Second opinion

I would hope 💯%!

This brings me to my rant for now. 👇

Why don’t patients get a second opinion regarding physical therapy?

1. It’s not a huge expense

This leads us to 👇

2. All therapists do the same thing

Sometimes the grass IS greener.

3. Convenience

Follow this example:

Want a second opinion, send me a message.

Back pain using MDT

“Low back pain is the worldwide leading cause of years lived with disability, with an estimated point prevalence of 9.4% and a lifetime prevalence of up to 39%”

If three people are sitting together, the odds are that one of those three had back pain, has back pain or will have back pain. That kind of sucks, unless your the one of the people without pain.

Point prevalence means that any one point in time about 10% of the population will have back pain. There are about 320 million-ish adults in the US. This means that about 30 million adults have back pain at any one point in time.

It’s a great time to be a PT, if we can educate the public that we are well trained and capable of treating back pain.

For patients reading this, not all PTs are equal and just like with a surgical procedure, you’d probably get a couple of opinions before making a decision on YOUR Guy or Gal (after you gain trust in the person all of a sudden they become YOURS). I get it! Some people call me their guy, but I’d like for more people to call me their guy.

***tangent: patients are paying more for healthcare. This could be in the form of a higher deductible, copay, coinsurance or straight cash based. As a patient, you should be looking around for the person that gives you the best value for your dollar. If you ever have questions regarding your treatment, feel free to message me and ask me questions in a free conversation. I have a long commute daily and love having these conversations, which have become a weekly occurrence. You can find me Here

“The presence of centralization is associated with good prognosis in patients with low back pain…recent studies have shown that directional preference and centralization, when I matched with adequate MDT treatment, result in better patient outcomes and then treatment with general range of motion exercises￼”

Centralization?🤔 I wonder what that is?

If you’re new to this page, you can go back and read my old posts on centralization here

Just know that centralization has been called the trump card to helping patients with back pain…it’s that powerful that it darn near always wins for the patient.

“The level of MDT training should also be considered, as it may impact interventions and risk-adjusted functional outcomes.”

Studies have been Published questioning the reliability of using MDT. I believe that these studies need to be looked at in depth because this particular study shows that those not certified in the method may not be the most reliable in noting a particular “syndrome” in the patient’s presentation. The level of training appears to play a role in the therapist’s ability to assess a Patient.

“only trails in which of therapists were MDT trained were included. To be considered MDT trained, therapist were required to have participated in at least one course offered by the McKenzie institute international focused on applying MDT to patients with LBP”

Based on the above research links, just using therapists that have taken courses in MDT decreases the likelihood that a reliable classification took place, therefore reducing the likelihood that the patient was treated according to the proper principle and finally leads me to believe that I was wasting my time in reading the remainder of the article….I digress. I read it anyways to hear what’s being talked about regarding MDT, both good and bad.

“review were’s screen 354 abstracts and selected 51 articles for fall text review. After review, 17 articles were retained for the meta-analysis; however, of these 17 studies, four did not provide sufficient data to be included in the statistical analyses”

This is part of the problem that I have with systematic reviews and meta analyses. So much of the research gets discarded and not used in the actual article, that we then start to see researcher bias based on the question asked and how the researchers go about obtaining information. Think of it, only 5% of the actual information that they found on their initial screen actually makes it to the cutting room floor.

“MDT versus manual therapy plus exercise: there was moderate evidence of a significant difference in pain after the intervention, with results favoring MDT…There was moderate evidence of no significant difference in disability after the intervention period between MDT and manual therapy plus exercise.”

I think this is 👌. Understanding that MDT is the assessment first and treatment second one must also understand the components of MDT. MDT incorporates manual therapy, exercises, postures and positions. This means that there is something specific to the way that manual therapy and exercises are prescribed in MDT that has a greater affect on pain that just manual therapy and exercise together.

No effect on disability or function over a time period is also not surprising for me. It’s well known amongst those of us that use this method that returning a patient to function is not well taught in MDT, as there are many other courses and methods that speak to this. MDT follows a certain paradigm, with returning to function as part of the paradigm, but because it varies widely from patient to patient, it is best learned from other resources.

“this study found that MDT plus first – line care resulted in significant, but small, improvement in pain intensity compared to first – line care only.”

This is significant! But small. For anyone going to an ED for back pain, they are in significant pain. I’ve spent part of my career working in an ED for this exact population. In the time I worked in the ED, only one patient was unable to find a position, movement or posture that provided relief. This is significant because these patients were able to receive the right care through an outpatient means instead of being admitted to the hospital for “non-specific low back pain”.

These patients didn’t receive the rapid MRI, which in some cases may actually make the patient worse over time. These patients didn’t have a hefty hospital bill and these patients were able to recover in their natural environment thereby reducing the risk of infectious disease acquired in the hospital.

This is significant!

“One study included in the review, despite lacking data for analysis, compared MDT to education and found no significant between – group differences for changes in disability.”

This is not too shocking for me. If the pain is acute (started recently), we know that many with back pain will get some relief over time. Education is powerful in and of itself and a large part of MDT is education based.

If both utilize education as the base for acute pain, then the outcomes may not be much different. No shock here!

“There was moderate evidence of a significant difference in pain after the intervention period, with the results favoring MDT. ”

MDT is a patient response system. This means that after every movement, position or posture the therapist is asking the patient if it reduced symptoms. If the answer is yes, then the PT will typically issue this for a home program. 🙄

It’s no wonder that the system is pretty good at reducing pain in a specific classification; the therapist is giving exercises that have been shown to reduce pain/symptoms.

“Two studies included in the review, which lacked sufficient data to be included in the meta-analysis comparing MDT to modalities, found significant between-group differences for changes in pain, favoring MDT.”

Again, comparing an active intervention (patient takes part in the intervention) to passive interventions (treatment is done to the patient) is expected to lead to an outcome favoring the active intervention. There are multiple reasons for this, but one may simply be interactions with another individual during the session.

“Three studies compared the effects of MDT to combined manual therapy plus exercise in participants with chronic LBP…There was moderate evidence of no significant difference in pain after the intervention period between interventions…There was high quality evidence of no significant difference in disability after the intervention period between interventions.”

Again, this is not too difficult. As a treatment strategy MDT is literally manual therapy plus exercise. It’s comparing two similar interventions, with similar results.

“One study had 2 comparison intervention groups consisting of either MDT exercise in the opposite direction as the directional preference or midrange lumbar/stretching exercises. Only this latter group was included as the comparison to MDT in the current analysis.”

This is the part of the analysis that I don’t quite understand. Why bother 🤷♂ comparing the interventions if one of the treatment groups is removed?

This article is cited frequently by PTs trained in MDT and you can read my analysis of the article Here

Removing one of the groups, specifically the opposite directional preference group, greatly changes how that article impacts the reader.

“There was high quality evidence of a significant difference in disability after the intervention period, with the results favoring MDT.”

Even with removing the group of patients that had a high dropout rate and poorer outcomes, the article still favored MDT over “evidence based” interventions.

“Also, MDT does not explicitly account for pain systems theory, specifically differentiating between pain that is central or peripheral in origin, and for a wider spectrum of psychological factors that could be present in patients with chronic low back pain. ”

This is a good point and those that are well versed in the system would state that there are other classification systems out there that would include this pain system. If you are interested in these systems, I highly encourage readers to take a course by Annie O’Connor, author of A World or Hurt.

You can learn more about Annie by following this Link

Thanks for reading.

Since my last post, I’ve gone through a major job change. I can now be found at PCJ

What would it take to convince you as a patient to give a PT with an MDT certification a chance?

What would it take to convince you as a PT to take an MDT course?

Link to article

PTA’s in an outpatient setting continued

“Low back pain syndromes (LBPS) affect more than 65 million Americans…For approximately 16 million people (8%), back pain is persistent or chronic…”

If you have a little bit of free time, you can read about back pain here.

“…a quarter of all referrals for outpatient physical therapy and one-half of all outpatient physical therapy visits are related to patients with LBPS.”

Hey New Grad ✊ are you 👂?

If you want to get really good at something and ensure job stability, then you should learn as much as you can about back pain.

If one out of every two visits per day is related to back pain, we should all be very comfortable with this diagnosis.

In my first job, I’d say that I had 2,500 visits per year with about 95% of those pertaining to the spine.

“Resnik et al reported that patients who spent more than half of their treatment episode of care with a physical therapist assistant reported worse functional outcomes and utilized more visits compared with patients with less physical therapist assistant involvement.”

Again, this is the second post in the series on PTA’s usage in the outpatient setting.  You can find the first post here.

“It is generally assumed that practitioners must possess many years of clinical experience to achieve the best results with patients and that years of experience are associated with better clinical outcomes.”

What?! I don’t agree with this.

Unfortunately, not all experience is good experience. I’ve read Tony Delitto state in an article that one year repeated twenty times is it ideal. I would much rather have a PT with two years of experience and two years worth of learning from mistakes.

“Almost half of the sample had chronic low back pain.”

This is in line with some of the statistics that I’ve heard stating that back pain makes up about 40% of all chronic pain.

“The top 3 diagnoses were pain (34.8%), sprain or strain (25.5%), and herniated disk (19.3).”

About 90-95% of all back pain is “non-specific”, meaning that we can’t attribute it to a specific tissue strain or sprain. Herniated did a are common in the population, but we can’t always attribute a herniated disc (HNP) as the cause of pain.

“On average, patients in the best clinic performance group improved 19.2 OHS points, while patients in the worst clinic performance group improved an average of 16.4 OHS points.”

This is great news!

This means that on average people get better. I used to work in a clinic in which the manager would try to schedule people with back pain as soon as possible. If we know that they will likely improve and they improve on our watch, then they are likely to use post hoc reasoning and attribute improvement to seeing the PT.

I used to joke with patients and say that they simply need to breathe the city air in the basement of the hospital in order to improve. Obviously, it’s a joke, but we have to tell patients that most injuries improve with time.

“Patients in the best clinic performance group utilized, on average, 7.7 (SD = 4.1) visits per treatment episode compared with 7.9 (SD = 4.1) in the middle clinic performance group and 9.3 (SD = 4.9) in the worst clinic performance group.”

This is where it gets interesting. There wasn’t a major difference in outcomes on the scoring improvement, but some clinics needed an extra 2 visits compared to other clinics, on average.

If an average PT sees 5 evaluations per week and it takes an extra 2 visits, then that ONE PT is averaging an extra 20 visits per month (assuming half of the evaluations are back pain). This means that the therapist keeping patients for more visits is making the clinic an extra $2,000 per month from taking longer to discharge patients.

“…clinics that were lower utilizers of physical therapist assistants were 6.6 times more likely to be classified into the high effectiveness group compared with the low effectiveness group, 6.7 times more likely to be classified into the low utilization group compared with the high utilized group, and 12.4 times more likely to be classified into the best performance group compared with the worst performance group.”

This is essentially stating that clinics that use PTAs with a lower frequency in outpatient tend to be better in terms of outcomes and faster to discharge. This mirrors the link to the study from above.

For me this is interesting because I would have never thought to ask the question in the first place. It’s good to see that someone is doing this research to help clinicians in their decisions to 1. Choose between PT and PTA school and 2. Utilize PTAs and how to best utilize PTAs in an outpatient setting.

“Our strongest finding was that clinics that had lower utilization of physical therapist assistants were much more likely to be in the “best” category of each type of group (i.e. highest effectiveness, lowest utilization, and overall performance).”

Link to article

To anyone that has ever felt rejected, you understand.

To anyone that was raised in a single/no parent home because of decisions, you understand.

This scene hits home for me because I have felt that rejection, along with many other kids. This scene plays out in homes regardless of race, income and religion. This scene still affects those that lost parents to addictions, divorce, jail, and choice.

Know that you are not alone and there are many of us that understand. We have been there.

What I still don’t understand is why scenes like this break some people and creates chips on others.

I’ve seen many overcome these situations and go on to become Uber successful due to that chip and having something to prove.

On the flip, I’ve seen some people become so broken that they continue the cycle that broke them.

We all feel rejected at some point.

My wish for the world is that people build resilience and grit in their personality so that these major hurdles become but small bumps as they grow into beautiful people that allow others to love them and be part of that circle of trust.

Check out the video that still makes me tear up.

Efficient and Effective Care

“Proliferation of these staffing models (increasing the use of PTA’s and aides) has been driven by managed care organizations, the introduction of prospective payment systems, and low reimbursement rates, as well as workforce shortages in allied health.”

For those that are unfamiliar with physical therapy and what the titles mean lets do a quick refresher:

PTA = licensed physical therapist assistant (high school + 2 years)

PT = licensed physical therapist (Bachelor’s or Bachelor’s + years)

aide = no required degree with on the job training (no degree needed)

MPT = Master of physical therapy degree (Bachelor’s plus 27 months)

DPT = Doctor of physical therapy degree (Bachelor’s plus 33 months)

Based on the above, one can see that the aide would be paid less than the PTA.  The PTA would get paid less than the PT based on education level alone and all other things are equal.

When insurance companies cut pay to professionals, companies have to decrease their costs in order to continue to make margin.  One way to cut costs is to have fewer PT’s and more PTA’s or aides.  The ethics/legalities of the decision are for a different day.

Some insurance companies are refusing to pay for services provided by PTA’s.

The reason that I bothered to look at this research was a large discussion that took place on a professional FB page in which PTA’s were arguing that the care shouldn’t change from PTA to PT, seeing as PTA’s can perform most treatments that a PT can perform.

I decided to look into this to see if there was a difference and I was shocked by what I found, based on my own experience working in a hospital system.  On the same note, I wasn’t shocked based on some of the reports that I hear from patients and others in the profession.

“Use of support personnel in outpatient therapy settings can double the number of patient visits a therapist can manage per day, thus increasing clinical productivity.”

If I am a PT making $50/hour (using round numbers to keep it simple) and in a typical day I could treat 10 patients with an average reimbursement rate of $95 (please go watch all the videos from Dr. Ben Fung ), then I would cost the company $400 dollars, but make the company $950 dollars.  A gross profit, with the removal of only the PT salary, of $550 dollars per day.

Now, if we have that same PT making $50/hour and a PTA making $30/hour (again round numbers to keep it simple), with each therapist seeing 10 patients per day, then the following numbers are the result.  The salaries would cost $640, but the therapists would generate $1900/day.  A gross profit, with salaries of the therapists removed, of $1260/day.

As you can see, the company would be able to generate more money by hiring PTA’s instead of a second PT.  The question then becomes is it cost effective to have the PTA compared to the second PT.  The answer at a glance is “of course”!, but looking a little deeper may force a company to weigh values (i.e. profit or outcomes) before making that second hire.

“While some advocate use of support personnel to increase productivity without loss of quality, others warn that an over reliance on support personnel can negatively affect outcomes and compromise quality.”

This is essentially the discussion that occurred on FB.  Some people say that PTA’s provide the same quality of care as PT’s and others state that PTA’s offer less quality care than PT’s.

I’ve worked with rockstar PTA’s (plus my wife is a PTA so I am already a little biased) and I’ve worked with some PT’s that I would never refer a patient to (no offense if you think that this is you).

“Three dependent variables were analyzed: high PTA utilization, number of visits per treatment episode, and patients FHS (functional health status) at discharge…high PTA utilization, defined as a patient seen by a PTA 50 percent or more of the treatment time”

High PTA utilization, in this study, meant that the PTA was seen by the PTA for over 50% of the visits.

Again, I have worked in locations in which this was true and locations in which we had no PTA’s, so I have seen the results from both.

Looking at treatments per episode is a means of measuring efficiency of treatment.  It may not be the best measurement, but is one way of looking at treatment efficiency.

Looking at outcomes is one way of looking at effectiveness of treatment.  Again, it may not be the best way, but it is one way.

“…less than 2 percent of patients were treated by the PTA for more than 75% of the treatment time, and 8 percent were treated by the PTA 50% of the time or more.”

I’ve been in clinics without PTA’s and with PTA’s.  This stat will be correlated with the amount of PT’s/PTA’s in the clinic.

In private practice, it was 0 PTA’s.  In the hospital we had 1.5 PTA’s for 4 PT’s.  Currently, in my practice there are 2 PTA’s for 1.5 PT’s.

“The second dependent variable, number of visits per treatment episode…We believed that fewer visits per treatment episode were a marker of greater efficiency of care”

This is debatable by people.  I’ve actually been involved in these on-line debates.  Some people will fight that more visits equals better, but more is not always better.

If we can get patients better in shorter visits, then this seems to be ideal to me.  If additional visits would correlate with increased function, then I would be all for increased visits if the patient is willing and able to pay for increased visits (time and money).

“The majority of physical therapy care was delivered by PTs with no reported assistance from PTAs.”

Again, in a clinic without PTA’s, there will be no reported assistance from PTA’s.  This study used data from FOTO, which included private practices and hospital based practices.

“PTAs were involved in the care of patients only 35% of the time. High PTA utilization was relatively uncommon, with only 7.7 percent of the patients seen by PTAs more than 50% of the time.”

This is interesting.  It is becoming more and more common to find clinics advertising/marketing that the patient will only be seen by a PT, or even a step further a Doctor of Physical Therapy.  I don’t know how well this marketing is going.

When seeing it, it subconsciously implies that a DPT is better than a PTA.  I think that this is very individualized.  For example, a PTA that has continued to improve over the years through independent study may be a better clinician than a PT that never sees patients (administration/teacher/manager).

“Medicare patients who were seen in private practice were 48 percent less likely to have had high PTA utilization.”

Some insurance companies require that a patient be seen by a PT and prohibit PTA’s from treating patients.  This will skew numbers towards the PT in private practice.

“Treatment with a therapy aide for 1-25 percent time and greater than 25 percent compared with 0 percent, and high utilization of the PTA were associated with 1.8, 2.6 and 2.0 more visits, respectively.”

Lets break this down.

Being treated by a therapy aide for 1-25% of the time resulted in 1.8 more patient visits per episode.

Being treated by a therapy aide for > 25% of the time resulted in 2.6 more visits per episode.

Being treated by a PTA for greater than 50% of the time resulted in 2.0 more visits.

Remember, an aide is someone that may not have any college experience or degrees.  The aide is not legally able to treat patients that are payed by the government.

Utilizing an aide only results in slightly more visits than using a PTA! Why is this?!

An aide is paid much less on average than a PTA.  For example, the aide may only cost the employer $12.50/hour.  The PTA will cost the employer $30.00/hour.

I see employers trying to cut costs by hiring more aides (not ethical to call it physical therapy if it is not provided by a licensed physical therapy professional IMO).

If it doesn’t change the outcomes though, who’s to argue against it?

I can see both sides of the coin.  Margins (profits) in physical therapy is small, so cutting costs is a business decision.

Providing quality care is something that IMO we should all strive for.

“Greater than 50% time spent with the PTA was predictive of lower discharge scores as was time spent with a therapy aide.”

This part may be the most important statistic in the article.  Seeing someone other than the PT led to worse outcomes.

This is the statistic that I was looking for because of the original question asked.

In other words, the PT will get a patient better than a non-PT and do it faster in an outpatient setting.

Strong words for businesses and people looking to go to PT school.

What is the future of PTA’s?  I don’t know.  Medicare just announced that they will be reducing reimbursement rates for PTA’s in an outpatient setting.  Pair this with the small margins in physical therapy and the question becomes is it profitable to hire PTA’s in an outpatient setting, seeing patients according to Medicare rules?

“…our analysis shows that Medicare regulations for continuous in-room supervision of PTA’s in private practice are associated with a decreased likelihood of high PTA utilization.”

“High utilization of PTA’s, and use of therapy aides were each independently associated with more visits per treatment episode, and lower functional health. Thus our findings suggest that use of care extenders such as PTA’s and therapy aides in place of PT’s is associated with more costly and lower quality care delivery in outpatient rehabilitation.”

I advise all people to look to the source:

link to article

Physio and whiplash

“Whiplash-associated disorders (WAD) is the term given to the variety of symptoms often reported by people following acceleration/deceleration injury to the neck.”

Most people understand the term whiplash is related to an auto accident. After the basics, everything else is like the teacher from the Charlie Brown An acceleration/deceleration injury is exactly what it sounds like.  I’m sure that if you have an older sibling you understand this concept.  My friends, I won’t say any names (Tom and Carl) used to brake abruptly to see if they could get someone to spill their drink.  It’s kind of like that, only more forceful.

When the car comes to an abrupt stop, the body will continue forward thanks to the laws of inertia.  It will typically be stopped by a seatbelt.  Some though, may be stopped by a windshield.

“Cardinal symptom is neck pain but neck stiffness, dizziness, paresthesia/anesthesia in the upper quadrant, headache and arm pain are also commonly reported.”

I have seen a plethora of patients after a motor vehicle accident (MVA).  Neck pain and stiffness seem to be the most common complaint anecdotally, but I have also seen the headache and arm symptoms.

Part of the problem with such diffuse symptoms is that not every professional will treat the patient, but instead will treat the situation.  This means that when a patient presents with symptoms that may not make sense, the professional then inserts individual bias and believes that the patient must be making up the symptoms.  I have seen this over the years in which the PT/PTA/PA/MD believe that the patient is FOS (not a medical abbreviation).  Be that the case, it is still our job to try to help that patient.  If the patient is exaggerating symptoms, we still have to sift through the exaggerations in order to determine what is organic (with a physical cause) and what is non-organic (without physical cause).

“…whiplash injuries comprise (about) 75% of all survivable road traffic crash injuries.”

Just this year I was involved in two MVA’s.  Neither of which were my fault.  As an aside, I have never met anyone that said an accident was his/her fault, in the clinic at least.  Luckily, both MVA’s that I was involved the other person admitted fault immediately.  The first accident involved me T-boning another car doing 45 mph (someone tried making a U-turn on a 4 lane highway). I experienced shock during the first accident and it took me a while to calm down.  I had back pain and neck pain, but as a professional, I knew that it would subside on its own.  This is exactly what happened, over the course of a month.  The best thing that I did was return to lifting and normal activities.  The second accident involved me being rear-ended with the other person going 40-45 mph.  Again, I had some back and neck pain.

Body heal thyself.  Father time is a powerful motivator and I was back to 100% within a couple of months.

“Consistent with international data indicate that approximately 50% of people who sustain a whiplash injury will not recover but will continue to report ongoing pain and disability one year after the injury”

There are so many variables that go into a person experiencing chronic pain.  Extent of tissue damage is not the only variable that needs to be assessed.  Sometimes people just feel wronged by life and this stress of life may contribute to symptoms.

We know that most tissue damage heals relatively quickly (at least quickly when relative to a lifespan).

“…recovery, if it occurs, takes place within the first 2-3 months following the injury with a plateau in recovery following this time point”

We know that most healing takes place over the course of weeks to months.  With this, we have to question the cause of this roadblock to recovery.  Is it truly tissue damage or is there something else at play?

“…good recovery, where initial levels of pain-related disability were mild to moderate and recovery was good, with 45% of people predicted to follow this pathway”

Glass half empty/Glass half full?

About half of the people with WAD will experience a good outcome.  Considering that not much has to be done with this group, I can see some healthcare providers taking responsibility for good outcomes.  I used to work for a clinic that tried to get people into the clinic as fast as possible with the idea being that if we don’t get the patient in fast enough, then the patient may get better on his/her own.

Think about that? We know that most things get better with time, so we want the patient to believe that it was us and our treatment that helped them the most.  As much as I can see this from a marketing perspective, from a global health perspective…it just ain’t right.

Sometimes the patients just need some advice to stay active and come back in 4-6 weeks if there is no change in symptoms.

I was in a course once talking to a PT and I asked that therapist, who also happened to be a business owner: “how do you know that you have had a successful episode of care?”

That therapist’s answer was: “The insurance has been exhausted”

Whether the therapist was joking or not, the fact that this perception is out there that the patient should be bled dry (at least monetarily) is disturbing.

Remember this when you are working in a clinic (if you’re a healthcare professional) or when you are going to see your healthcare professional.

“…initial moderate to severe pain-related disability, with some recovery but with disability levels remaining moderate at 12 months. Around 39% of injured people are predicted to follow this pathway.”

Now we are starting to play.  I use this term “play” as a measure of patient severity.  For instance, when playing basketball with my 4-year old, it’s not really playing the game as much as it is just toying around.  When playing the game against someone that I have never beaten before, I have to study the player, understand the player’s moves, his/her strengths and weaknesses, tendencies when under pressure, establish my game plan against their moves etc.  This is how I perceive a patient and symptoms when they enter the clinic.  I am studying that patient and the symptoms in order to best understand what that patient is experiencing.

I believe that only through understanding the tendencies of the symptoms are we truly able to help/assist the patient in this journey to reduce pain and return to full function.

“…involves initial severe pain-related disability and some recovery to moderate or severe disability, with 16% of individuals predicted to follow this pathway”

I love listening to this guy. He has a way of explaining severity of pain that is just not taught in most healthcare programs.  Understanding that pain is an experience is more important for the healthcare providers, because without this understanding, we can not explain this phenomenon to the patient.

“The most consistent risk factors for poor recovery are initially higher levels of reported pain and initially higher levels of disability.”

With this, the thought exists that we may be able to affect recovery with WAD if we can simply reduce pain.  We may be able to reduce pain in some populations through education.

Maybe we should attempt to use education as a means to reduce pain before we try other interventions such as heat, cold, manual therapy, etc.

It may go something like this:

Therapist: You know Mr. Smith, I have done my evaluation and there is some good news; you’re going to get better.

Mr. Smith: How do you know?

Therapist: There was nothing in my exam that showed that there was any major structural damage and we know that tissue injuries tend to improve on their own over the course of weeks to months.

Mr. Smith: That is good news!

“lower expectations of recovery have been shown to predict poor recovery”

This may be the factor that healthcare professionals should focus time trying to change.  As much as we speak to patients about tissue damage and injuries, we need to spend time in conversation understanding what they believe the barriers are to a successful recovery.

Taking the extra 10 minutes per session to have these conversations and together problem-solving ways to overcome these barriers may be more important than an extra 2 minutes on an arm bike or an extra set of banded rows etc.

Patients are people first and foremost and not a sum of body parts.  Breaking through perceived barriers is an important first step to providing the right interventions to patients.  Sometimes the intervention is only education and other times it may be more integrative of exercise, manual therapy and other modalities at our disposal.

“Some factors commonly assessed by physiotherapists do not show prognostic capacity. These factors include measures of motor and sensorimotor function such as the craniocervical flexion test, joint repositioning errors and balance loss”

We all learn tests and measures in school.  A great world would be inclusive of tests that actually mean something.  Testing balance and strength and positional awareness are all good tests to take time and give information to physicians or insurance companies, but in the end they don’t actually do much to tell the story of the patient.

We need to identify patients that will respond to therapy and those that may need for than just PT.  With that said, we also need to be able to identify those patients that will get better on their own.  Not all patients need to see a physical therapists, we just don’t have a way of telling one subset from another at this time.

“The QTF classification of whiplash injuries was put forward in 1995 and it remains the classification method still currently used throughout the world”

This is the Quebec Task Force Classification:

I No neck complaints and no physical signs
II Neck complaints of pain, stiffness or tenderness only and no physical signs
III Neck complaints and MS signs including 1. Decreased ROM 2. Point tenderness
IV Neck complaints and Neuro signs including: 1. Decreased or absent DTR 2. Muscle weakness 3. Sensory deficits
V Neck complaint and fracture or dislocation

“Current clinical guidelines for the management of acute WAD recommend that radiological imaging be undertaken only to detect WAD grade IV and that clinicians adhere to the Canadian C-Spine rule when making the decision to refer the patient for radiographic examination”

For those that are unfamiliar with, or forgot, the C-Spine rules (including myself), here is the link.

“…the same general examination procedures usually adopted for the examination of any cervical spine condition but with some additional procedures based on research findings of WAD”

When a patient presents to therapy, with complaints of neck pain, after a motor vehicle accident here are some things that a patient can expect (if you are a PT, then these are the things that we should be doing as an at least)

  1. Range of motion using a large compass
  2. Assessing strength in the arms/neck
  3. Assessing any loss of sensation
  4. Assessing loss of reflexes
  5. Assessing grip strength
  6. Assessing patient perception of symptoms using an outcome meaure
  7. Assessing joint integrity using special tests and symptom change
  8. Assessing nerve irritability

“…many patients with WAD will report diffuse symptoms of sensory loss or gain and generalised muscle weakness, both of which may be bilateral, but these findings do not necessarily indicate peripheral nerve compromise and may be a reflection of altered central nociceptive processes.”

Some clinicians think that if a symptom doesn’t match what was learned in school that the symptom must be made up.  We’ve all been around these clinicians that believe that patients must be “faking”, “malingering” or just out for the $$$ after an accident.

Truth is that we have no reliable way to tell if a patient is “faking”.  We may be able to tell if a patient is providing full effort during our examinations, but we can’t know anything beyond this.

The first thing that we need to understand is that the nervous system is complex.  Now, when I see a patient that reports increased sensitivity in an area, I report it as such.  Previously I would report a decreased sensation in the opposite side tested.  I didn’t understand, at that time, that a person could experience hypersensitivity in an area.

“…strong evidence for the presence of augmented central nervous system processing of nociception in chronic WAD and moderate evidence that cold hyperalgesia is associated with poor recovery from the injury”

The nervous system appears to be boss. When it is experiencing stress, it can drastically change how the person perceived different stimulus. I recently had a patient that was so sensitive that she noted her pain increased with the breeze from a ceiling fan.

Think of a car alarm set to really sensitive. We all have seen a car alarm that goes off from a sideways glance. This appears to be happening with the nervous system. The system has difficulty processing what is a real threat to the system and what is a normal stimulus.

Patients that have difficulty tolerating cold appear to have a heightened car alarm, which may indicate a poor overall recovery.

“The clinical course of WAD, where most recovery occurs in the first 2-3 months”

In my opinion there are too many of us in healthcare with big egos. We tend to use this basic rationale:

Patient got better. Patient was in physical therapy during this time of improvement. Physical therapy must be the reason the patient got better. 🤔

This type of logic is unfortunately mislead.

Other variables, such as time may have a role more so than the interventions performed during this time.

“The mainstay of management for acute WAD is the provision of advice encouraging return to usual activity and exercise, and this apprpach is advocated in current clinical guidelines.”

ADVICE!? That’s the mainstay?!

Not ultrasound?!

Not massage?!

Not electrical stimulation?!

How can this be?!

Body heal thyself. 💪🏼👊

“…recent systematic reviews concluding that there is only modest evidence available supporting activity/exercise for acute WAD. It is not clear which type of exercise is more effective or if specific exercise is more effective than general activty of merely advice to remain active.”

The 🥖 and butter of PT may or may not be affective for treating patients immediately post accident.

Lately, I have been seeing many of these patients and there is much education that goes into time based healing on the first few visits.

“…six sessions of physiotherapy was only slightly more effective than a single session of advice from a physiotherapist”

As much as it pains the many wallets of our profession, I definitely agree with this. Some patients that I have seen actually get some relief just from knowing the clinical expectations post WAD.

“…a graded functional exercise approach and advice demonstrated greater improvements in pain intensity, pain bothersomeness and functional ability, compared to advice alone.”

Think of those six sessions from above.  A traditional clinic may use 6 sessions in 2 weeks.  A clinic that understands the research may use those visits over the course of 6-8 weeks.

A graded functional exercise approach means that the patient is slowly performing more work load over the course of time in order to improve function.  This time period is probably no less than 6 weeks since we know that we see significant changes in strength and movement ability over the course of 6 weeks.

“…the recommendation to clinicians is that health outcomes should be monitored and treatment continued only when there is clear improvement.”

It’s unfortunate that this has to be said.  I have seen some patients treated in a clinic for months without appreciable improvements.  At some point, we have to do what is in the best interest for the patient first and foremost.  Having a patient continue to come into the clinic, in the absence of improvement, is a red flag that there may be something else causing symptoms.  Also, continuing to treat a patient may do more harm than good because the patient takes on attributes of a “sick” person.

It’s a case in which the medical system may actually cause problems through the use of treatments and information.  This type of change in the patient has been labeled as iatrogenic (caused by the medical system).

“Analysis revealed no significant differences in frequency of recovery between pragmatic (medication/physiotherapy/CBT) and usual-care groups at 6 months. There was no improvement in non-recovery rates at 6 months, indicating no advantage of the early interdisciplinary intervention.”

I read previously (I’ll have to go back and look for the article) that early aggressive therapy may actually increase symptoms of patients after a motor vehicle accident.

“Education and advice to return to activity and exercise will still remain the cornerstones of early treatment for WAD”

This year I was rear ended on the highway and T boned on another highway.

Excerpts from:

Sterling M. Physiotherapy Management of Whiplash-Associated Disorders (WAD). Journal of Physiotherapy. 2014;60:5-12.

Symptoms may or may not change

Excerpts from here

Ways to mitigate burnout

“Burnout…is a syndrome of depersonalization, emotional exhaustion, and a sense of low personal accomplishment leading to decreased effectiveness at work…primarily affected those in ‘helping’ professions”

Hey!…  Hey!…  You!… PT’s!…Are you listening?!….

Does this sound like someone you know?

“The high prevalence of burnout among physicians results in lowss of engagement and commitment…5 out of every 10 physicians affected by burnout”

Loss of engagement and commitment with patients.  Hmmm? How many therapists do you know that are “punching the clock”?

I have a problem with a lack of engagement.  It just isn’t something that I tend to do often and I have a short attention span.  Maybe not as short as the new average of 9 seconds, but pretty darn short.  I just shift the engagement to something different.

A therapist that isn’t engaged with the patient is problematic.  Patients are coming to us for our professional opinion and placing trust in us to help them along their journey of pain or functional restoration.  To have loss of engagement places that trust at risk.

Not only is trust lost between the patient and the physical therapist, but also between the patient and the profession of physical therapy.

Remember young Jedi, YOU REPRESENT THE FORCE (by force I mean the PT workforce).  Your burnout makes me look bad.  Not that it’s all about me, but really…it’s all about me.

50% of physicians are affected by burnout?!

I haven’t seen any studies on prevalence in our profession, but I hope it’s not that high.

“Many factors contribute to burnout, including high workloads; an inefficient environment; problems with work-life integration; lack of flexibility, autonomy, and control; and loss of meaning in work.”

I’ve seen research showing that treating 20 patients per day may lead to burnout.  I don’t know if it’s the 20 patients or the notes that come along with the 20 patients, but….20 patients!!! REALLY?

At my busiest time, I was only seeing about 15 per day.  This may be why I have yet to experience burnout from treating patients.

An inefficient environment.  I have experienced this multiple times.  Sometimes people and companies are just set in their ways and don’t see a good enough reason to change.

Problems with work-life integration: this is what I am struggling with right now.  Is the juice worth the squeeze?  This is a phrase that I am thinking of more and more currently.  When I think of how many hours that I am away from my kids and wife, I have to think (or my wife makes me think) about where do I want to be in life 5 years from now.  Managing a clinic takes a ton of time.  If you have never tried to build a “brand”, it takes a lot of time and work in order to get a personal brand out to the community.

Autonomy and control: I haven’t personally experienced a loss of control in the clinic,  but I hear from PT’s all over the country that their boos/manager/director almost dictates the care in order to create a “comprehensive care plan”. Now this sounds all good and nice and all, but in the end the question has to be asked…Why? Why does the boss want a comprehensive plan?

The reason is no different than any other business and it has to do with money.  Clinics make more money by doing multiple different treatments than providing one treatment that may have the best outcomes.  It’s sad…but I hear it frequently.

“Physicians who suffer from burnout are impaired and they and their organizations are at risk of having higher rates of medical errors, less professionalism, lower patient satisfaction, and lower productivity, as well as more turnover and suicidal ideation”

Does burnout sound good?

Not like the burnout that I would do on my BMX bike as a kid or in my F-150 as a teenager.

Burnout leads to major issues at a personal and corporate level.  I wonder though if the companies care about burnout.  Turnover happens in physical therapy.  Although it costs money to train a new therapist, it may not matter since many companies see a PT as a widget instead of as an autonomous practitioner.  If one therapist can easily be swapped out for another, is burnout an issue at the corporate level?

Rhetorical questions of course.

“Organizations that make investments in leadership development experience substantially higher returns than those that do not.”

This is a great quote. Invest in your people, more so than seeing your people as an investment.

For instance, when you put money into an IRA, it sits there and you hope it grows (at least matches the 10% historical APR). You are passive in this role. Hopefully money makes money. This is what typically happens in a company. The employee is expected to go out and grow individually, which benefits the company, although the company may not take part in that individual investment.

I would like to see it more as owning a home. This is an investment also. It averages about a 2% gain per year, but the individual living in the home has to actively care for the investment in order for it to keep growing. I would love for more businesses to see employees as an investment for which they should foster care. High tides raise all ships. When the employee is successful both on an individual and business sense, everyone wins.

“Clinician engagement is empirically linked to more effective organizations, with outcomes including lower turnover rates, superior clinical outcomes, better patient experience, and superior financial performance”

Does this sound like a positive experience for clinicians and patients alike?

If the clinician is engaged in not only treating patients but also regarding the health of the business everyone wins.

Some therapists don’t see themselves as business people, which is a shame because if we don’t get the patient in the door, then we can’t help that person. We have to feel confident in attracting our customer (someone with functional complaints that may or may not relate to pain), educating our customer, selling to our customer and then accepting their money. Sales doesn’t have to be a bad thing. I have been reading Rabbi Daniel Lapin and have learned that money is just as much a show of appreciation and gratitude as it is a financial transaction.

“Physicians experience highest levels of engagement when they have a degree of control over their work environment. Engage Physicians tend to receive higher patient satisfaction ratings.”

This is an indication of autonomous practice. When a clinician gets to dictate care, instead of having care dictated to the clinician, then everyone wins again.

“Combating physician burnout is a twofold process that involves 1. mitigating the structural and functional drivers of burnout and 2. bolstering individual resiliency.”

This is the Mayo Model to try to reduce burnout in physicians. This appears useful for many other health professionals also.

Quick Link to the article here

Healthcare fraud and abuse

“During Fiscal Year (FY) 2017, the Federal Government won or negotiated over $2.4B in health care fraud judgments and settlements…$2.6B was returned to the Federal Government or paid to private persons.”

Put this into perspective.  If you were born today and started counting one…two…three…four, you would get to 2B right around retirement age.  This is of course assuming that you don’t sleep.

That’s a lot of money!

What’s important is to read that the money was returned to the government or paid to private persons.  This means that the Government is at least paying this much out to health care providers in order to recover the money at a later date.

There is a saying in health care…”it’s not about how much you make, but how much you keep that matters”.

“In FY 2017, the Department of Justice (DOJ) opened 967 new criminal health care fraud investigations…filed criminal charges in 439 cases.”

Again, I’d love to say that health care is a field full of altruistic people, we we know that some people suck!  They just suck. They take advantage of people.  They may have been bullied as a child and feel the need to get payback.  They may have been the bullies and just continue to try to take advantage of others.  It doesn’t matter the why, but they can’t be trusted to do the right thing when placed in a situation in which personal gain is an option.

“HHS-OIG also excluded 3,244 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs.”

When a health care provider attempts to defraud a federally funded program, the health care provider can be excluded from seeing any patients that participate in these programs.  For instance, if I were to be a shady individual and overbill or bill for services that I didn’t actually provide, the government can then say that I am no longer allowed to see these patients.  The government could also enter into a corporate integrity agreement with the person or company and allow them to see patients, but the company would have to prove that steps are being taken in order to minimize abusing the system.

“Under the joint direction of the Attorney General and the Secretary, the Program’s (Health Care Fraud and Abuse Control Program) goals are:

  1. To coordinate federal, state and local law enforcement efforts relating to health care fraud and abuse with respect to health plans;
  2. To conduct investigations, audits, inspections, and evaluations relating to the delivery of and payment for health care in the United States;
  3. To facilitate enforcement of all applicable remedies for such fraud; and
  4. To provide education and guidance regarding complying with current health care law. “

Imagine that you have the full force of the Federal Government tracking you as a health care professional.  How confident are you that you are doing everything correctly? We are responsible for complying with health care laws and regulations.

It’s unfortunate, but there are many therapists that still struggle with how to bill appropriately and will just take the word of another health care provider instead of looking up the rules and regulations.

“Relators’ Payments: $262,095,000…are funds awarded to private persons who file suits on behalf of the Federal Government under the qui tam (whistleblower) provisions of the False Clams Act”

In my opinion, this is where it gets interesting.  If anyone sees an injustice of abuse or fraud and reports it to the government, the government may pay that person(s) a percentage of what is recovered from the abusing person or company.

About 10% of what was recovered was paid out to individuals and groups that reported this fraud.

Someone is hitting the lottery by doing the right thing and reporting on those that are taking advantage of the system or are ignorant of the rules of the system.

“The return on investment (ROI) of the HCFAC program over the last three years is $4.20 returned for every $1.00 expended.”

If you are the federal government, “would you put more or less money into trying to recover more money from those committing fraud or abuse?”

I don’t see these recovery attempts to slow down over the years.

“Health Care Fraud Prevention and Enforcement Action Team (HEAT)…The Medicare Fraud Strike Force teams are a key component of Heat.  The mission of Heat is:

  1. To marshal significant resources across government to prevent waste, fraud, and abuse in the Medicare and Medicaid  programs and crack down on the fraud perpetrators who are abusing the system and costing us all billions of dollars.
  2. To reduce health care costs and improve the quality of care by riding the system of perpetrators who are preying on Medicare and Medicaid beneficiaries.
  3. To highlight best practices by providers and public sector employees who are dedicated to ending waste, fraud, and abuse in Medicare.
  4. To build upon existing partnerships between DOJ and HHS, such as our Medicare Fraud Strike force Teams, to reduce fraud and recover taxpayer dollars. “

If you are in healthcare…are you listening?!

Does this sound personal?

This is to crack down on perpetrators costing us billions of Dollars.

“DOJ and HHS have expanded data sharing and improved information sharing procedures in order to get critical data and information into the hands of law enforcement to track patterns of fraud an database and increase efficiency in investigating and prosecuting complex health care fraud cases…enables the DOJ and HHS to efficiently identify and target the worst actors in the system.”

As a therapist, you should be shaking in your boots…if you are breaking the rules.  When the DOJ gets involved, it gets serious.

If you aren’t sure if you are one of the “worst actors in the system” you should check out the statistics.

Scary statistics for some

“In January and February 2017, 4 defendants pled guilty…conspiracy to commit health care fraud and conspiracy to commit money laundering…submit false claims to Medicare and Medicaid for among other things, fraudulent physical and occupational therapy services…patients received medically unnecessary services that were later falsely billed to Medicare and Medicaid…totaling over $55 million were submitted to Medicare and Medicaid in connection with the scheme”

This may be more than most people can perceive regarding fraud, but it doesn’t always start this way.  I’ve heard that it starts with overcharging by a couple of minutes and when a person doesn’t get caught, then the billing becomes more and more unethical.  Before you know it, the person is billing for thousands of dollars of services that weren’t actually performed.

“In March 2017, an owner of several physical and occupational therapy clinics in the Central District of California was sentenced to 5 years and 3 months in prison after pleading guilty to health care fraud conspiracy…ordered to pay more than $2.4 million in restitution to Medicare…instructed therapists and others to bill Medicare for physical and occupational therapy services that were medically unnecessary and not provided”

This is unfortunately all to common.  I received calls just in the past year from PT;s in Minneapolis, Houston, NYC, and San Diego describing similar situations.  This is happening all across the country, but very few people are saying anything about it.  It is much easier to ask opinions of others that have no vested interest in the topic than it is to actually call the compliance officer for the company or call the office of inspector general.

“In July 2017…a 2-count indictment against 5 high-billing medical professionals who worked at a network of Brooklyn-area clinics where patients were paid illegal kickbacks in return for subjecting themselves to purported physical and occupational therapy, diagnostic testing and other medical services.”

Kickbacks are illegal.  Kickbacks come in many forms.  Money is the easy one, but there are others.  I’ve heard of free sports tickets, free trips to medical conferences, paying patients to show up for sessions, waiving co-pays for all patients in order to keep them in the clinic, etc. etc. etc.

If you are a patient, this is illegal and needs to be reported.  If you are a therapist, this is illegal and needs to be reported.

“In October 2016, the owner and medical director of Christian Home Health Agency in New Orleans were sentenced to 8 years and 6 years in prison, respectively, after being convicted of health care fraud for billing Medicare for home health services that were not medically necessary or were not provided.”

People go to prison.  Some worry about whether they will be shunned by their job, so they don’t report the wrongs noted in the clinic.  Some people worry about whether they will lose their job, so they don’t report it.  People are going to prison.  Jobs come and go, but time served isn’t something that one can just walk away from.  Walk away from a negative situation while you still have time…or you may find yourself doing time.

To see the report in whole click here

To learn more click here.


Combining childhood vaccines at one visit is not safe? Wrong, wrong, wrong!

I sensed a disturbance in the antivaccine (i.e, the dark) side of the Force yesterday. No matter where I wandered online and on social media, I kept running into a new article, an article by Neil Z. Miller about vaccines. For example, the merry band of antivaccine propagandists over at Age of Autism seem to like Miller’s article very, very much. So did the vaccine truthers over at—where else?— I kept seeing it on Facebook and Twitter, too.

Even though the current vaccine schedule is safe and effective as well as evidence-based and the claim that we give too many vaccines too soon is an antivaccine myth, that doesn’t stop Miller from claiming otherwise in an article just published in the Journal of American Physicians and Surgeons (JPANDS) entitled Combining Childhood Vaccines at One Visit Is Not Safe. Now, the first thing I think whenever I see an article published in JPANDS is that it must be so horrible that no reputable journal would touch it with a ten foot cattle prod. After all, JPANDS is the house organ of a group, the Association of American Physicians and Scientists (AAPS), best known for its extreme right wing politics, its members’ belief that they are brave maverick doctors who don’t follow the “herd,” and its utter disdain for any evidence that conflicts with its ideology.

As hard as it is for me to believe, I first discovered the AAPS over ten years ago and was astonished at its embrace of antivaccine views, HIV/AIDS denialism, and other forms of pseudomedicine and medical conspiracy theories. Examples abound. Basically, the AAPS is known for being against vaccine mandates, against Medicare (calling it “unconstitutional”), and against any form of regulation of health care by government. It’s called public health programs “tyranny.” The AAPS has also published bad papers claiming to find that abortion causes breast cancer, has promoted the vile idea that shaken baby syndrome is a misdiagnosis for “vaccine injury,” supported HIV/AIDS denialism, and (of course!) done what all crank medical organizations like to do, attack evidence- and science-based medicine as placing unacceptable limits on physician autonomy. Perhaps my favorite example of AAPS crankery is when it published a blog post (now removed, no doubt in embarrassment) claiming that then-candidate Barack Obama was possibly “deliberately using the techniques of neurolinguistic programming (NLP), a covert form of hypnosis.” The AAPS doesn’t even limit itself to medicine in that it’s also published papers attacking anthropogenic global warming, as though physicians had the necessary expertise to judge the science in that field. Truly, the crank magnetism and arrogance of the AAPS know no bounds. If you don’t believe me, consider this. JPANDS has published articles by the father-son team of antivaccine “scientists,” Mark and David Geier.

We’ve also met Neil Z. Miller before. Well do I remember an article by him and co-author Gary S. Goldman published five years ago that resurfaces from time to time. Basically, it was an “analysis” purporting to show that infant mortality correlates with the cumulative number of doses of vaccine in the childhood vaccination schedule. Let’s just say Miller and Goldstein’s rationale, methods, and analysis were rather suspect. No, wait. Strike that. Let’s just say it was a giant, drippy, stinky turd of an article—and amateurish to bood—whose conclusions were not at all supported by the data or analysis. He and Goldman also teamed up for an equally inept attempt to show that more vaccination correlates with more hospitalizations and deaths. They failed.

So, given how much antivaccinationists like this latest article by Miller, combined with the abysmal (and well-deserved) reputation of JPANDS and Miller’s track record, I was not optimistic that this wouldn’t be more of the same. My pessimism was justified. The main difference is that this latest article is not an attempt at an original investigation, but rather an attempt at a systematic review. Unfortunately, in a systematic review, one is supposed to review the existing literature as comprehensively as one can, discussing its strengths and weakness, not cherry pick a few studies to misinterpret and cite one’s own “studies” far more prominently than they deserve. Let’s take a look.

You can tell from the abstract that this article is basically going to be a rehash of Miller and Goldman’s previous “analysis”:

Although health authorities including the Centers for Disease Control and Prevention (CDC) claim that childhood vaccines are safe and recommend combining multiple vaccines during one visit, a review of data from the Vaccine Adverse Event Reporting System (VAERS) shows a dose-dependent association between the number of vaccines administered simultaneously and the likelihood of hospitalization or death for an adverse reaction. Additionally, younger age at the time of the adverse reaction is associated with a higher risk of hospitalization or death.

Which is basically what Miller and Goldman tried, and failed, to show four years ago.

The first mistake Miller makes is the same mistake he’s made time and time again: Dumpster diving the VAERS database. Why do I call it “dumpster diving”? Easy. The VAERS (Vaccine Adverse Event Reporting System) is a problematic database, whose contents are useful for a very limited range of analyses. However, it is also a public database that can be freely downloaded by anyone; so naturally it attracts antivaccine “scientists” like catnip attracts cats. As longtime readers of this blog and vaccine science advocates know, VAERS is a passive reporting system. Anyone can report a suspected vaccine injury to the database. You don’t have to be a medical professional to do it, and there doesn’t even have to be a plausible relationship between the vaccine and the suspected adverse reaction. Indeed, it’s long been known that vaccine litigation distorts the VAERS database, with plaintiffs’ attorneys encouraging their clients to report their children’s cases to VAERS. Consequently, VAERS cannot be relied upon for anything close to the true incidence of specific adverse reactions. If you don’t believe me, let me just mention once again that reports of vaccines turning people into The Incredible Hulk and Wonder Woman have been successfully entered into VAERS.

Why would the government want to set up a system like this? Simple. It’s an early warning system. Even though the database can be distorted and even though its contents are not a reliable estimate of the incidence of vaccine injuries, it’s still useful in that when scientists notice an uptick in the reporting of an adverse event due to a vaccine in VAERS it’s an impetus to study it more deeply and see if the increase is real.

Of course, at some level, Miller must know this, as he spends much of the first page trying to convince the reader that VAERS is valuable and citing CDC studies using VAERS data. (Of course, VAERS is valuable and useful, just not in the way Miller thinks it is.) First, Miller tries to convince us that adverse events are underreported in VAERS:

Since 1990, the VAERS database has received more than 500,000 reports of suspected adverse reactions to vaccines. Although this represents a large number of people who may have been hurt by vaccines, under-reporting is a known limitation of passive surveillance systems. This means that VAERS only captures a small fraction of actual adverse events. In fact, shortly after VAERS was established, a large vaccine manufacturer, Connaught Laboratories, estimated “about a 50-fold under-reporting of adverse events in the passive reporting system.”3 Perhaps 98% of all adverse reactions to vaccines are not included in the VAERS database, and up to 25 million U.S. citizens could have been adversely affected by vaccines in the past 25 years. This well-known disadvantage of a passive reporting system, as opposed to an active surveillance system in which medical workers are trained to systematically collect all cases of suspected adverse vaccine reactions, is rarely acknowledged by health authorities when vaccine safety is discussed.

A better way of looking at this would be that certain kinds of adverse events are underreported and certain others are likely to be massively overreported, thanks to the way lawyers petitioning the National Vaccine Injury Compensation Program insist that their clients enter their suspected adverse reaction, no matter how implausible. Miller cites the Institute of Medicine’s report on vaccines to bolster his view, but this is what the IOM actually wrote:

Care must be taken in interpreting information from passive surveillance systems. The extent of underreporting cannot be known. Duplicate reports of the same event for the same patient are common and are not always easy to detect, making totals questionable. Medical information provided on reporting forms is often incomplete. In general, passive surveillance systems are useful in flagging potential problems and suggesting hypotheses. See Chapters 2, 10, and 11 for further discussion.

Which is exactly what I just explained above. The IOM also noted:

Miller then cites three studies by the CDC using VAERS: a 2015 study looking at the MMR vaccine in adults; a 2014 study looking at live attenuated influenza vaccine (LAIV3); and a 2013 study examining intussusception after a rotavirus vaccine. The first study is described thusly:

Although 5% of reports were serious, including several deaths, CDC researchers concluded that “in our review of VAERS data, we did not detect any new or unexpected safety concerns for MMR vaccination in adults.”

Note the implication that the MMR vaccine is very dangerous. What Miller neglected to mention (almost as if he didn’t read anything more than the abstract) is that the medical records of patients suffering serious events were reviewed. Of the seven deaths, two were due to cardiovascular disease, one due to a drug overdose, one due to chronic preexisting myocarditis, one due to pulmonary embolus, one due to an arrhythmia. The last one was a patient who had had a renal transplant and was on immunosuppression who died of disseminated varicella. In other words, none of them appear to have been due to the MMR vaccine.

Next, Miller characterizes the LAIV3 study thusly:

Although 8.9% of reports were classified as serious (e.g., cardiovascular events, neurological debilities, and fatalities) CDC researchers concluded that “review of VAERS reports are reassuring, the only unexpected safety concern for LAIV3 identified was a higher than expected number of Guillain-Barré syndrome reports in the Department of Defense population, which is being investigated [sic].”

Note again how Miller tries to paint the LAIV3 as dangerous. This paper is actually a bit more nuanced. For one thing, the rate of serious adverse events reported was generally under 2 per 100,000 doses, which one would note if one reads the whole paper. Be that as it may, this paper only found a possible increased incidence of Guillain-Barré syndrome in the Department of Defense population, which is being investigated—which is exactly what VAERS is for: Early warning and hypothesis generation.

Finally, the last paper cited looked at intussusception after rotavirus. This one was interesting in that it looked at the number of days after vaccination that reports of intussusception were made and found a clustering between 3-6 days, which suggests that there might be a causal relationship based on what is known about intussusception and rotavirus. Also:

In summary, after distribution of 47 million doses of RV5 in the United States, we observed a persistent clustering of intussusception events during days 3 to 6 after the first-dose vaccination. When we combined all 3 doses of RV5, we estimated a small overall excess risk of ∼0.79 intussusception event for every 100 000 vaccinated infants. This level of increased risk in the United States would translate to 33 excess annual intussusception events after rotavirus vaccination with the coverage expected for a fully mature rotavirus vaccine program. This is substantially lower than the number of diarrhea hospitalizations prevented annually (∼40 000) since rotavirus vaccine introduction.

Emphasis mine. Risks versus benefits. Risks versus benefits.

Perhaps the most hilarious part of Miller’s paper is this:

These studies and others confirm that CDC considers VAERS an important post-marketing vaccine safety surveillance tool. Therefore, nobody should be swayed into believing the VAERS database does not contain immensely valuable raw data to be used by independent researchers conducting studies that evaluate the safety of U.S. mandated vaccines. For example, Mark Geier, M.D., Ph.D., independent researcher and former professional staff member at the National Institutes of Health (NIH), published several studies utilizing the VAERS database showing that vaccines containing thimerosal (mercury) significantly increase the odds of developing neurological disorders, including autism.

That’s right. Miller actually cited the Geiers as though they were real researchers and not antivaccine advocates pretending to do research. There’s a reason why I refer to anything the Geiers do with VAERS as “dumpster diving.” In fact, numerous studies have failed to find an association between thimerosal-containing vaccines and autism or other neurological conditions.

All of this, of course, was just a lead up to Miller regurgitating his 2012 “study.” I deconstructed that incompetently performed study in detail back when it was originally published; so I don’t really feel the need to go into too much detail, given that you can simply click on this link if you want to go into the truly Oracian-length Insolent deconstruction. there were some truly hilarious abuses of statistics, a seeming fetish for trying to fit Miller’s data to a straight line in the absence of a plausible rationale why it should fit to a straight line, a failure to control for historical trends in infant mortality, and a failure to control for obvious potential confounders, such as birth cohort. It was truly a crappy “study.”

Of course, to Miller, his Truth is being suppressed by The Man:

No. It. Doesn’t. In actuality, the current vaccine schedule is both safe and effective, and, contrary to claims by antivaccin activists, are evidence-based. Nothing Miller has published changes that.

Why is The Truth being suppressed by The Man? I think you know. It’s big pharma, of course:

These findings are so troubling that we expected major media outlets in America to sound an alarm, calling for an immediate reevaluation of current preventive health care practices. But 4 years after publication of our study, this has not happened. Could it be because, according to Robert Kennedy, Jr., about 70% of advertising revenue on network news comes from drug companies? In fact, the president of a network news division admitted that he would fire a host who brought on a guest that led to loss of a pharmaceutical account. That may be why the mainstream media won’t give equal time to stories about problems with vaccine safety.

Boo hoo.

I wonder if Miller knows just how pathetic it is to whine about how a paper he wrote four years ago failed to catch the attention of the press or the scientific community when it was originally published. I wonder if he knows just how much more pathetic it is that he published his complaint in JPANDS, one of the crankiest of crank journals. Obviously, it never occurred to Miller that maybe—just maybe—the reason that his “study” wasn’t picked up by major media is because it was a stinking heap of crap. Unfortunately, so far, it’s worked because memories are short and antivaccine activists don’t care about any evidence that doesn’t support their ideology. Hopefully, this post will serve as a reminder of why Miller’s study is not evidence that the current vaccine schedule is unsafe.


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Brain stimulation technology improves memory overnight

Brain stimulation technology improves memory overnight

A new research suggests that a noninvasive brain stimulation technology delivered overnight during sleep may help in the improvement of memory.

Findings, published in the Journal of Neuroscience demonstrate that closed-loop transcranial alternating-current stimulation (tACS) delivered overnight for the augmentation of endogenous slow-wave (SW) oscillations in humans improved generalized memory.

Nicholas Ketz, Information and Systems Sciences Laboratory, Center for Human-Machine Collaboration, HRL Laboratories, Malibu, California, and colleagues investigated the potential for augmenting endogenous slow-wave (SW) oscillations in humans with closed-loop transcranial alternating current stimulation (tACS) with an aim toward enhancing the consolidation of recent experiences into long-term memory.

The transfer of memories from the hippocampus to the neocortex for long-term storage is thought to be enabled by synchronization of these brain parts during sleep, note the researchers.  A closed-loop tACS system was used to the phase and frequency of ongoing SW oscillations during sleep, in an attempt to enhance this natural process.

For the study, Sixteen (three female) participants were trained presleep on a target detection task identifying targets hidden in complex visual scenes. During post-training sleep, closed-loop SW detection and stimulation were used to deliver tACS matching the phase and frequency of the dominant oscillation in the range of 0.5–1.2 Hz. Changes in performance were assessed the following day using test images that were identical to the training (“repeated”), and images generated from training scenes but with novel viewpoints (“generalized”).

The 6-day protocol included an initial orientation session, three nights spent in a sleep laboratory, and two-afternoon follow-up testing sessions. When a participant correctly indicated “target present,” they saw a short video depicting the mission progressing as planned with a voiceover praising the participant for choosing correctly. If the participant incorrectly indicated that a target was present, a voiceover chastised them for delaying the mission or insulted them by indicating they were cowardly. If the participant correctly indicated no target present, feedback was given that the mission was progressing as planned. If participants incorrectly indicated no target present when there was one, they saw a video showing the consequence of missing the target.

Also Read: Yes, Radiation from mobile phones adversely impacts memory

Key Results:

  • Daytime, active tDCS stimulation demonstrated no significant difference in performance compared with the sham condition [t(32.9) = 0.881; P = .385],, and there was no difference in performance for the repeated vs generalized images [t(29.18) = −1.067; P = .295].
  • when participants receive tACS stimulation overnight they showed improved performance in detecting targets the next day vs when they did not receive overnight stimulation. This finding suggests an integration of recent experience into a more robust and general memory.
  • With the overnight tACS treatments, a t-test comparing the post- vs presleep change in F1 score on generalized images for active vs sham conditions showed a significant difference [t(15) = 2.79; P = .014].
  • The researchers found spatiotemporal biomarkers in sleep EEG spectral power that correlate with overnight performance changes. The biomarkers can be used to control the number of stimulations that must be applied for each user in future applications.
  • Results showed no significant effect of tDCS with a 1.0-mA current dose, even though a nonsignificant difference in the appropriate direction was observed.

“This human study demonstrates the use of a closed-loop noninvasive brain stimulation method to enhance endogenous neural oscillations during sleep with the effect of improving consolidation of recent experiences into long-term memory,” concluded the authors.

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Medha Baranwal

Medha Baranwal

Source: With inputs from Journal of Neuroscience

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Steven Avery's Lawyer Kathleen Zellner Speaks Out On Why She's Determined To Fight For Exonerations

Steven Avery and his family are not giving up. Having previously spent 18 years in jail for a crime he didn't commit, in 2007, Avery was convicted of the murder of Teresa Halbach, and is currently in prison again. Avery claims that he did not commit the crime, and the story of the trial has been chronicled in the Netflix docuseries Making a Murderer. Avery's new lawyer believes that he is innocent, and is scouring for new evidence with which to reopen the case in hopes of securing an exoneration. On Tuesday, Newsweek released an interview in which it became clear what motivates Kathleen Zellner in her quest for exonerations.

"What drives me is the abuse of power — the bullying and the victim. I have such a strong reaction when I see people who can’t defend themselves," Zellner said, claiming that the police bullied Avery (which they adamantly deny). This need to defend the powerless stems from her youth. Zellner studied martial arts guides as a young child, and said she used her physical powers against a teenage boy who threw a neighbor's pet duck to some penned-up dogs in her hometown of Bartlesville, Oklahoma. Zellner's protective instinct extends to human beings, and she's made a career out of it. "I do not like people that are bullies. I felt from a very young age that I was strong enough to protect people that were weaker or victims," she told Newsweek.

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Zellner has successfully exonerated 17 men convicted of murder throughout her career, and plans to do the same for Avery. She told Newsweek that about half of her cases have resulted in not only getting innocent men out of jail, but in finding the actual perpetrators of the murders for which they were convicted, as well. "I have probably solved way more murder cases than those homicide detectives," Zellner said.

After watching Making a Murderer , Zellner felt that Steven Avery was the victim of socioeconomic discrimination, saying, "The reason I took the case was because I felt that he had been discriminated against because his family was poor and they were uneducated." After analyzing the case, Zellner determined that several important factors were neglected, including Halbach's phone records — which, according to Zellner, suggest that Halbach left Avery's house alive — as well as details about Halbach's life that reportedly point to others as likely suspects in her murder. The Manitowoc Sheriff's Department has said it correctly followed all steps in the process, with Ken Kratz claiming Avery is absolutely guilty.

Zellner explained how she decides when to attempt an exoneration. "You always have a very deep-seated feeling that there's been an injustice, that's the first feeling," she told Newsweek. "The second one is I always have a strong sense that I know how to get to the resolution of the case." Zellner is hard at work putting her combination of righteous indignation and superb legal skills into Avery's case.


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Should governments legislate to prevent monopolies

Published: Mon, 5 Dec 2016

Monopolies have long been criticized for “miss-allocating” resources as well as affecting general welfare, nevertheless, firms continue their strives in becoming monopolists while governments in many cases tolerate them as oppose to legislate to prevent their emergence. Monopolies have proven to be very disadvantageous to society. Imposing higher prices than competitive markets leads to a decline in overall consumer surplus. The fact that a monopoly has no close substitutes, makes supernormal profits and has merged with the industry, dis-incentivises monopolists to be efficient and may lead to possible diseconomies of scale. [1] In general, monopolies are expected to have negative implications on efficient resource allocation and welfare seeing that the factors that compose a monopoly are assumed to give little way for the contrary (ie: increase social benefits).

This widespread disdain of monopoly power is compared to the ideal nature of a perfectly competitive market. A monopoly’s profit (private benefit) is illustrated on the graph below:

Having no competitors means that a monopolist can set any given price for a good or service, while setting output where Marginal Revenue is equal to Marginal Cost ( making profits of BCDE). [2] By contrast, were the market competitive, prices would be lower and output higher. This in turn diminishes consumer surplus and leads to a deadweight welfare loss. In a monopoly the prices are higher than the marginal cost, P > MC, which can be described as allocatively inefficient, whereas in a competitive market prices would be decreased and consumer welfare would increase. Moreover, an example of a monopoly being productively inefficient is shown when it is not producing at the lowest point of the AC (Average Cost) curve [3] . Stating that it has the potential of producing the given output at a lower cost. The AC curve is commonly higher than it should be in a monopoly firm due to the absence of competition, decreasing incentives to cut production costs.

Be this as it may, governments tend to tolerate monopolies rather than preventing them. Disassembling a monopoly takes a lot of effort and in many cases the industry has grown so dependent on the monopoly that its dissolution would lead to economic turmoil. Governments therefore tend to impose regulations on monopolies. For example, “Ofwat is the economic regulator of the water and sewerage sectors in England and Wales” [4] and state that they “make sure that the companies provide household and business customers with a good quality service and value for money.” [5] In some cases monopolies prove to be relatively efficient. It is common for a monopoly to experience economies of scale, this is to say that a firm obtains cost advantages due to expansion. As the magnitude of output increases, a firm’s average cost per unit decreases. Finally, monopolistic firms aren’t necessarily counterproductive for society. A dominant example being Google. Google is arguably the largest monopoly in terms of search engines, however, this isn’t to say that it is an inefficient firm seeing that innovations are presented constantly, (Google books, Google mail, Google maps, etc.).

As previously stated, a monopoly charges a price higher than the marginal cost. This higher price is undesirable from the consumer’s viewpoint. The higher price however provides profit to the monopoly making it highly desirable by the producer’s viewpoint. Taking total welfare as the sum of consumer and producer surplus, it is arguable to say that a monopoly can be desirable from society as a whole, seeing that the increase in producer surplus increases total surplus. The respective surpluses can be measured in the following way:

consumer surplus = consumer’s willingness to pay – cost of given good

producer surplus = revenue of good – cost of production of good

The monopolist is taken as the single producer of the market. In a competitive market, the equilibrium point of supply and demand is seen as a natural and favourable outcome. Total surplus is at its maximum level because of the efficient allocation of resources set by the “invisible hand of the market”. Overall economic welfare fails to reach its highest level seeing that a monopoly allocates resources differently from a competitive market.

Consider a monopoly in which the profits earned by the firm and consumers’ benefit is cared for. In order for both the producer and consumer to maximise profits, this monopoly tries to maximise total surplus.

Total surplus in this market would be maximised at the level of output where the demand and marginal cost curves meet. Below that level the value of the good to the consumer trumps the marginal cost of producing the good, so by increasing output total surplus would also increase. Conversely, over this level, the value of the good to the consumer is less than its marginal cost, so by decreasing output total surplus again increases.

This “ideal” monopoly could achieve the an equilibrium by charging a price relative to the social optimum level of output. Namely, where the demand and marginal cost curves meet. Much like a competitive market, the “ideal” monopoly would charge a price equal to the marginal cost of the good or service.

Evaluating the implications of a monopoly on welfare includes a comparison of the level of output set by a typical monopolist, to the level of output set by the “ideal” monopolist. The typical monopolist produces at the output where the marginal revenue and marginal cost curves meet. Whereas the “ideal” monopolist sets the output relative to where the demand and marginal cost curves intersect. This example is illustrated by the diagram overleaf:

The fact that a monopoly charges a good at a higher price than its marginal cost, leaves consumers with little incentive to purchase it at more than it is valued, rendering the quantity a monopoly chooses to sell below the socially efficient level. The shaded area between the demand and marginal cost curve is known as the deadweight loss.

It is at this point that monopolies take the blame for making profit by exploiting consumers’ willingness to pay. It is one thing to blame a monopoly for making more money and another to argue that they have an effect on welfare. A monopoly profit-maximising firm does not necessarily conjure any issues for society. Welfare in an monopolistic market involves the consumer and the producer. Every extra pound spend on a good goes to the producer, increasing his surplus but leaving the total surplus unaffected. The “losers” are the consumers for purchasing an overpriced good. Presenting an argument as to how consumers were wronged in this situation becomes more of a moral matter, however in plain monetary terms, a monopoly doesn’t affect welfare in this sense. The problem welfare faces is not in terms of the pricing but of output. A monopolist produces a quantity below the surplus-maximising level. The deadweigt loss is a measure of much the market diminishes as a result. The problem arises from the inefficiently low quantity produced.

As proven above, monopolies fail to allocate resources efficiently. They produce less than the social optimum level of output which in turn leads to higher prices. Governments may intervene in one of four ways to deal with a monopoly. Making a monopolistic market more competitive, regulation, publicising private firms or doing nothing.

In order to make a market more competitive, governments take legal measures in the attempt to prohibit company mergers that coincide with public well-being. Governments also tend to regulate monopolist behaviour. This course of action is more dominant when firms monopolise utilities like water gas or electricity. Firms are no more price setters, government agencies impose prices. It is suggested that prices should equal the monopoly’s marginal cost of producing a good. If this were the case, consumers would consume producer surplus and resources would be allocated efficiently. Nevertheless, seeing that natural monopolies have a declining average total cost, the marginal cost is less than the average total cost. If prices were equal to MC, they would also be lower than the firm’s ATC resulting to the firm losing money. The firm would then exit the industry instead of charging such a low price.

Another governmental policy includes nationalising former privatised firms. Government intervention in this case may prove to be counterproductive in the sense that a privatised firm would be incentivised by the increased market share to minimise costs of production. If firm managers are not reaching expectations concerning maintaining lower costs they are replaced in order to avoid any inefficiencies. This behaviour is popular throughout the European Union seeing that numerous countries have privatised most utility companies.

Every governmental policy has repercussions so governments are generally advised not to take any action.

In conclusion, although monopolies tend to employ profit maximising strategies by charging higher prices, this doesn’t necessarily affect social welfare directly, despite the fact that a fall in total surplus may be traced back to the elevated prices. It has more to do with the quantity supplied, or lack of, seeing that a monopoly will produce at a lower quantity than is socially optimum. In this sense, governments should intervene to prevent monopolies from exploiting consumers’ willingness to pay and their inability to provide a good or service by some other means. On the other hand however, by privatising valuable resources such as coal or water or gas or the environment in general, firms would be forced to maintain a certain level of efficiency while keeping costs to a minimum. Nevertheless by regulating monopolies and preserving competitive markets governments are able to ensure economic stability.

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Portrait of Asiel Adan Sanchez

Asiel Adan Sanchez

Asiel Adan Sanchez is an organic, gluten-free, vegan, single origin, ethically sourced gender fluid. They may be found in late-night hospital shifts writing lines of poetry in between melancholic insulin orders. Born and raised in Mexico, their work is an attempt to reconcile culture, race, gender and sexuality. They spend their free time kissing boys and crying in public.


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Dating site for creation of a family italy

This remains an important and sacred event in both towns.Gubbio was also one of the centres of production of the Italian pottery (maiolica), during the Renaissance.Ubaldo, each team carrying a statue of their saint mounted on a wooden octagonal prism, similar to an hour-glass shape 4 metres (13 ft) tall and weighing about 280 kg (617 lb).

The historical centre of Gubbio has a decidedly medieval aspect: the town is austere in appearance because of the dark grey stone, narrow streets, and Gothic architecture.

Many houses in central Gubbio date to the 14th and 15th centuries, and were originally the dwellings of wealthy merchants.

One of these wars saw the miraculous intervention of its bishop, Ubald, who secured Gubbio an overwhelming victory (1151) and a period of prosperity.

In the struggles of Guelphs and Ghibellines, the Gabrielli, such as the condottiero Cante dei Gabrielli da Gubbio (c.


confusing a meteorite

This ancient meteorite travelled in outer space for billions of years, finally drawn to the earth by its magnetic field. It was found in a desert after entering the earths atmosphere which created a momentary shooting star.  This nickel-iron rich piece of metal will be perpetually attracted to magnetic fields. The meteorite has become an intriguing object, because it is small enough to handle, enabling reflection on the size of infinity.


The government provides jobs with a living wage for everyone who wants work and can not find suitable work in the private sector. These jobs should emphasise work that the private sector overlooks or ignores the external costs of.

If there is unemployment then the government is not spending enough. The deficit should be expanded to cover full employment. The return benefits of such a program are high, both in personal benefits to the employee from having secure work, and also to the economy down the track as unemployment generates undesirable costs such as increased health care, higher crime rates and more instability in families. The job guarantee should focus on improving sustainability rather than the current economic growth at any cost model that drives private sector growth. Programs should focus on benefiting society, e.g. - environmental renewal (reforestation, preventing coastal erosion, clearing pollution) - recycling initiatives that are not economically viable for private sector (e.g. door to door collection services) - community sports programs (hint, take the 2 billion flagged to rebuild stadiums in NSW) - personal assistance to less able members of the community

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