CrossFit: a True Gift to Physical Therapy

If any of you have come across the newest fitness craze, CrossFit, you know that this is hyped as the next best thing in personal training.  I was introduced to this program at a party a few months ago where I was able to talk to an owner of 2 such facilities.  He let me know that these programs are run in his gyms at a cost of roughly $135/ month per client.  Their programs emphasize small group workouts with personal trainers that specialize in high intensity, compound movement exercises that get your heart rate up quickly and fatigue you in a 20-30 minute session.  Appropriate warm up is provided before the workout.  He emphasized that their trainers carefully watch form and provide close supervision at all times.  It all sounded like stuff I'd heard before and I didn't think much of it, until I saw the CrossFit World Championships last weekend on ESPN2.  After witnessing that, I became much more interested.  To bring you up to speed, here's what it all seems to be about:

• Crossfit World Championships show young, incredible athletes going through a series of activities that would put the average person in bed on Advil and ice for a week.  It is a newer, hipper version of the Worlds Strongest Man contests that you can usually catch at 2 am on ESPN.  Check out this link to get a feel for it. http://games.crossfit.com/    I had such a montage of emotions watching this event, I had to write this blog.  A combination of laughing, wincing, analyzing body mechanics, and watching in amazement at what the athletes could tolerate and overcome.  Certainly worth tuning in if you get the chance.  I was amazed I didn't witness a significant shoulder or knee injury during the finals due to the brutality of the event activities.  
• CrossFit Centers regularly include exercises in their training workouts that include squats, box jumps, lifting objects such as tires, various types of push-ups, inverted push-ups, lunges, medicine ball activities, and most accepted types of plyometric exercises for the upper and lower extremities to name a few.  
• The workouts are changed almost daily, to help confuse the muscles and get better strength results.  Similar to the P90X philosophy.  The list of exercise activities I made above is only a small slice of what you would see at one of these facilities.  
• An entire video library of examples can be seen at: http://www.crossfit.com/cf-info/excercise.html#Exer.   I added one here so you can get a feel for one of their milder exercises.

 This quote was taken directly from their website:

The CrossFit program is designed for universal scalability making it the perfect application for any committed individual regardless of experience. We’ve used our same routines for elderly individuals with heart disease and cage fighters one month out from televised bouts. We scale load and intensity; we don’t change programs.

Isn't that great, the same routines for our elderly and our cage fighters.  I don't care how you scale it down, certain exercises are not appropriate for the elderly.  The above example, the full squat, while great on a young healthy knee, puts incredible compressive force on the knee cap as well as the knee joint surfaces between the thigh and leg bones of the knee.  This video would be the perfect way to tear a meniscus or irritate a mildly arthritic knee.  The real question you should ask yourself before trying an exercise like this is, why do I need to do this exercise?  If you are a furniture mover and need to bend down fully many times a day, you might have a reason.  But if you are the average 9 to 5'er that sits at a desk all day, you really don't need to punish your knee joint like this to strengthen your hips and thigh muscles.  If you don't believe me, go see a physical therapist and they will show you how to save your knees while doing squats.  Maybe a good topic to discuss in a future blog.

After looking at a few of the exercises on the CrossFit website, I thought I'd pull out an example of an exercise that really has no place in an exercise regimen when exercising the elderly (or average weekend warriors for that matter).   An example would be the box jump, which is an activity where an individual either jumps down from a box, or up onto a box repeatedly.  The faster the transition from the jump down to the jump back up, the better.  This family of training techniques are referred to as plyometrics and were originated in The Soviet Union for olympic athletes in the 1970's to improve speed and power.    A video is worth a thousand words, to see the CrossFit version of these activities, see below:

Even from the most modest heights this exercise could be a nightmare for an osteoporotic grandmother wanting to "get in shape" given the increased risk of compression fracture in the spine, hip fracture, or joint damage on arthritic lower extremity joints.   If a physical therapist were to prescribe these exercises to a Medicare patient and they subsequently broke a bone, at best you'd never see another patient from the referral source, and at worst you'd be sued by the patient.  I would hope CrossFit trainers receive training that would make them aware of some of these contraindications, but I have no way to verify that, and I probably wouldn't bet on it.  

For those 40-50 year olds wanting to give these workouts a try, I would advise you to remember a few things.

• Most of the athletes you see doing these exercises are in the prime of their lives (20 to mid-30 somethings).  Their joints and discs are in very different places than someone 20 years older.  What is a challenging workout for them, could be pathological to an older, less fit individual.
• Plyometrics were designed originally for olympic athletes.  These are individuals that are professional athletes.  A tenth of a second in a sprint event, or an extra inch or two of vertical jump can be the difference between being on a medal podium or watching from the bleachers.  For them, these exercises are required to excel in their respective sports.  Therefore, the risks of plyometric exercises are an acceptable part of their training regimens.
• Risk you ask?  These exercises have a much higher risk/ reward ratio than doing traditional exercises on weight machines or with controlled free weights or bands.  Simply put, plyometrics do have the potential to provide great power and strength increases for an individual.   But they are also some of the most risky activities to include in a work out program due to their explosive nature.  They put extremely high loads on tendons and muscles, which greatly increases the chance of muscle/ tendon strains or worse, rupture.  And that's only the contractile tissues!   They also place incredible loads on passive structures like ligaments, bones, fascia, cartilage, and discs to name a few.  These activities can easily land you in an orthopedist's office, even with the best of form.  
• Pro and college teams usually only include these activities in the off season workouts due to the increased time muscles need to recuperate from these workouts.  Performing plyometrics during the regular season would overload muscles and tendons and put athletes at increased risk for injury.  That should hopefully get your attention as to how serious these exercises are, especially if you are reading this in the capacity of a weekend warrior.  
• If you are not a relatively fit individual, be very cautious entering into one of these programs.  Make sure you have excellent instruction, know the risks involved, ask yourself if you need to take these risks, and know your medical history.  If you have any kind of joint, disc, or bone density pathology, check with your physician or physical therapist before you proceed.  
• Exercise is needed in most individuals lives to be happy and healthy individuals.  Fortunately, to gain the health benefits from resistive exercises, you are not required to perform exotic exercises that involve jumping off boxes or lifting up tires.  Moderate resistance exercises performed 3 x week is adequate to gain strength in a 4-6 week period.  Moderate intensity resistive exercise has also been shown to improve bone density in many studies.  Use common sense when choosing your workout plan.  

A wise physician once told one of my patients "All things physical, are not therapy."  Keep that in mind as you weigh your exercise choices.  Be smart and remember, exercise is supposed to help you stay healthy, not hurt you!

How Can PT's Get on The Same Page Clinically?

I can remember being in PT school during the late 90's and talking about an article written in the mid 90's by an under cover reporter who went to 10 PT clinics and got 10 different diagnosis for their back pain.  It was not a flattering article for the PT profession!  My classmates and myself sat around and said "wow, glad we are going to be part of changing all that inconsistency."  We figured with our classes in differential diagnosis and up to date orthopedics, this would certainly change.  Not to mention, we were going to have the brand new "Guide to Physical Therapy Practice" to lean on, we were all set.

• Well, I've had two encounters in the past week that makes me think we still have a very long way to go.  The first case was a lady that came to my clinic from a familiar referral source requesting this patient see a McKenzie Trained therapist.  Although I am not McKenzie certified (and I explained this to both the MD office and the patient before seeing her) I am very familiar with the concepts and know how to treat a patient with discogenic pain with radicular symptoms.  I find out after evaluating the patient she spent 4 weeks at another PT clinic that didn't give her one extension exercise or trial traction with her during that time.  Her presentation was textbook disc, unilateral pain down lateral calf and foot.  Increased pain with flexion, relief with extension.  Numbness and tingling, worse with sitting, better in standing.  And so on, and so on.  I mean, you could have used her for a licensure board question.  So how is it that there are clinics out there that have no idea about standards of care for a disc injury?  This was not some tricky, fringe diagnosis, or even something that required a series of special tests.  This was a disc injury, arguably the most diagnosed back problem in the United States.  You can easily argue that the clinic should be categorized as incompetent.  When I encounter these stories I don't jump up and down thanking the PT gods that I gained a new patient, I get frustrated that I have to associate myself with this level of therapist that holds the same license I do.    
• The second case I happened across was on the sidelines of my daughter's soccer game.  One of my fellow parents had an ankle splint on.  I asked him what he did, and he mentioned he fractured his distal fibula 4 months ago at work and was dealing with a non-union injury.  He was trying to avoid surgery, and had been receiving PT over the past 2 MONTHS!  He also mentioned this was a work comp injury.  My question is this: what the heck are you doing with a fractured ankle for 2 months in a PT clinic?  His range seemed fine, so last time I checked it needed rest, protection from a boot and possibly a bone stimulator.  The boot was removed after 4 weeks, no bone stimulator, and the PT clinic kept treating him with band exercises, stretches, and ice and electrical stimulation.  As a reminder, I work for one of the "substandard quality of care POPTS" and this person was being seen by a PT working at a PT owned and operated clinic.  That obviously has everything to do with quality of care.... but I digress.
• Anyway, I told the guy that non-union fractures don't need exercise they need protection, a bone stimulator trial, and making sure his calcium/ vitamin D intake was at recommended levels (which it wasn't since he didn't like to drink milk).  He agreed, and was wondering why the clinic kept doing the same things over the past 2 months despite his ankle not getting better.  I told him it really wasn't a PT issue until that bone starts healing.  Did the clinic need the business that badly to max out this guy's work comp benefit?  Or is it simply another case of negligence?  The nice second part of the story will be that when it comes time to gait train this guy and work on his significant leg atrophy, he will have used up his 24 visits the state provides and be left out of the clinic during the time he needs this benefit.  
• In both cases, I walked away feeling queezy about our profession.  I think it is time we start looking for ways to guarantee that our PT work force is up to date and weed out the dead wood.  Yes, that might mean we have to take board exams on regular intervals similar to what MD's do.  We are trying to talk about ourselves as doctors right?  Well, maybe it is time we do a little more from within our profession to improve the care we are providing as a whole which would only strengthen our argument for direct access.  When I hear these stories, I wonder if my brethren are really qualified for direct access responsibilities?  Think about the PT's in your clinic, would you trust them to treat your mother as a primary care provider?  How about PT's you encountered during your clinical education or from your PT program?  The number I would trust are counted on one hand, maybe two.

Anyone else out there seeing these types of problems?  If so, I would like to hear the ideas and possible solutions to this significant problem you have come across.  It's a discussion that obviously warrants more attention from the PT profession.  

And The CA POPTS Winner By TKO is.........

The California Medical Association (CMA) is on the brink of dealing the California PT private practice effort to stop POPTS (physician owned physical therapy service) a deathblow.  CMA's funding and support of senate president Darrell Steinberg has landed them a piece of legislature (SB 543) on the desk of Governor Jerry Brown's desk that will prevent the PT Board of California from being able to take action against the PT's that are working in Medical, Chiropractic, and Podiatric Corporations.  It easily passed through the senate with a vote of 32-5 earlier today.
If signed into law, it will make the Board's interpretation of the Moscone Knox Act irrelevant.  Even though the Board feels physical therapists are working illegally for these corporations, they may very well find themselves powerless to do anything about it.
For all the fanfare the Private Practice Special Interest Group of California raised for their stalling of AB 783 (which would have flatly made these medical corporations legal by all accounts in California), they ultimately lost the fight by knockout to SB 543.  The submission of a bill that voids the Board's authority on this entire issue was brutally clever, and obviously caught the PT lobbying group with their guard down.  If passed, the anti-POPTS issue becomes about as dead as disco over night.
I have mixed emotions about this matter.  For one, I have gained a healthy respect for the power of the CMA in this state and their ability not to simply support and pass a bill, but to fund and pass an entire idea.  They wanted POPTS to stay, and worked on multiple pieces of legislation and multiple congressman/ women to make it happen.
With regard to the PT effort, maybe it is time the PT world starts admitting that going head to head with the AMA is not a great solution to many of these issues.  I'm seeing a prize fight that offers up a Heavy Weight vs. a Middle Weight.  Do PT's think they can out maneuver the CMA/ AMA?  Out spend them?  Do they think PT's have more influence in the healthcare debate then doctors do?  We might be able to slip in a jab here and there, but the probability of a knockout punch on any of the major issues of direct access, POPTS, fair representation in the ACO discussion, and equal reimbursement amongst providers is slim at best.  
If the PT leadership cannot change its tact slightly to work towards thoughtful and meaningful compromise, as other states have on some of these issues, I fear PT's are doomed to see very little change in the coming years in the state of California, and maybe even see things get worse.   By drawing lines in the sand and taking an all or nothing stance on issues such as direct access and POPTS we ultimately leave ourselves open to stark defeat.  This same flavor of politics is being played out in our nation's capital as we speak, and look how effective that has been over the past couple years!?
Hopefully this significant defeat will serve as a beacon that it is time to re-think the physical therapy position and really focus on the most important issue on the table, REIMBURSEMENT.  By doing so, PT's can make sure they don't repeat their POPTS battle mistakes when entering the political ring for that title fight.  

SI Pain Subjective Feedback Key

Are any of you clinicians who might be wondering what historical feedback can help cue you into a patient with SI pain?  The good news is you only have to ask one question (that has any real relevance statistically).  


Michaelsen, Pauza, McLarty, and Bogduk showed that most historical data are not useful for diagnosing SI joint dysfunction with the exception of patients stating “relief with standing” which had a likelihood ratio of 3.9. This means that people who report reduced pain at the lower back with standing are 3.9 times more likely to have a SI joint dysfunction.  The Confidence Interval (CI) was not reported.  


So if you are thinking of altering your back evaluation forms to help screen for SI dysfunction, make sure this question is included.  

The Answer: Why PT Board CA Backs-Off

Based on this August 30, 2011 report from NBC LA, I think I understand why the PT Board of CA changed its tune so quickly.

The California Medical Association and its legislative allies in Sacramento have triggered a state audit of a regulatory agency that, they say, is too cozy with independent practitioners in the lucrative physical therapy trade.

On April 23, the Assembly's Joint Legislative Audit Committee voted 12-2 in favor of a five-month examination of the Physical Therapy Board of California, the watchdog agency responsible for overseeing "PT" clinics and practitioners across the state.

To see the entire article, click on link below.

http://www.nbclosangeles.com/news/politics/Physical-Therapy-Group-Audited-by-State-128717163.html

You can only guess if this audit had anything to do with slowing down the Board on enforcing action against POPTS clinics, but my guess is this is what put the brakes on things.  Of course, the whining about this matter couldn't be louder from the PT world as noted by most of the comments on this story.  For a detailed build up to this point, please read my previous blog dated 8/31/11 on this topic.

Insight on PT Board Backing-Off POPTS Enforcement with Commentary on the Private Practice Special Interest Group of CA

As of August 25, 2011 the Board has backed off enforcing their July 2011 interpretation of the Moscone-Knox Act.  As with most good stories, there is more than meets the eye with this one.  A timeline will help clarify the Board's recent position change.

Business arrangements between MD's and PT's that were deemed completely legal by the California Physical Therapy Association in 1990, magically became taboo in 2010 when the California Private Practice Special Interest Group stumbled upon a piece of legislature from 1968 that provided a loop hole to move the anti-POPTS movement forward.  They quickly lobbied to change the code of the California Practice Act and made way for its recent interpretation of the Moscone-Knox Professional Corporation Act which is what AB 783 was intended to amend, making it legal for medical corporations to employ PT's.  AB 783 was subsequently hung up in a state senate subcommittee in June 2011, that effectively killed the bill through 2012.   A victory for the CAPTA.

May 2011, the following letter was sent to the Audit Committee at the California State Capital regarding the actions of the CA PT Board from Mary Hayashi, congresswoman and author of AB 783.  Apparently there might be a few problems with how the Board and the Private Practice Section have been interfacing, how the Board has been adjudicating this process, and if public funds have been used appropriately by the PT Board members.     

July 20, 2011 despite this letter, the Board pushed the button (by the urging of the Private Practice Section) and sent out 155 letters to therapists that had been reported to them by "the public", otherwise known as, competing out-patient therapists.  

August 3, 2011 at their quarterly board meeting, the Physical Therapy Licensing Board (PTBC) had a change of heart.  They heard testimony from the Department of Consumer Affairs, the California Orthopaedic Association, the California Physical Therapy Association, and the California Private Practice Group.  The two former groups pressed the Board to hold off on enforcement of Moscone-Knox Act.  Paul Gaspar and Jim Dagostino, both PT's speaking on behalf of the Private Practice section urged immediate action continue to proceed against POPTS clinics.

August 25, 2011 the Board sent out letters to those POPTS therapists who had submitted compliance plans informing them that they were suspending enforcement of all pending cases until additional legislative time passes to clarify the existing law.  A total reversal of their July position and a clear defeat for the private practice group.  

Why did the Board change course?  Take a look at this timeline and draw your own conclusions.  But I think their actions make it clear that the PT Board realizes there are more than a few holes in their case and want to hold off on getting hammered in court as things stand currently.  Especially if you consider that the Board's big push to enforce the Moscone Knox Act was based on two factors.  One, they had to change the PT practice act that had been in effect for over 20 years to accommodate enforcement procedures by the Board.  Second, the entire basis of their legal argument was based on one or two legal opinions, which don't necessarily have any jurisdiction on the Board or its members.  Specifically:

• Lawyers on the CMA (California Medical Association) have pointed out that this move was based on the opinion paper by Legislative Counsel which isn't binding to the board or its licensees.  
• Unenforceable underground regulation is the term that was used by CMA lawyers to define the CA Boards move to change the practice act in order to enforce their "new" interpretation of Moscone Knox.  This term does not seem to be one that would hold up in court if proved to be true.
• For the entire CMA argument, see my previous blog: CMA Responds to CPTA POPTS Mandates.  Although this letter was dated December 2010, it clearly was a shot across the Board's bow letting them know enforcement of Moscone-Knox, based on an opinion paper, was definitely going to be challenged in court.

• And to put a cherry on top of this story, an email was sent out to orthopedic section members on August 29, 2011 from the CA Private Practice Group Board of Directors stating that due to the actions of Mary Hayashi, the key proponent of AB 783, and her recent inquiry into the PT Boards actions, they want to try to organize a recall of the congresswoman!  Are you kidding me?  
• Shouldn't the private practice section be focusing on clearing themselves of the accusations made in the May 2011 inquiry and focus on the strength of their legal argument (as well as start raising funds for the impending legal battle) instead of going off on yet another emotional rant regarding this issue?   This type of back biting, reactionary politics is unsightly and ineffective at best.  It begs the question: Can the CAPTA afford to waste time, money, and effort on a cause like recalling a political opponent when its Board has misfired this badly over the span of one month?  
• One final point that I hope does not get lost in the minutia of this story.  For all those involved in the POPTS debate both in California and nationally, it should not be overlooked that AB 783 and the surrounding legal debate is serious legislation that has the potential to effect the lives of thousands of therapists not only in California, but the entire United States when you consider how it will be used for precedent in other states.  It should be treated as such by our elected PT representatives.  
• A question for my colleagues.  Why would the private practice section feel the need to go down the recall road (a day after they realized the Board was backing off enforcing their anti-POPTS position) when they successfully defeated this congresswoman and her bill just a few months ago?   Recall her!?  Going in this direction would appear to only muddy the water, making it more difficult to appreciate the good work they just recently accomplished.   
• The Private Practice Section of CA might need to be reminded that they are representing a group of educated professionals in this debate.  Their arguments and actions should be based on fact and merit, and regardless of what tactics are being used on the other side of the isle, conduct themselves with dignity at all times.  If they are deemed to be on the right side of this legal matter, their voice will eventually be heard.   With this in mind, my sincere hope is that they start conducting themselves accordingly.  

CA PT Board Backs Off POPTS Enforcement on California PT's

If you are one those people that thought September 1, 2011 was going to be the end of POPTS (Physician Owned Physical Therapy Service) clinics in California, you probably lost sleep on the eve of the Rapture too.  Allow me to be the one to break it to you, September 1 has as much to do with the end of POPTS as the Rapture did with the end of the world.  
For those of you that have been following this blog, you know that I direct a POPTS clinic and submitted my compliance plan to the board several weeks ago (see blog dated 7/27/11).   Today, I received their response letter and what did it say.....

On August 3, 2011 the Board adopted a motion to suspend enforcement of all pending cases relating to alleged violations of the Moscone Knox Professional Corporations Act.  The Board took this action in order to afford the Legislature time to clarify the existing law.  Accordingly, the Board will take no further action until the Legislature has had an opportunity to take appropriate legislative action to address the issue.

They go on to later state they will continue to monitor the issue, place it on future meeting agendas, but will not be seeking additional compliance plans at this time and no further action is required by individuals working in a POPTS structure.   In other words, it's business as usual..... indefinitely.  Imagine that!?  The home run that the CA Private Practice Section has been so busy patting themselves on the back for over the past 2 months, is really just a long fly ball to right field.