University Profits as a Component of the Student Debt Crisis?

*The following is a guest blog contribution from our friend Alan Fredendall SPT*


*Correction statement 11/30/2017Following the initial publication of this post yesterday afternoon, the spreadsheet had some rows deleted to enhance the appearance which changed calculations. This was fixed when noticed but some whom viewed it may have seen incorrect calculations. I apologize for this error. It was not intentional but as the sole owner of this spreadsheet, it is ultimately my responsibility for these errors. The spreadsheet is now displaying as intended and I will no longer make any cosmetic changes. Schools will still be added as there are about 10 schools who still haven't returned FOIA requests. The purpose of using Google Sheets is to create an open source for these costs that can grow as more data becomes available. 

I want to emphasis that the point of this post is not to single any school out but rather to identify that university profits are a key issue when evaluating why the cost of education and PT student debt have been rising disproportionately. While the excess cash is certainly not held by individual PT departments,  it's use to subsidize infrastructure improvements,  athletics, or other operational expenses is ethically debatable as public institutions are supposed to use tax funds and endowments for these purposes. 

We thank everyone who provided comments, feedback, and criticism. For those that do not believe this post and data is comprehensive enough to be shared, we inviteyou to collaborate and share your data with us, we will absolutely incorporate it and would be very grateful for the contribution* - Sincerely Alan Fredendall SPT


 

 

 

The cost of PT education has become a popular topic in our profession as tuition continues to skyrocket. Overall student loan debt has increased from $363 billion to $1.38 trillion between 2005 and 2016.  Awareness that the current course is unsustainable has inspired encouraging innovations such as alternative approaches to traditional PT school education.  For example, South College has created a hybrid 2 year model which cuts tuition costs by 33% in addition to reducing commonly ignored costs such as traveling to campus every day that occurs within a traditional program. While several solutions will be required, one obvious area for consideration needs to be whether the price tag universities are putting on DPT programs is reasonable and appropriate. What ARE the costs of PT education and just how large are the "profit" margins at universities with PT programs? That is the question we recently set out to answer.

 

A group of colleagues and myself have spent the past few weeks doing a deep dive of the revenue and costs of tuition at each public university with a PT program in the United States. We chose public schools because with a few exceptions these universities receive state funding and therefore are required to publish their financial information to the public. In addition, for those schools that do not have this data readily accessible, they are required to comply with Freedom of Information Act requests at the state and/or federal levels. Since public schools host the majority of PT programs in the country, evaluating them provides a robust sample of the revenue and costs of PT school education. For the purposes of this analysis, revenue was calculated to be the tuition and fees published by each university multiplied by the cohort size and the number of cohorts taking class simultaneously. There are additional revenue sources for schools including charging for printing, mandatory clothing and equipment, etc. but are too varied to standardize. In addition, the revenue is almost always lower than the true cost to students as they must purchase books, specific clinical clothes, vaccinations and often some sort of verification service for background checks. Costs were calculated as the salary and benefits of the faculty of each PT department plus any additional operating expenses if published. These operating expenses range from postage for sending information packets to prospective students to reimbursing expenses for conference attendance. Unfortunately, no school publishes a line item budget. Without this data, it is impossible to follow every dollar within a university system. Most schools simply list "Other costs" on their budget book summaries such that total university revenue equals the total costs, thus the college remains non-profit.

 

The data we gathered is available at http://bit.ly/2gT6S3k for your review. I welcome and encourage feedback, comments, and criticism that can serve to deepen the important conversation surrounding the cost of physical therapy education. I believe this data makes it much easier to see how fast loan debt can rise with profit margins so high.  Our goal of organizing and presenting this information is to encourage creative thinking from faculty and university leadership. We believe there is plenty of fat to trim and that new models of education such as the South College model should be recommended to prospective students. Additionally, we hope this information makes it into the hands of undergraduate students considering our profession so that they may be as informed as possible when choosing to select and support a physical therapy program.

 

I want to thank my colleagues who helped with this project including Dan Crusoe, Leor Giladi, Rachel Selina. In addition I want to thank Joseph Reinke of FitBux for spending the time with me many times over the phone helping me make sense of budget documents that were often hundreds or thousands of pages long. Finally, a big thank you to Dr. Jeff Moore who initially approached us about gathering this data and publishing it as well as his generous offering to post this blog on his website.

 

Alan Fredendall is a 3rd year DPT student. He can be reached by email (alan.fredendall@gmail.com) or on Twitter (@AlanFredendall). 

 

 

With the Shoulder: Keep it Simple

I was chatting with an orthopedic surgeon the other day, and he asked me what I thought the easiest joint to rehabilitate was.  My mind flashed between several joints, and then oscillated between knee and shoulder.  I ultimately chose shoulder, not because it is a simple joint, but because there is so much one can address between posture, strength, and mechanics.

 

 The shoulder girdle is a complex interaction of 3 true joints, and 1 psuedo-joint. And this is the beauty of working with the shoulder: if one aspect of the shoulder girdle complex is injured or dysfunctional, we can work around this dysfunctional piece through the other pieces of the shoulder girdle complex and often improve one’s overall function.  A large part of rehabilitating the shoulder involves increasing postural awareness and improving the dynamic stability of the shoulder girdle complex.   Namely increasing rotator cuff and periscapular strength and endurance. 

 

Therefore, therapeutic exercise and neuromuscular reeducation are vital parts of a shoulder rehabilitation program.  Too often I see patients that have failed conservative management of the shoulder injury/dysfunction with another physical therapist; not from addressing the wrong deficiencies, but from not paying attention to the details.  Simply put, the execution of their rehab fell short.  Since we relay heavily on a patient performing a home exercise program, one better make sure that strict attention to detail is given when instruction them in their exercises. 

 

Choosing the correct exercise to target the appropriate muscles is also crucial.  It often tempting to get too creative with shoulder strengthening, but the truth is basic exercises that have been shown to have high EMG activation are often the most effective.   Regardless of the shoulder injury or dysfunction, be it subacromial impingement syndrome, a SLAP tear, or shoulder instability, the following exercise are often going to make up the foundation of the strengthening portion of your rehabilitation program.  These videos show a few of my foundational exercises for many patients with shoulder dysfunction:

 

Hip To The Literature

The British Journal of Sports Medicine recently released an excellent issue with some great insight on current concepts regarding femoral acetabular impingement (FAI).  Of note, is the open access consensus statement regarding current best practice in regards to diagnostics and treatment and the promotion of individualized care for individuals with FAI syndrome.

 

Yes, the consensus’ addition of the word syndrome to FAI is important, as we have learned that there is more to this topic than just hip joint morphology. Symptoms of hip pain, clinical signs of decreased range of motion, painful hip flexion-adduction-internal rotation (FADIR/Impingement Test), hip strength and motor impairments combined with diagnostic injections and pathoanatomical findings via diagnostic imaging are required to make the correct diagnosis.  This is the easy part.

 

The expert panel recommended that the patient should then be exposed to all treatment options and requires individualized care.  The literature offers us no clear path on choosing that course of care.  The debate of conservative or surgical care remains challenging.  With physiotherapy-led rehabilitation, the goal is to regain hip strength, stability, and motor control while improving (and protecting) appropriate mobility and movement impairments.  The surgical goal is eliminate a potential pain generator and restore impingement-free motion.  Then the individual will undergo a course of rehabilitation, tackling the same goals previously mentioned.  Ultimately, all paths eventually lead to physical therapy.

 

The FaSHioN randomized controlled trial (Wall) offers suggestions on current best practice of a conservative course of care.  Of importance for success includes proper patient subgroup selection and intervention selection.  Freke’s review of symptomatic FAI revealed consistent impairments of hip mobility, hip strength, motor control, and single leg deficits.  It makes sense that that the FaSHioN group attempts to take on these functional limitations.  However, what those terms mean to each physical therapist is different, and falls in line with a lack of consistency of care in the literature.  (All Open Access!  Go Read Now!)

 

When clinically reasoning through these cases, it makes sense to be careful about pushing mobility, considering morphological blocks and irritants.  Without irritating the key lesion, assessing and treating lumbopelvic and soft tissue mobility, along with pragmatic inferior and posterior glides of the hip joint, may create increased pain-free mobility and movement. This serves as a gateway to the desired avenue of exercise. Loudon & Reiman (PT in Sport 2014) provide an excellent review on potential pathomechanics and provide clues on mechanisms that could be assessed and treated conservatively.  After appropriate assessment, exercise intervention may benefit by paying attention to tiny details provided in the research of Selkowitz, (JOSPT September 2016, February 2013) and Khuu (IJSPT April 2016), in that subtle technique variations to bias motor recruitment and biomechanical function has the potential to feed or attack potential impairments. How we choose to gain mobility, stability, dose exercise and achieve motor recruitment and control matters. 

 

So what did we really learn from this influx of new evidence?  The consensus is that there is no consensus beyond diagnostics and complexity remains in treating this syndrome.  The picture is less clear than ever, as we spin our wheels slowly moving forward and awaiting clinical trials to comparing conservative and surgical care.  At the minimum, a patient-centered and individualized plan of care is a must.  Regardless of the course of care, similar impairments will be present and targeting regional mobility, hip strength, single leg stability and motor control of the hip and pelvis are necessary.  If you are still with me, check out a few of our current ways of addressing these through exercises on the video posted below!

 

Disclaimer:  This is not medical advice and these opinions are independent of any entity.  These thoughts were likely fueled by consumption of too much coffee and great music.

 

References:

 

Griffin DR, Dickenson EJ, O'Donnell J, Awan T, Beck M, Clohisy JC, Dijkstra HP, Falvey E, Gimpel M, Hinman RS, Hölmich P. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. British Journal of Sports Medicine. 2016 Oct 1;50(19):1169-76.

 

Freke MD, Kemp J, Svege I, Risberg MA, Semciw A, Crossley KM. Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence. British Journal of Sports Medicine. 2016 Oct 1;50(19):1180-.

 

Wall PD, Dickenson EJ, Robinson D, Hughes I, Realpe A, Hobson R, Griffin DR, Foster NE. Personalised Hip Therapy: development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomised controlled trial. British Journal of Sports Medicine. 2016 Oct 1;50(19):1217-23.

 

Loudon JK, Reiman MP. Conservative management of femoroacetabular impingement (FAI) in the long distance runner. Physical Therapy in Sport. 2014 May 31;15(2):82-90.

 

Selkowitz DM, Beneck GJ, Powers CM. Comparison of Electromyographic Activity of the Superior and Inferior Portions of the Gluteus Maximus Muscle During Common Therapeutic Exercises. journal of orthopaedic & sports physical therapy. 2016 Sep;46(9):794-9.

 

Selkowitz DM, Beneck GJ, Powers CM. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. journal of orthopaedic & sports physical therapy. 2013 Feb;43(2):54-64.

 

Khuu A, Foch E, Lewis CL. NOT ALL SINGLE LEG SQUATS ARE EQUAL: A BIOMECHANICAL COMPARISON OF THREE VARIATIONS. International journal of sports physical therapy. 2016 Apr;11(2):201.

 

 

'Maintenance' manual therapy: Is it time to stop discharging patients?

The story starts off nicely.  Jack comes in with chronic non-specific low back pain and a bit or right leg pain of 6-8 months in duration.  He has tried a number of medications, has rested and tried to modify activities, however he just can’t seem to shake it.  You question and test for a directional preference but nothing surfaces.  FOTO has given Jack a low fear score and while you didn’t actually give him The Pain Catastrophizing Scale, FABQ, or Orebro, you see no indication for pain science education early on.  The prone instability test is negative and there are no aberrant motions during lumbar flexion.   Jack reports years back that he had a similar episode and a physical therapist cracked his back which he found very helpful.   Considering the info and the positive expectations for thrust manipulation, your first few treatments focus on HVLAT and basic ROM exercises to the lumbopelvic region.  After two weeks Jack’s pain is down 50%, you have already pole vaulted well over the expected FOTO change, and he has referred his wife to you in hopes of the same excellent results.  He backs it down to one session over the next few weeks and with your encouragement returns to all of the activities he loves.  You and Jack decide to wrap it up as he reports “feeling better than I have in years” and shows minimal disability on FOTO.  Spirits are high, time for a successful discharge and for Jack to enjoy a life with minimal back pain! It is a wonderful story and a very nice picture to paint, unfortunately evidence suggests this is not how it usually goes down.  To be fair, a lot of it IS true.  In fact, MOST of it is true.  Right up to the last sentence, this is a scenario that plays out on a daily basis in clinics including mine all across our country.  To get the whole picture however, let’s peek at some literature where they examined the use of spinal manipulation in the treatment of CLBP.  In 2011 Senna and colleagues looked at an intensive course of spinal manipulation (12 tx over 1 month) compared to a “maintenance” group which got the same intensive course but also received a session of spinal manipulation every two weeks for the following nine months1.  Take a look at the chart below.  The difference between the ‘maintained’ and ‘no maintained’ is striking to say the least.

Another article by Descarreaux and colleagues examined an intensive one month period of spinal manipulation followed by no treatment, versus preventative spinal manipulation for chronic low back pain2.  This second chart is pulled from that article (black squares represent maintained manipulation), look familiar? Here again is this nice drop in disability during the initial “intensive” period of thrust manipulation treatments.  Over the next 9 months the group that received “preventative” spinal thrust manipulation once every three weeks continued to improve whereas the discharged group watched their progress slowly and steadily erode.

This data brings up a question:  Should the generally accepted plan consisting of intensive treatment followed by the complete discontinuing of care be challenged?  Just the other day I had a patient come in who I treated two years earlier for recurrent non-complicated low back pain.  I asked him how I could help today and he literally said the following: “Sorry I am back Jeff, I fell off from my exercises and my job has been demanding a lot more sitting out of me this past few months.  I really tried to shake it by getting back to my workouts but I think my current job demands are making it impossible.  It has been worsening to the point that I am struggling to concentrate so I finally had to call you”.  While it's great this patient is trying to use exercise and activity modification to take control of his symptoms, it is borderline ridiculous that he would be out there suffering through his days reluctant to reach out for my help.  Thinking back to his last few visits it makes a lot of sense though.  I made plenty of comments along these lines:  “You’ve got to avoid sitting for long periods if you don’t want this to come back” and “You have control of this now, you don’t need me anymore”.  All fine and dandy, but completely absent were comments like these:  “If this tightens up on you again just give me a buzz and get back in here” ; “Don’t let it get really bad next time, swing in earlier so we can tune you up with a few visits and refresh the stretching program if needed”.  I mean seriously, do dentists clean your teeth once and then expect you to abstain from any potential cavity causing substances?  No, they accept that life throws dietary challenges your way and they hope to see you on a somewhat regular basis to tune things up and make sure they don’t get head down a bad path.  Sure these dentists remind you to drink less soda and eat less chocolate, but they don’t hammer it so hard that you suffer with a severe toothache for months on end before calling out of fear that you let them down!  In an effort to empower this guy and prevent dependency I went too far.  No longer did he feel like we were a therapeutic team going forward, it was as though I told him "Hey I've done my job, now don't screw it up".   Slice it how you will, from a business and customer service perspective this was a significant fail.

I know many will be tempted to turn this into a discussion about how adding cognitive behavioral therapy or specific stabilization exercises or additional interventions beyond HVLAT and lumbopelvic ROM exercises would be the solution, and certainly I welcome and appreciate that conversation.    However looking at a recent systematic review for stabilization exercises we see “no significant effect in the long term…”3 while dramatic improvement with cognitive functional therapy during an intensive period is seen to be slowly back peddling as the year mark nears in a piece by Fersum et al.4. Honest reflection on my clinical experience supports this literature with patients often doing great for a period of time after ‘discharge’ only to lose half of that progress in the few months that follow.   In response to this emerging data my goodbyes to patients look a lot different these days.  While I still stress the importance and value of self-management, I also let each patient know that we understand life happens, and we are here to give them a boost up whenever they need it.   We should be coming alongside patients for a lifetime, not for 6-8 weeks.  “Am I discharged?” they ask me, “never, but get out there and fight the good fight, tap me whenever I can be of service”.

Thoughts?

References:

  1. Senna, M. K., & Machaly, S. a. (2011). Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome? Spine, 36(18), 1427–37
  2. Descarreaux, M., Blouin, J. S., Drolet, M., Papadimitriou, S., & Teasdale, N. (2004). Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: A preliminary study. Journal of Manipulative and Physiological Therapeutics, 27(8), 509–514.
  3. Smith, B. E., Littlewood, C., & May, S. (2014). An update of stabilisation exercises for low back pain: a systematic review with  meta-analysis. BMC Musculoskeletal Disorders, 15(1), 1–21
  4. Vibe Fersum, K., O’Sullivan, P., Skouen, J. S., Smith, a, & Kvåle, a. (2012). Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. European Journal of Pain (London, England).

The KEY to Thrust Manipulation = Mobility Exercises

As physical therapists we are aware of the benefit that can be achieved with thoracic thrust manipulation for spine pain.  

A developing body of literature also supports the effectiveness of this intervention for patients with shoulder pain.(1)  Improved shoulder range of motion, function and reduced symptoms, immediately following manipulation, has been demonstrated in several studies.(1)  The mechanisms to explain this benefit are likely neurophysiological with further consideration for non-specific effects and patient expectations.(2,3)

One can leverage this immediate reduction in pain with adjunct exercise.  Adjunct interventions could consist of active mobility, passive stretching and motor control exercises.  Active mobility exercises are an excellent bridge between thoracic manipulation and motor control/strength training.

This side-lying thoracic rotation mobility exercise is a great technique to utilize immediately post manipulation.

The patient assumes the sidelying position with the arms at 90 degrees of shoulder flexion.  Thoracic rotation is initiated by rotating the arms apart while hip and knee flexion is maintained to create tension through the lumbar spine.  The clinician can provide overpressure to the shoulder and opposite hip in order to achieve a greater amount of rotation.

Progression can occur by integrating more advanced techniques in the quadruped position or with a fixed lower extremity such as the following mobility exercise.

Sources

  1. Sueki D, Chaconas E. The effect of thoracic manipulation on shoulder pain: a regional interdependence model.  Phys Ther Rev. 2011;16(5).399-408.
  2. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model.  Man Ther. 2009 Oct;14(5):531-8.
  3. Bialosky JE, Bishop MD, George SZ, Robinson ME.  Placebo response to manual therapy: something out of nothing? J Man Manip Ther. 2011 Feb;19(1):11-9.

The Other Side of Advocacy

  “Why invest so much in your education to become a physical therapist if you can’t completely use those skills when you graduate”?  That’s the statement I made to a group of students from North Dakota last week.  I didn't realize they have full unrestricted direct access and minimal scope of practice limitations.

Are the advocacy efforts complete in those 30 states with minimal direct access limitations?  A lot of additional state and federal political efforts are still needed in a variety of areas but putting that aside for a second let’s focus on the social component of advocacy.  What we are not doing is marketing in such a way that most people in the United States think of seeing a physical therapist first when experiencing musculoskeletal pain or injury.  We are not meeting the needs of society if only a small portion of people are aware of our value and skill set.  A recent blog by Ryan Klepps highlights the notion that physical therapists probably only see about 8% of the musculoskeletal injury market.

Who cares if you have direct access when such a small amount of people seek your services?  Why aren't people aware of the physical therapists role?  Why do they seek other options for musculoskeletal care or avoid care altogether?

It boils down to professional branding, public awareness efforts, and every single one of us displaying our skill set and value every day, to everyone we know and every patient we see.  These APTA commercials are a great place to start.

And when people don't know the vision of the profession you can send them this

http://www.apta.org/Vision/HumanExperience/

*Special thanks to all our colleagues from the Florida Physical Therapy association who keep advocacy interesting and entertaining every year as we work to modernize our practice act to reflect our training and skill set.

 

Why We Need To Keep Taking Students

I write this in response to a call I got from a major DPT program last week asking if we could take a few more students this year.  They informed me that  "many of our sites have stopped taking students".  This is troubling and while I don't have any statistics, rumor has it that clinical sites with C.I.s who are seriously committed to student development are getting more challenging to come by.  I thought I would take a few minutes and speak to this topic....  

I'll never forget a number of years back reading this quote from an article by Dr. Boissonault published in JOSPT:" Although considerable variation currently exists in how TJM is integrated into professional degree physical therapy program curricula, a majority of faculty responsible for teaching manual therapy believe that the most beneficial way to enhance their students’ preparation in TJM is to increase emphasis on this intervention during clinical education experiences"(1).  WHAT??  So we are saying that arguably the most challenging psycho motor technique in all of physical therapy is not being taught by the faculty but instead they are hoping that unpaid volunteer C.I.s will take the lead on this?? At the time I happened to love TJM, was recently certified by James Dunning and his crew over at the Spinal Manipulation Institute, and had no problem working on this with my new student who just told me he had minimal exposure to TJM in school.  However, the notion that this is how it should go down just seemed a bit off.

 

There are basically just two ways to respond to the situation we see here, one that extends well beyond the example of TJM.  The first is to take a strong stance that doctorate program faculty shouldn't be able to sit back and collect a student's tuition money while unpaid C.I.s work their butts off for 12 weeks teaching them complicated and clinically important material.  This is not an unreasonable stance, and I am lying if I say over the past 5 years of training doctorate students at a rate of 4-6 per year I don't occasionally find myself hanging out in that camp.  The other choice is to realize that DPT programs are in a really tough spot as CAPTE requires them to cover a ton of material, much of which we outpatient folks may not feel is "need to know" information.  The bottom line is that doctorate students aren't learning in school many critical skills which will hinder their ability to be successful in practice and thus advancing our profession.  An army is only as strong as its individual troops, and for that reason alone we can not turn a cold shoulder to these students.  We need them to come on to the scene playing offense.  We need them to be aggressive in every aspect of their careers, from marketing directly to the public to lobbying for legislation and demanding it passes sooner rather than later.  With the right tools this next generation of physical therapists will storm in and use the momentum our profession is already building to push us the rest of the way up the mountain.  Want our profession branded?  Want unrestricted direct access in all 50 states? Then take the time to polish up our soon to be colleagues, build their confidence, and unleash them on the world.  That or we can keep sitting around complaining about CAPTE, your choice.

 

1. Boissonnault, W., & Bryan, J. M. (2005). Thrust joint manipulation clinical education opportunities for professional degree physical therapy students. The Journal of Orthopaedic and Sports Physical Therapy, 35(7), 416–23.