Reasons to Seek Cash Based Physical Therapy

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We pay a lot for our insurance. We want something back in return. However, using your insurance to cover your physical therapy services may not always be in your best interest. Here are some reasons to seek care out of your physical therapy network: 

  1. Access to clinical care. If you live in a larger city, chances are you will need to wait to access PT. In a largely HMO dominated area, that wait could be as long as six to eight weeks. If pain has you sleepless or unable to do the things you love to do or even just daily activities, this is time to search for an alternative. Once you access care through your insurance, there will be restrictions on visits. Oh and don’t forget, any billing through your insurance means, they have access to your notes. This could be a problem should you ever later have a similar injury related to an auto or workman’s compensation claim. Insurance may try to deny you treatment based on a prior existing condition.
  2. Past experience and/or continuing education. Many patients don’t take into account prior experience or training when they go to their insurance based PT. So when you have the choice of seeing the PT who does the minimum continuing education yearly versus the PT who attends multiple courses yearly, who would you pick? Most hospital systems barely cover the cost of one course for continuing education annually. Typically private practices offer many more training opportunities and PTs in the private sector seek out the most up to date care and information. It is also easier for private practice PT to have specialty services at their clinics as they do not need to go through multiple levels of approval to do so, unlike larger hospitals or clinics. Additionally, certifications quantify experts in various areas. So if the price of PT is comparable or slightly more, why not chose that expert? They will most likely get you on the road to recovery sooner! This will save you in the long run on time off of work attending visits, traveling to visits and monetarily.
  3. Total cost of Care. If a cash based PT at $50/session gets you better in 4 visits ($200/total) and an insurance co-pay PT at $30/session gets you better in 8 visits ($240/total), the cash based PT is actually less expensive in the long run, in both time and money. Oh and that $30 co-pay, your insurance is really being billed hundreds/hourly, what does that do to your future insurance rates? Or even better, what if your insurance denies payment, who gets stuck with that bill? You do. If I walk into a grocery store to buy a gallon of milk, I have to pay the price listed for it. If its $3, I can’t tell the store, today I feel like paying $1 and stick someone else with the $2 difference. Insurance, however, typically undercuts the amount billed leaving you responsible for the remainder of the bill. If I try to use my insurance to pay for my healthcare, there is no guarantee they will pay for it. I get stuck with whatever difference the company does not pay which is most likely going to be more expensive in the long run.
  4. Shop local. Going to a private cash based facility offers you the opportunity to support the local economy. Chances are with a cash based clinic, they are not outsourcing jobs. They are also more likely to support other local businesses.
  5. No rules. OK that may not be entirely true. We still have laws and regulations to abide by as PTs. But, when you use your insurance, you may only be approved a couple of visits. What if you are going to need more visits or a longer window of treatment and your insurance won’t cover it? Paying cash for your physical therapy services puts you at the helm of determining what kind of care you need, not your insurance company.
  6. Sports. It amazes me how many clinics claim to have services geared towards running, golf, throwing, swimming, biking, etc. However those PTs running those clinics don’t always participate in those sports. When you choose a clinic doing running, biking, skiing or other sporting assessments make sure your PT really understands all aspect of the sport. Why do most clinics do video analyses on treadmills? Do most runners train or race on treadmills? It makes no sense! Who cares if you get 200 frames/second in your camera that films treadmill running. This tells you nothing if it is not in your true running environment. Or let’s say, I’m going do hire someone to do a skiing assessment, I want them to understand not only the mechanics, but the evolution of equipment, be able to demonstrate techniques or drills to improve my abilities and even have other people within the local community they can recommend such as boot fitters, coaches, strength trainers, etc. to compliment their services. Unless they participate in that sport, they most likely won’t have those complimentary recommendations to their services.

So my advice to consumers and physical therapists alike is to assess your benefits of care under different clinics. We comparison shop most things in life, why not shop your wellness care too! You might just surprise yourself in what you learn.


Top 5 Fridays! 5 Myths About Spinal Flexion

I am tired of hearing lumbar flexion will “blow out a disc.” Yes it happens, but for some reason it’s an epidemic like tight hamstrings. The body in amazingly resilient and designed to move. Just a few short days of immobilization and the representation of that body part in the brain is now blurred, and prone to motor control dysfunction. We encourage people with knee pain to move all the time and certainly don’t say, “Hey, quit bending your knee and stiffen your quads, otherwise you’ll blow out a meniscus!” Here are 5 Myths About Spinal Flexion.

It’s bad for you
  • sure there is research showing x amount of thousands of reps causes annular tears, etc etc
  • that’s obvious, you know what else fails after thousands of stressful continuous reps of bending? EVERYTHING!
  • variability is the name of the game, keep moving but vary it, in life, and in training and things tend not to break down
  • if we do not tell patients or our fitness clients to stop bending their hips and knees, we shouldn’t really promote a rigid core for every single activity, the spine is designed and built to bend (and rotate for that matter)

Disc issues cause pain
  • expanding on the failure of disc annular walls, sure it happens
  • in fact, depending on the study, it may be in 50-80% of pain free individuals in their cervical or lumbar spines
  • these protrusions, if symptomatic can be reduced in the lumbar spine under certain conditions with repeated loading strategies
  • if there are symptomatic fragments or herniations, not to worry, often they spontaneously absorb within several months, that’s certainly a better option than irreversible surgery that fails more than 50 of the time

Flexion provides movement variability
  • certain schools of thought often quote “flexion provides movement variability”
  • it does not if you’re doing it thousands of times a day (average person flexes a few thousand times/day)
  • neither does extension, or ANY OTHER SINGLE MOVEMENT
  • the only thing that provides movement variability is movement variability – weird, huh?

Hard abdominal bracing is the safest way to move
  • there are certainly better, safer, and more efficient strategies to lift heavy things, swing kettlebells, etc
  • however, when certain experts educate that a high threshold bracing strategy is the best way to do simple tasks like open doors, that defeats the purpose and may cause increased kinesiophobia
  • the best way to keep a joint/area of the body healthy is with varied movement

Everyone should be able to touch their toes prior to performance
  • a lot of these hard rules go back to common sense
  • sure, toe touches are a great screen for a flexion pattern mobility
  • however, as long as you’re relatively close, and there is no significant perception of tightness or pain in any area of the body under stress in a flexion pattern, that should suffice for most movements
  • some people due to bony abnormalities – see this post by The Movement Fix will not have the ability to have full hip ROM
  • same goes for other areas of the body, but it seems more common in the hips

Use the same principles for the spine as you do for extremities. Promote movement, educate to decrease kinesiophobia. Use gentle terms and Stop Thought Viruses.

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic…

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Ethical issues in physical therapy.

online ethics course for physiotherapists and physical therapists

Healthcare professionals can be confronted with a wide range of ethical and regulatory issues in today’s ever-changing practice environments. While achieving best practice standards, physical therapists may need to compromise what is best for patients due to fiscally driven rules, regulations, and limited benefits. Scenarios may surface where ethical issues and associated dilemmas become paramount between what is versus what should be. A challenge that should be in the forefront of professional endeavors is staying current with published rules, regulations, and conditions of participation, as applied to various practice models and environments while still adhering to ethical codes.

Knowing and utilizing available resources especially American Physical Therapy Association (APTA), websites, documents, and references can strengthen practice patterns and treatment options are integral to managing ethical issues within physical therapy practice.

Professionalism dilemmas, moral distress and the healthcare student: insights from two online UK-wide questionnaire studies.


The aim of this study was to understand the prevalence of healthcare students’ witnessing or participating in something that they think unethical (professionalism dilemmas) during workplace learning and examine whether differences exist in moral distress intensity resulting from these experiences according to gender and the frequency of occurrence. Two cross-sectional online questionnaires of UK medical (study 1) and nursing, dentistry, physiotherapy and pharmacy students (study 2) concerning professionalism dilemmas and subsequent distress for (1) Patient dignity and safety breaches; (2) Valid consent for students’ learning on patients; and (3) Negative workplace behaviours (eg, student abuse). The most commonly encountered professionalism dilemmas were: student abuse and patient dignity and safety dilemmas. Multinomial and logistic regression identified significant effects for gender and frequency of occurrence. In both studies, men were more likely to classify themselves as experiencing no distress; women were more likely to classify themselves as distressed. Two distinct patterns concerning frequency were apparent: (1) Habituation (study 1): less distress with increased exposure to dilemmas ‘justified’ for learning; (2) Disturbance (studies 1 and 2): more distress with increased exposure to dilemmas that could not be justified.

Tomorrow’s healthcare practitioners learn within a workplace in which they frequently encounter dilemmas resulting in distress. Gender differences could be respondents acting according to gendered expectations (eg, males downplaying distress because they are expected to appear tough). Habituation to dilemmas suggests students might balance patient autonomy and right to dignity with their own needs to learn for future patient benefit. Disturbance contests the ‘accepted’ notion that students become less empathic over time. Future research might examine the strategies that students use to manage their distress, to understand how this impacts of issues such as burnout and/or leaving the profession.

The Tight Hamstring Debate

How many people think they have tight hamstrings? Ca’mon, raise your hands, I know you think your hammies are stiff. I hear this from my patients all the time. When I ask them to do multisegmental flexion (touch their toes) many will automatically say ” I haven’t been able to do that in years” or “my hammies are way too tight to do that!” I’m here to say that yes, some people can have a physiological contraction of sarcomeres causing a shortened resting position of the hamstrings, which is what we classify as a truly “tight” muscle. However, it is my contention through clinical observation that most of the time this is not the case. I know this because I am often able to change their ability to touch their toes in a single session…something I would never be able to do if they truly had physiologic hamstring shortening.
A few weeks ago I had the pleasure of meeting up with my friend Erson Religioso while he was teaching in Toronto. On the course we used PNF type movements of the anterior chain to help increase length of the posterior chain. Some might call this reciprocal inhibition, other might say it’s simply a novel input to help reduce perceived threat thus allowing the nervous to relax it’s hold on the hamstrings. I am more inclined to believe that latter.. my explanation for why the following manual technique and subsequent exercise works is by reducing threat. I believe that hamstrings are generally felt to be tight to protect the lumbar spine, as many people with “tight” hamstrings also suffer from low back pain. The nervous system deems maximal lumbar flexion to be threatening to the spine so it creates neurologically mediated tone of the hamstrings to prevent full lumbar flexion…all in an effort to “protect” it. This might be good for those with an acute symptomatic disc bulge, but for many it’s overkill.
Here is a video demonstrating a pretty neat little technique you can readily do in the clinic to help ease tension in the hamstrings without having to stretch them (which might actually make the problem worse!).
If this technique works to help increase toe touch, the following home exercise is a fantastic way to help the patient maintain their newly found hamstring length…ahh the freedom!
Hope these tips help you in your clinical practice. Enjoy!
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic…

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Multimodal manual therapy vs. pharmacological care for management of tension type headache: A meta-analysis of randomized trials.

cervicogenic headache

Manual therapies are generally requested by patients with tension type headache. The aim of this study was to compare the efficacy of multimodal manual therapy vs. pharmacological care for the management of tension type headache pain by conducting a meta-analysis of randomized controlled trials. PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, PEDro and SCOPUS were searched from their inception until June 2014. All randomized controlled trials comparing any manual therapy vs. medication care for treating tension type headache adults were included. Data were extracted and methodological quality assessed independently by two reviewers. We pooled headache frequency as the main outcome and also intensity and duration. The weighted mean difference between manual therapy and pharmacological care was used to determine effect sizes. Five randomized controlled trials met our inclusion criteria and were included in the meta-analysis. Pooled analyses found that manual therapies were more effective than pharmacological care in reducing frequency (weighted mean difference -0.8036, 95% confidence interval -1.66 to -0.44; three trials), intensity (weighted mean difference -0.5974, 95% confidence interval -0.8875 to -0.3073; five trials) and duration (weighted mean difference -0.5558, 95% confidence interval -0.9124 to -0.1992; three trials) of the headache immediately after treatment. No differences were found at longer follow-up for headache intensity (weighted mean difference -0.3498, 95% confidence interval -1.106 to 0.407; three trials).

Manual therapies were associated with moderate effectiveness at short term, but similar effectiveness at longer follow-up for reducing headache frequency, intensity and duration in tension type headache than pharmacological medical drug care. However, due to the heterogeneity of the interventions, these results should be considered with caution at this stage.

Prepare for your ski trip with Emily Sarsfield

Centred Balance

Britain’s top ski cross skier shows us how she uses the SkiA Ski Trainer to prepare for her winter season

Emily Sarsfield is Britain’s top ski cross skier – racing on the World Cup and European Cup circuits in a discipline that requires skill, strength and exceptional balance. Ski Cross is a downhill race with 4 skiers competing against each other on the same course, with twists and turns, large jumps and the danger of colliding with your competitors, the event exploded on the world scene during the 2010 Winter Olympics in Vancouver, Canada.

For a professional snowsports athlete, they must be fully prepared and utilise many tools to help them and the SkiA Ski Trainer specifically works on centred balance, a crucial element in skiing at any level and absolutely essential to perfect at the very top of the sport.

Emily uses the SkiA Ski Trainer to help her prepare for the season and also during the winter to help stay in shape – for anyone considering a ski holiday, whatever level from beginner to advanced, using the trainer will help to improve technique in many ways.

The SkiA Ski Trainer is also used by coaches and instructors to help with an overall program of fitness in preparation for skiing. It will also be very useful in the clinic to get your injured skiers back on track!

Find out more about SkiA