opinions and comments PT, An Endangered Species? To the Editor:
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I read with disbelief and sorrow the comments of Harriet S. Rosen, RPT, in the Opinions and Com ments section of the January issue of PHYSICAL THERAPY. MS. Rosen is concerned that we are "trying to usurp the function of another profession and, in so doing, are downgrading our own." She also states that physical therapists often confuse "evaluation" with "diagnosis" and that we are an endangered species because of PT assistants. It appears to me that physical therapists are not trying to become physicians but are merely trying to make our position in the medical world more secure. Yes, we are indeed on the verge of extinction but not entirely because of PT assistants but more importantly because too many physicians are prac ticing physical therapy. Some believe they are ex perts in rehabilitation and look at us as technicians while others just ignore us and practice various physical therapy modalities and procedures in their office using unqualified personnel. The latter even have the nerve to biH patients for physical therapy services. I believe that most of us are not "frustrated physicians in the wrong field," as Ms. Rosen sug gests, but are simply professionals who seek recog nition for what we do best —helping people over come disability, deformity, and discomfort. In order to accomplish these goals, we have to determine the problems of our patients and postulate what their causes might be. Some might call it diagnosis, others evaluation, but does it really matter? As long as the patient gets better, who cares what name you give a particular set of findings. I think we have all seen patients where the physician was not able to make a definite diagnosis, but we achieved good results anyway. We too often lose sight that our profession is an art and not a pure analytical science where every thing is either black or white, appropriate or inap propriate. Much of our success is based on our willingness to get involved with our patients, to get on the floor if we have to, and our ability to continually reevaluate the patient's status. If we are bound to do only what the referring physician orders, we may be doing our patients a disservice
and may be guilty of malpractice. Yes, we need better communication between physician and ther apist, but we also need to be recognized as indepen dent experts in rehabilitation. I do not want to be promoted to a first line practitioner (because I believe too many in our profession are not ready for it), but I would like to see our knowledge more independently utilized. This can be done by discour aging cookbook prescriptions and demanding only general referrals with the physician's estimation of the problem and some type of time frame to work in prior to a reevaluation by the physician. By produc ing good results and showing a willingness to get more involved as a profession, we might just prevent physical therapy from being an extinct entity. CHARLES A. KIBBEY, RPT Whiteflint Professional Bldg 11119 Rockville Pike Rockville, MD 20852
Comments on Knee Rehabilitation
To the Editor: As a therapist and athletic trainer who has over 100 patients each year with medical and/or lateral reconstructions, I would like to add several com ments to Mr. Ostrom's article (Phys Ther 57:13761379, 1977). We begin PRE the day the cast is removed, as most of these patients have been performing quad riceps settings and leg lifts since a few days after surgery. PRE is performed completely, throughout the painfree range of motion. By increasing strength early, additional range of motion is gained. The early use of isometrics is important in reedu cation. In the pes anserinus transfer, the patient is instructed to palpate the tendons as he flexes and internally rotates the tibia on the femur isometrically. This way he can feel the muscle actions. While performing hamstring PRE, he also internally ro tates the tibia to further train the pes transfer. These people need to be reminded to subconsciously "tighten" the knee before internally rotating that knee. Failure to do so results in the knee continuing to give way as it did before surgery. A number of patients are seen each year with a knee that gives way from lack of quadriceps PHYSICAL THERAPY
JOE GIECK, EdD, ATC, RPT Curriculum Director Head Athletic Trainer University of Virginia Charlottesville, VA 22903
Support for Geriatric/Long Term Care Section To the Editor: I write this hoping it might be an appropriate letter for "Opinions and Comments" of the Journal of the APTA: The members of the Washington State Physical Therapy Association (WSPTA) Geriatric Special Interest Group and I totally support and recom mend the formation of a Geriatric/Long Term Care Volume 58 / Number 4, April 1978
Section within the APTA. We feel there is a great need for a national section with a primary focus on geriatrics. Justification for Geriatric Emphasis: 1. As Senator Frank Moss points out in his book, Too Old, Too Sick, Too Bad, 1977, historically physicians have abdicated their responsibility for nursing home patients. During the 1969-76 sub committee hearings, it was pointed out that the whole system of health care in America seems to be ill designed for the aged. One physician, Dr. Lionel Cousin, added that the average patient is better off in England than in America because of the American medical community's lack of inter est in problems of the aged. Unfortunately, I have seen many physical therapists who are part of that uninterested group of health profession als. Many of us have been turning our backs toward the problems of the elderly. 2. A recent report of the Congressional Budget Office states that by 1985 the number of resi dents in nursing homes will reach 2.9 million; up from 1.5 million in 1976. The population age group of those 85 and older is expected to grow much faster than the growth of the rest of the US population. So you can see that our increased involvement with this age group will be more critical as time goes on. 3. There are several legislative proposals under consideration by Congress which would liberalize benefits so as to sharply increase the demand for sheltered living (such as nursing homes, institu tions for mentally retarded, retirement homes) and home based services (such as home health and day care centers). So we as physical thera pists will most likely have additional opportuni ties to get involved in treatment of the elderly. 4. Studies are beginning to show that many health professionals are suffering from the "YAVIS Syndrome." Many of us (but, fortunately not all) prefer treating patients who are Young, Attrac tive, Verbal, intelligent, Successful. One study cited in Butler's Why Survive: Being Old in America stated that psychiatrists were spending less than 2 percent of their time with the elderly, yet the percentage of the elderly in the commu nity requiring these services was dramatically higher. I wonder what this percentage would be for RPTs? 5. The Long Term Care Facility Improvement Study by the US Department of Health, Educa tion, and Welfare, July 1975, pointed out that 47 percent of patients in skilled nursing facilities needed physical therapy and that 70 percent of
483
Downloaded from https://academic.oup.com/ptj/article-abstract/58/4/482/4559375 by guest on 25 October 2019
strength. Most of the people that choose this oper ation want to remain active and, in many cases, athletically competitive. Before they are allowed to run, they need to lift about 45 pounds in full knee extension 10 times. A goal of roughly 70 pounds for the quadriceps and 45 pounds for the hamstrings is reasonable. It would be difficult to attain this strength with straight leg raising or using a rubber tubing for hamstring strengthening. Endurance is gained by walking, stepups, jogging, and running several miles daily, depending on the stage of the rehabilitation period. The Delorme method of PRE is used and is believed to be as good a program as when it was first described in 1945. Use of Cybex or Orthon equipment often results in little training effect on terminal extension as knee extension stops 5-15 degrees short. For this reason, PRE is necessary with the lifting device, indicating when the patient achieves terminal extension. Active range of motion is begun immediately after removal of the cast, usually in conjunction with hydrotherapy. As long as the patient makes ROM progress, active assistive or PNF techniques are not employed, especially in extension before 912 weeks postoperatively. Earlier motion stretches the pes transfer, reducing its effectiveness. Early extension stretching gains more motion than the quadriceps can effectively extend, thus an extensor lag becomes an additional problem. For complete rehabilitation to be effective, the patient has to return to his activities and perform. The patient psychologically will not have confidence in the knee until he can perform successfully. Many patients have to be encouraged to perform as they will be hesitant to test the knee. Unless they regain total use of the joint, rehabilitation is not complete.
482
Downloaded from https://academic.oup.com/ptj/article-abstract/58/4/482/4559375 by guest on 25 October 2019
I read with disbelief and sorrow the comments of Harriet S. Rosen, RPT, in the Opinions and Com ments section of the January issue of PHYSICAL THERAPY. MS. Rosen is concerned that we are "trying to usurp the function of another profession and, in so doing, are downgrading our own." She also states that physical therapists often confuse "evaluation" with "diagnosis" and that we are an endangered species because of PT assistants. It appears to me that physical therapists are not trying to become physicians but are merely trying to make our position in the medical world more secure. Yes, we are indeed on the verge of extinction but not entirely because of PT assistants but more importantly because too many physicians are prac ticing physical therapy. Some believe they are ex perts in rehabilitation and look at us as technicians while others just ignore us and practice various physical therapy modalities and procedures in their office using unqualified personnel. The latter even have the nerve to biH patients for physical therapy services. I believe that most of us are not "frustrated physicians in the wrong field," as Ms. Rosen sug gests, but are simply professionals who seek recog nition for what we do best —helping people over come disability, deformity, and discomfort. In order to accomplish these goals, we have to determine the problems of our patients and postulate what their causes might be. Some might call it diagnosis, others evaluation, but does it really matter? As long as the patient gets better, who cares what name you give a particular set of findings. I think we have all seen patients where the physician was not able to make a definite diagnosis, but we achieved good results anyway. We too often lose sight that our profession is an art and not a pure analytical science where every thing is either black or white, appropriate or inap propriate. Much of our success is based on our willingness to get involved with our patients, to get on the floor if we have to, and our ability to continually reevaluate the patient's status. If we are bound to do only what the referring physician orders, we may be doing our patients a disservice
and may be guilty of malpractice. Yes, we need better communication between physician and ther apist, but we also need to be recognized as indepen dent experts in rehabilitation. I do not want to be promoted to a first line practitioner (because I believe too many in our profession are not ready for it), but I would like to see our knowledge more independently utilized. This can be done by discour aging cookbook prescriptions and demanding only general referrals with the physician's estimation of the problem and some type of time frame to work in prior to a reevaluation by the physician. By produc ing good results and showing a willingness to get more involved as a profession, we might just prevent physical therapy from being an extinct entity. CHARLES A. KIBBEY, RPT Whiteflint Professional Bldg 11119 Rockville Pike Rockville, MD 20852
Comments on Knee Rehabilitation
To the Editor: As a therapist and athletic trainer who has over 100 patients each year with medical and/or lateral reconstructions, I would like to add several com ments to Mr. Ostrom's article (Phys Ther 57:13761379, 1977). We begin PRE the day the cast is removed, as most of these patients have been performing quad riceps settings and leg lifts since a few days after surgery. PRE is performed completely, throughout the painfree range of motion. By increasing strength early, additional range of motion is gained. The early use of isometrics is important in reedu cation. In the pes anserinus transfer, the patient is instructed to palpate the tendons as he flexes and internally rotates the tibia on the femur isometrically. This way he can feel the muscle actions. While performing hamstring PRE, he also internally ro tates the tibia to further train the pes transfer. These people need to be reminded to subconsciously "tighten" the knee before internally rotating that knee. Failure to do so results in the knee continuing to give way as it did before surgery. A number of patients are seen each year with a knee that gives way from lack of quadriceps PHYSICAL THERAPY
JOE GIECK, EdD, ATC, RPT Curriculum Director Head Athletic Trainer University of Virginia Charlottesville, VA 22903
Support for Geriatric/Long Term Care Section To the Editor: I write this hoping it might be an appropriate letter for "Opinions and Comments" of the Journal of the APTA: The members of the Washington State Physical Therapy Association (WSPTA) Geriatric Special Interest Group and I totally support and recom mend the formation of a Geriatric/Long Term Care Volume 58 / Number 4, April 1978
Section within the APTA. We feel there is a great need for a national section with a primary focus on geriatrics. Justification for Geriatric Emphasis: 1. As Senator Frank Moss points out in his book, Too Old, Too Sick, Too Bad, 1977, historically physicians have abdicated their responsibility for nursing home patients. During the 1969-76 sub committee hearings, it was pointed out that the whole system of health care in America seems to be ill designed for the aged. One physician, Dr. Lionel Cousin, added that the average patient is better off in England than in America because of the American medical community's lack of inter est in problems of the aged. Unfortunately, I have seen many physical therapists who are part of that uninterested group of health profession als. Many of us have been turning our backs toward the problems of the elderly. 2. A recent report of the Congressional Budget Office states that by 1985 the number of resi dents in nursing homes will reach 2.9 million; up from 1.5 million in 1976. The population age group of those 85 and older is expected to grow much faster than the growth of the rest of the US population. So you can see that our increased involvement with this age group will be more critical as time goes on. 3. There are several legislative proposals under consideration by Congress which would liberalize benefits so as to sharply increase the demand for sheltered living (such as nursing homes, institu tions for mentally retarded, retirement homes) and home based services (such as home health and day care centers). So we as physical thera pists will most likely have additional opportuni ties to get involved in treatment of the elderly. 4. Studies are beginning to show that many health professionals are suffering from the "YAVIS Syndrome." Many of us (but, fortunately not all) prefer treating patients who are Young, Attrac tive, Verbal, intelligent, Successful. One study cited in Butler's Why Survive: Being Old in America stated that psychiatrists were spending less than 2 percent of their time with the elderly, yet the percentage of the elderly in the commu nity requiring these services was dramatically higher. I wonder what this percentage would be for RPTs? 5. The Long Term Care Facility Improvement Study by the US Department of Health, Educa tion, and Welfare, July 1975, pointed out that 47 percent of patients in skilled nursing facilities needed physical therapy and that 70 percent of
483
Downloaded from https://academic.oup.com/ptj/article-abstract/58/4/482/4559375 by guest on 25 October 2019
strength. Most of the people that choose this oper ation want to remain active and, in many cases, athletically competitive. Before they are allowed to run, they need to lift about 45 pounds in full knee extension 10 times. A goal of roughly 70 pounds for the quadriceps and 45 pounds for the hamstrings is reasonable. It would be difficult to attain this strength with straight leg raising or using a rubber tubing for hamstring strengthening. Endurance is gained by walking, stepups, jogging, and running several miles daily, depending on the stage of the rehabilitation period. The Delorme method of PRE is used and is believed to be as good a program as when it was first described in 1945. Use of Cybex or Orthon equipment often results in little training effect on terminal extension as knee extension stops 5-15 degrees short. For this reason, PRE is necessary with the lifting device, indicating when the patient achieves terminal extension. Active range of motion is begun immediately after removal of the cast, usually in conjunction with hydrotherapy. As long as the patient makes ROM progress, active assistive or PNF techniques are not employed, especially in extension before 912 weeks postoperatively. Earlier motion stretches the pes transfer, reducing its effectiveness. Early extension stretching gains more motion than the quadriceps can effectively extend, thus an extensor lag becomes an additional problem. For complete rehabilitation to be effective, the patient has to return to his activities and perform. The patient psychologically will not have confidence in the knee until he can perform successfully. Many patients have to be encouraged to perform as they will be hesitant to test the knee. Unless they regain total use of the joint, rehabilitation is not complete.
