4P or PQRI.

For all we know about our insurance healthcare benefits (if we have any), the statutes of state and federal government play an important role.

Suburban recently hosted its two Assemblymen of District 40 to discuss reimbursement issues in healthcare:

Kevin O’Toole  O’Toole’s web site (now running for retiring Senator McNamara’s seat) and

Dave Russo  Russo’s web site.

Senator Henry McNamara McNamara’s web site 

of District 40 was traveling at the time but was also contacted to support the legislative changes necessary to support rehabilitation coverage and administration in New Jersey.

Janie Lewis, Suburban’s Billing Director, collaborated with me to produce a 100+ page briefing book of Suburban for each assemblyman in referencing the non-standardized and often contradictory and/or inconsistent issues in rehabilitation reimbursement.

Subsequently the New Jersey Society of Independent Physical Therapists Society’s web site 

proposed legislation to address some of the most egregious problems of the below cost reimbursement fees and to eliminate the private carriers’ (Horizon, United Health Care, Aetna, Oxford, and others) restrictive preauthorization and certification/recertification restrictions and constrictions.

NJSIPT got A3790 and S2600, addressing some of the reimbursement and allowable visit provisions of private carriers, submitted for NJ state lawmaker deliberation. Assembly A3790 passed before summer recess Type A3790 Into This Link’s Upper Right Box and now, hopefully, the Senate is considering S2600 so Governor Corzine can sign it. The Governor has stated himself, the value of the rehabilitation he is receiving.

Consider this:

Where ever did the arbitrary 30 visits/ year come from in the first place? Perhaps the visit number equates to the deductible amount. For example: $58/visit insurance allowance (-) $20 co-pay (or $30, $40, $50 co-pay - that’s right some policies have a $50 co-pay) X 30 visits (maximum sessions allowed) = $38 X 30 treatments = $1140 (about the monthly premium for an average family policy).

Since New Jersey state law does not require a prescription for physical therapy, if you have a $1000 deductible and you don’t need care from any other health professional, it really looks like rehabilitation coverage might only amount to $140.

As we live longer, healthier, and remain much more active into our 80’s and 90’s,  I think we will come to realize our health insurance premiums are still predicated on mortality (AT WHAT AGE WE WILL LIKELY DIE)            tables of the past when we were supposed to be sicker, require more hospitalization (notice how many hospitals are being closed these days?), cost more to keep alive and running than we are now experiencing. We live longer. We live beyond the “private insurance carrier” projections so that (at least today when I am writing this) it is Medicare, not private carriers as Horizon, United Health Care, Aetna, Oxford, and others, that need to prognosticate or “death date”. The private carriers should be predicating their actuarial tables on likelihood for sprain and strain health costs, not medical illness costs. Medicare will deal with those; and that’s a different concern.

Perhaps we now need coverage based more on the less costly care of rehabilitation for sprains and strains than what may now be the less frequent occurrence for chronic medical care issues.

Rotator Cuff Tendinitis

We’ve all heard about this subject; with many people calling it “rotor cuff”, which I place in the same “dys-phonetic” vein as “prostrate” when referring to the male prostate gland. Nevertheless it is a common musculo-skeletal entity seen in orthopedic offices (physician, physical therapist, and occupational therapist practice locations). Mechanistically, even with “the” literature arguing with the logic and anecdotal explanations as to the “why” “when”, and “what” of it as not evidence based; but the “where” of it (under the acromion) is less in dispute (although the coraco-acromial ligament may also sometimes be implicated.

The key for many impingement syndromes manifesting as rotator cuff tendinitis is to strengthen the muscles stabilizing the scapula and the result will be a more proper facing glenoid fossa (shoulder joint) in a more upward and outward direction permitting the greater tuberosity to not impinge its attached rotator cuff tendons against the underside of the acromion.

Regardless of what it is or how it happens though, Physical Therapists and orthopedic oriented Occupational Therapists can greatly help with that process. Call Suburban for advice and then maybe an appointment.       �

Plantar fasciitis:

What is that $100 dollar sounding word - plantar fasciitis?  Well, it’s on the bottom of your foot/feet if you have it. Why? Because it is the toe muscles of your foot, including their tendons which help to propel you forward and provide sensory input and terrain contour information that are the active ingredients of the plantar fascia foot function. If they get over used from too much standing, walking/hiking, or running in poorly fitting/conforming supportive shoes, the soft tissue rebellion begins. It can be vengeful.

Interestingly, I don’t know of any “bare foot” walkers who get it. MBT brand shoes seem to predicate their shoe based on that concept. In cultures where bare feet are de rigueur de jour, the incidence of plantar fasciitis may be thwarted through sustaining the evolution of bipedal locomotion. Perhaps, however, cold weather and new terrain, as our bipedal relatives spread out to new lands 40,000 years ago, and perhaps influenced by some ice age related event(s), feet had to be protected from cold land features (when feet weren’t covered with insulating hair) resulting in ‘inventing” “soled footwear” while other self-evident human calculating methods and tools (fire, arrowheads, the wheel concept) concomitantly evolved.         

Anyway, it seems some runners, some over weight individuals, and other people with failing foot structures, stress the ligaments of the natural foot arches, shorten up their heel cords, maybe get posterior tibialis tendinitis too, and begin propelling with plantar fascia injuring mechanisms.

Stretch - stretch – stretch heel cords and toe flexors for fairly certain relief. Ask your orthopedic or sports certified physical therapist specialist what to do. You’ll be glad you did or I’m that proverbial Darwin precursor monkey you’ve heard so much about.

Do you have a regular or recurring headache? What are you taking for it? How about a Mulligan? A Brian Mulligan technique, known, by some physical therapists he has taught, as a C-2 mobilization. You may not need the pill(s) you usually resort to for it. �
 

Your headache may likely be caused by a greater occipital nerve impingement irritation. The cranio-vertebral joint complex has a space, the atlanto-occipital space. The first cervical nerve known to some of us as the greater occipital nerve, can get pinched right there. Patients regularly appear in my clinic with them. They usually refer themselves or are referred by other clinicians for treatment for some musculo-skeletal pain or dysfunctioning/dysfunctional body region but coincidentally also have a headache; believing they simply ” have to “write it off” and live with it; routinely  treating it with “Advil” or something like that. �
 

If you have a recurring headache you may not need medication. You may need neither a p.o. administration nor percutaneous administration, but rather the non-invasive physical therapist orthopedic clinical specialist. Check us out.     

There’s an old precept in business when one might be asked “how many years of experience do you have?” Answers of course in a group of accomplished business persons may be expressed as 10, 20, or in my case 35 years. The actual answer is supposed to be 2 years. That is because business cycles and trends are always changing and only those living/making decisions in the “present” are going to succeed with decisions based on the “current trends”. That may be mostly true for manufacturing and information businesses but not for medicine and in Suburban’s case rehabilitation.  Where am I going with this? A clinician is only as good as the number of years in practice times 15 (by NJ State law, the annual number of CEU’s needed by NJ doctors of physical therapy) divided by total life time CEU’s. If your clinician has a score of 1.0, you have some one keeping up with the law and if the courses are germane to the practice, then is also keeping up with the trends of rehabilitation; at least on paper. A score of more than 1.0 and they should have their license revoked until the number is 1.0 or less. The lower the number the more likely the clinician will be making informed and perhaps even evidenced based decisions for his or her patients. I suppose my life time would be close to 0.15 (some years 0.125 or even 0.10) with all the CEU’s I’ve accumulated long before CEU’s were even being considered to be necessary. The point is: experience is a teacher too. So CUE’s + experience = competent clinician. In fact there was no physical therapy continuing education when I began my career (NJ did not yet even have a Practice Act let alone care if therapists were keeping up with the times). I found myself having to take physician and nurse courses just to get any idea of what was going on in healthcare. There were no journals specifically for physical therapists either. We treated primarily patients with neurological conditions (Parkinson’s, CVA-Stroke-Brain Attack, MS, MD, ALS, “essential” ataxia, OBS [organic brain syndrome]) or patients with other conditions such as lower extremity amputation (from diabetes complications) and emphysema; my first 7 home care (also a new health care delivery concept) patients were for postural drainage – few therapists today even know what that is unless they work with cystic fibrosis (www.cysticfibrosis.com ) or emphysema or COPD; just to name categories in which 80% of our work “fell”. Sidney Licht wrote a compendium (500-800 pages I don’t remember) and arguably the “Bible” for rehabilitation information and “treatment recipes” for those times. A Physiatrist Journal was also available but in those days journals were pretty heady and arcane, not written for the rehabilitation clinician. Our PT journal was minimally helpful to a private practitioner. There was no internet.  Fractures and orthopedics in general were often not referred to PT at all except for gait training. Great Britain’s John Charnley’s total hips were just getting started in the United States. Many times hip fractures not secured with Jewitt Nailings, (Ender rods weren’t even here yet) were either Austin Moore Prostheses, or Girdlestone procedures (named for Gathorne Robert Girdlestone 1881–1950 –another renowned Oxford Englishman). I relied on orthopedic surgeon resources for information such as Journal of Bone and Joint Surgery, the quarterly published Clinical Orthopedics, and those expensive texts books like Campbell’s Orthopedics, Turek’s Orthopedics, and Stan Hoppenfeld’s books. They were expensive to replace when new editions were published but I had to keep buying books just to have a ready reference.   ��

Atul Gawande is my new favorite medical doctor writer. He recently published the book Better, in 2007 - which I highly recommend to physicians, patients, and care givers.

His recent article in the New Yorker, April 30, 2007 is a must read on aging for all of us; either those of us who are old or are caring for the old or infirm. http://www.newyorker.com/reporting/2007/04/30/070430fa_fact_gawande. His third paragraph lead sentence gives the tenor of his profundity: “Even as our bones and teeth soften, the rest of our body hardens”. In the United States he says we have reached the population demographical phenomenon called the “ ‘Rectangularization’ of survival”. Japan is perhaps one of the forefront societies already into the phenomnenom, and Italy and France have gotten into a cultural pickle over it. (That’s another blog some day).
 [As an aside: He mentions the 3 commonly known risk factors for falling (a condition Suburban Therapy Center treats): poor balance, taking more than four medications, and muscle weakness. In fact, there are many studies ( I was at a conference more than 10 years ago in San Diego dealing with just this issue) showing exercise, and specifically PRE’s (progressive resistance exercises) can get the elderly off medications and reduce or eliminate the ambulatory assistive devices they use in nursing homes, maybe even improve their health and balance enough to let them live alone (or with their aging spouse) or at least with their younger family members (like “mother daughter” accommodations or simply be “at home with the grand children” ). ]
 

Dr. Gawande interviews some geriatricians in NYC, Boston, St. Paul, among others,[ see my blog from last October 23^rd: http://www.suburbantherapy.com/blogs/peter/wp-admin/post.php?action=edit&post=13

Dr. Felix Silverstone from the Parker Jewish Institute in New York speaks of “The Old Crock” as being deaf, having poor vision, having a somewhat impaired memory, needs to have slower conversation to avoid a lot of “what’d you say’s”, and doesn’t have one medical complaint but FIFTEEN. In a sense we can do a lot for ourselves, if we’re “old”, or for our elderly if we know any by just having common sense and applying it. Dr. Gawande  interviewed Dr Juergen Bludau in Boston who is reported to “prescribe” for us: 1) See a podiatrist when we can no longer reach our feet; diabetes, often linked to poor over-eating habits [see Suburban’s nutrition site: http://www.suburbantherapy.com/nutrition/index.html?f2page=viewArticle.htmlWITHaid=78ANDtid=2ANDpag=1ANDpid=3ANDtopic=Preventive%20Nutrition], is on the rise world wide, even in those societies which once did not have obesity concerns. Eating poorly can lead to diabetes and the feet can be the first to go, literally.

2) Eat snacks, or if on a low budget, “a” snack, during the day to ensure we have the calories to sustain our metabolic energy needs. Those calories should include fat calories (remember, we’re speaking of aged bodies in compromised, comorbid sunset years; not the healthy vibrant aged bodies types) which are double the per unit portion when compared to carbohydrates and proteins [see Suburban’s nutrition site: http://www.suburbantherapy.com/nutrition/index.html?f2page=viewArticle.htmlWITHaid=120ANDtid=1ANDpag=1ANDpid=3ANDtopic=Nutrition%20101] .

3) Throw out low- calorie and low-cholesterol foods.

4) Have a daily meal with a friend, family member, or other(s) because “eating alone is not very stimulating”. Dr. Chad Boult from the University of Minnesota was a researcher in St. Paul comparing the results of an 18 month study involving 568 men and women; half saw a team of geriatricians in a university clinic, the other half continued care with their PCP (primary care physician). 18 months later, 10% in both groups had died; For the remaining 90%,  the geriatric team care (about 20 members apparently MD’s, DO’s, RN’, and MSW’s), using little or no “high-tech medicine”, resulted in 30% less likely disability of patients; 50% less depressed; 40% less need for home health services. All the team “did” was SIMPLE: simplified the medications, controlled the arthritis, kept toenails trimmed, ensured meals were balanced, monitored patient “isolation tendencies”, and had a social worker check to see the homes were “safe”. Nevertheless the university said the average annual cost of care was $1,350 more than it saved and the program was closed, the 20 people team members had to go find work elsewhere. Thankfully Dr Boult stayed with geriatrics and went to Johns Hopkins in Baltimore where he now says in our nation of the United States, only 300 medical graduates will specialize in geriatric medicine (70 million baby boomers are just around the corner), 97% of medical students take no course in geriatrics at all, and for those rare practitioners in gerontology, they’ll get paid more to teach than to practice the medicine they set out to provide. Dr. Silverstone had to give up medicine to care for his aging wife.Why would anyone reading this have a detached mind about it? As I said last October: “I sure hope we’ve done our job when the baton has passed on to the one caring for me.”   Š

 

 

Hi everyone,

I’ve been busy in my “hamster wheel” and by the time I am finished with paperwork du jour, I have so much email to sort, readings to do in general (daily news), journal article stuff to look at (on-line or paper form), medical information synopsis sites (all sorts of medical resource compendiums), and review entries on the 50+ forums of Medrise.com, I’m just too tired to think clearly enough to blog.

Well, one of our clinic acquaintances has a very strong wood working talent, among many others (he’s a good cook/chef, understands plumbing, motorcycles, and anything else related to mechanical engineering). He recently brought in a nest box (you’ll notice in the glass exercise room – he actually called it a bird house but the correct term is now nest box so that we focus our attention on its camouflaged requirements and not colorful  design which, besides making it a bulls-eye for predators may also make it too hot (paint seals natural wood breathing, birds may swallow harmful paint flecks they peck from it, and dark paint absorbs heat making it like an oven, literally killing nestlings from over heating) and invited our staff to come to his work shop to make some more, for free. He says he salvages wood for free from all sorts of sources (and that process is itself a type of therapy for him) and offered our staff the opportunity to try some “wood working therapy”.

Anyway that got me to thinking. Why not make nest boxes to sell at Suburban as a fund raiser – all proceeds go to the NJ Audubon Society for undesignated (general use) or designated (use for up keep of its visitor centers [http://www.njaudubon.org/Centers/]   land purchase [http://www.njaudubon.org/Education/], and education programs [http://www.njaudubon.org/Education/], etc). 

So be on the look out. Hopefully by this Autumn he’ll be up and running. I expect to have them at the clinic to buy directly (where you can “kick the tires”) or on line at our soon to be on-line store.

Thanks

Everybody knows age is “in” and actually it may also be where the money is (Generation “X’s” financiers). (http://en.wikipedia.org/wiki/Baby_boomer). They may be one of the last generations to have jobs with employer subsidized healthcare insurance as the October 26, 2006 New England Journal of Medicine is intimating (“Consumer Directed Health Care”). Nevertheless people will be sick, they will need care. The practitioner will want compensation for “rendering care”. Tendency will be to “go where the money is”. Opt-out programs will be on the rise as “High-deductible health plans” carve out the “pool of the poor” and skewer them in the raging health benefits fire.

In the October 18 NYTimes on-line, “Geriatrics lags in Age of High-Tech Medicine”, by Jane Gross: New York Times link it seems only 9 of 145 medical schools have a geriatric department. In the USA there is only 1 geriatrician per 5000 Americans 65 and over, only 1in 45 internal medicine residents choose it, despite a 2002 Archives of Internal Medicine survey reporting it to “have the highest job satisfaction rating of any specialty”. It is considered to be at the bottom of compensation, $150,000, but tin Britain it is the 3rd most popular. “It is about managing not curing, a collection of overlapping chronic conditions…”. In Britain, Ms Gross reports, the physician compensation goes up as patient age level goes up: more is paid for treating the elder elderly. NYU, she reports is “building a cadre of geriatric nurse practitioners”. Those Boomers ought to get pro active now.Well if they don’t, somebody should, even if it has to be a case by case basis. When people are home bound “managing their overlapping chronicities”, it may be the PT who has to intervene as advocate for the betterment of healthcare delivery. How about the ethics? The co-pay is now to some extent the friend of competent health rendering practitioners. It will really be the friend when the co-pay “is the payment”. Some will be “fighting city hall” while the firehouse burns down. Hopefully Therapists will have the mettle, foresight, insight, and oversight to look out for the elderly and be a good model for the crisis rather than a disgruntled unethical one. It isn’t necessary to disinter Florence Nightingale or Mary McMillan (www.apta.org) for that matter, as the need for healthcare services persists and healthcare insurance coverage desists. . I sure hope we’ve done our job when the baton has passed on to the one caring for me.