The Thinking Practitioner Podcast:
Episode 101: Interprofessional Communication (with Lane Blondheim)

Whitney Lowe:

Welcome to the Thinking Practitioner where Books of Discovery has been a part of massage therapy education for over 20 years. Thousands of schools around the world teach with their textbooks, e-textbooks and digital resources. And Books of Discovery likes to say learning adventures start here. And they see that same spirit here on The Thinking Practitioner Podcast and are proud to support our work knowing we share the mission to bring the massage and bodywork community enlivening content that advances our profession.

So, check out their collection of e-textbooks and digital learning resources for pathology, kinesiology, anatomy and physiology at booksofdiscovery.com where Thinking Practitioner listeners can save 15% by entering the word THINKING at checkout.

This is Whitney and Til is off this week. I'm delighted to be joined by a longtime friend and colleague, Lane Blondheim. Lane is a physical therapist in South Bend, Indiana. And our topic today is looking at some issues that we share in common between our professions and maybe some things that we can learn from each other as well.

So Lane, welcome to The Thinking Practitioner and great to see you again.

Lane Blondheim:

Whitney, thank you for having me here. It's fantastic to see you again and to be in collaboration with you on any project that you have that's available. I love working with you on a lot of things.

Whitney Lowe:

All right, great. So, I'm going to ask you, Lane, just to talk a little bit about your history background and what you are currently doing. And again just as a note to everyone, we do have Lane and I go back probably to what, the early '90s or so I think it was when we were first teach-

Lane Blondheim:

1993.

Whitney Lowe:

Yeah, teaching together back a long, long time ago. So, I've been following your career and the wonderful things that you've been doing since that time. So tell us a little bit about what you do and where you are currently.

Lane Blondheim:

Well, prior to '93, I got a degree from the University of Alabama in Political Science and was considering medical school or physical therapy school. Decided to go to the Atlanta School of Massage to get my certificate and massage therapy. Got to work with you and Benny Vaughn and a host of other really fantastic people that really have shaped my world for physical therapy.

I eventually went to a physical therapy school. I graduated in 1998 from the University of Mobile down in Saraland, Alabama on the coast near Mobile. And from there, I worked at a hospital for a short bit and then wanted to work for a larger company that had a private practice. They were bought out by Venture Capital Group.

I moved on and opened my own practice and had one for 12 years in Montgomery, Alabama. Sold it or merged it into another practice and then eventually ended up here in South Bend, Indiana with a company called Athletico Physical Therapy which has been fantastic. It's been more of a dream job and allows me to do a lot with coworkers and students and physicians ranging from the bottom of Lake Michigan to Fort Wayne, Indiana.

Whitney Lowe:

Yeah, wonderful. You've got such an interesting diverse educational background. I know you and I talked about this probably some many, many years ago and I would like to just share a little bit with the listeners. You said you had an intention to become a physical therapist earlier on when you went to massage school, but tell me how that training in the work that you did in massage therapy, how did that shape your perspective about your work as a physical therapist?

Lane Blondheim:

Well, as you may or may not know from some of our prior discussions, just personally between us, there was a time when I really got focused on being a physical therapist. And knowing that a physical therapist has to touch their patients, what better way to get more mastery than to be a massage therapist and researching different programs from the Carolinas through Georgia, through to New Orleans, the Atlanta School of Massage for me, not to really plug them, but what they had at the time was such a more focused opportunity that I felt would segue better into physical therapy for me.

Ben Vaughn, yourself were huge draws for me in terms of what you brought to the table. When I sat down and interviewed the school and was completely impressed and knew that this is where I wanted to go to start my direction to be a physical theorist.

So, it was a true launch pad. And what I learned there has provided me the opportunity to work with students on a university setting and in a one-on-one and small group clinical setting to really learn how to relate to your patients, gain their trust for touch, listen to your patient's body, to listen to your patient when they say things, and really try your best to work the diagnostic process.

Whitney Lowe:

Yeah.

Lane Blondheim:

And that way, you can then have a better intervention for treatment.

Whitney Lowe:

A couple of years ago, I was doing some work with an organization that was trying to focus a great deal of attention on interprofessional education and just that's essentially how we learn about what other professions do. And one of the things that's very clear to me as an educator in the massage therapy world is that I hear a lot of things from practitioners in our field about other professions and fields that I think are misunderstandings. And you have a particularly unique perspective I think from being trained as a massage therapist and then also working as a physical therapist.

I'm curious to know, from your perspective, what are some of the common misconceptions that maybe physical therapists have about massage therapists or that massage therapists have about physical therapists and the work they do?

Lane Blondheim:

Well, let's start from the physical therapist standpoint first. I think that it's one of the more clouded ones. And it's that massage therapists are basically flowers and beads and granola kind of people who are low educated that just like to rub on people or work in a spa. And you and I both know that's absolutely not true that the level of education that one receives before I was even in massage therapy school is much higher than that.

Certainly it's not at a full university setting for an advanced degree, but the very basis of what's available as a massage therapist to be educated is pretty strong. And then once you do with it, once you get out, of course it is on your own. And yeah, there are some people that are alternative not by design but by draw and massage therapy. But there's some also fantastically clinical practitioners out there who hauled in on some really specific ways to make people feel better.

From the massage therapist to the physical therapist standpoint, PTs are arrogant and they do exercise modalities. And there's whole veins and branches of physical therapy that are very much into manual interventions ranging from Stanley Paris, Ola Grimsby, Brian Mulligan, Maitland, et cetera, that have brought us to where we're at in current practice where we really understand that you have to find ways to touch your patients.

Of course you need to be a master of exercise, know how to use your modalities, but if you don't sit down and actually work with your patient, touch your patient, make your patient comfortable. And the fact that you can break down their problem in a more holistic fashion. McGill, first name escapes me. Stuart. Yeah, Stuart McGill. Fantastic, fantastic practitioner, fantastic educator. And his books and then some of his podcasts and I think he did one with you sometime back.

Whitney Lowe:

He did, yeah. A couple actually, yup.

Lane Blondheim:

Understanding the biomechanics, the anatomy, et cetera, the different things that make a patient tick, not looking at what was ... One thing that he said that was poignant on one of his podcasts and it may have been yours that iliopsoas, it's not one muscle, they're two muscles. They are innervated differently. They activate differently. They are used differently. Your body tells them to work different manners and their timing and whether you're standing or sitting or whatnot and how that breaks down into that individual's problem.

And then, he also brings in very appropriately the psychosocial issues of the individual patient. And I'm probably getting ahead of where you're at. But when massage therapists and physical therapists think along those lines, we're all on the same page and we can all drive forward to make those individuals better.

Whitney Lowe:

Yeah.

Lane Blondheim:

So, yes, PTs are very arrogant. When we're talking to other practitioners, especially when we think they are below an educational level than we're at such as a massage therapist who only requires a certificate or maybe it's an associate's degree depending on who's running their program as compared to the current physical therapy entry level degree which is a clinical doctorate.

When I graduated, it was a master's degree and they were just beginning the clinical doctorate programs. But years ago, it was a certificate just like a massage therapist.

Whitney Lowe:

Yeah.

Lane Blondheim:

We had to do all of the anatomy, physiology and modality of physics, et cetera. It was just a certificate. So, the background between a PT and a massage therapist ultimately has a similar history. Massage therapy is just not advanced in the formal education realm at this point.

Whitney Lowe:

Yeah. I'm curious to hear a bit more from your perspective as an individual within this field because this is my perception from an individual outside of the physical therapy world because I do hear in reading various social media forms and things like that, a fair amount of discussion kind of some of which you alluded to here about manual therapy versus not manual therapy.

Is there sort of a schism or kind of a division in the field of people who are very strong advocates for doing a lot of hands-on manual therapy versus those that aren't? Or is that just like a small thing?

Lane Blondheim:

I think it boils down to formal education. In physical therapy school, you get a few days of massage and a little bit of joint mobilization and some very rooted material. The big focus is on diagnosis, basic science, psychosocial pharmacology, et cetera. And all those are wonderful. But when it comes down to practice and taking all those things that you've learned, they've learned more about exercise than they have about putting their hands on you.

So, the schism and in my humble opinion is that we don't facilitate the learning for the physical therapy student to be better with their hands as a source of data to then provide care. It always amazes me when a therapist does nothing but exercise and they often get some very fine results. But they miss a tremendous amount of data that could help refine their intervention and more expediently make a change in that patient or provide them a completely different perspective that could help some of the hang-ups that that patient has in their care or progress I guess is a better way to say it.

Whitney Lowe:

Yeah. So if there is that limited amount of time with actual instruction and hands-on manual therapy, are most practitioners who are doing more manual therapy stuff learning that stuff in continuing education courses after they finish their degree? Or how are they developing those skills?

Lane Blondheim:

They are going out to other courses. Some are becoming massage therapists and then going back into the clinic. Others are going to courses of some of the aforementioned names, Ola Grimsby, Maitland, et cetera, associated themselves with more of manually therapy-oriented associations in the country and internationally. And they see a grand opportunity there to really intervene with their patients in a completely different thing.

Whitney Lowe:

Yeah.

Lane Blondheim:

The benefit of mobilizing a joint, improving vascular flow via soft tissue manipulation, neurogliding, other mobilizations of tissues, et cetera. Plus understanding the anatomy becomes a deeper perspective, an addendum to that. Things like dry needling, cupping, Graston technique, IASTM technique, you need a different perspective of how you're going to intervene with your patient other than exercise.

It allows them to know that some type of touch and I'll include dry needling and that touch loosely. Having a different understanding of that anatomical series of structures and how they interplay has been very beneficial to a lot of therapists.

Whitney Lowe:

Yeah. Tell me a little bit about in terms of your clinical work over the years. And let me sort of back up, did you have any, for example, massage therapists working with your clinics in Mobile where you were or where you are currently in Indiana?

Lane Blondheim:

We don't have any working with us here. And in Alabama, we for a brief time had massage therapists working with us, but their lives took a different term because of relationships and they moved out of town. We brought in a physical therapist who's a lymphedema specialist. And her activity was probably 98% hands-on manual therapy for lymphedema, probably more like 85, and the rest was taping and strapping and a little bit of exercise, but it was primarily manual lymphatic drainage.

It's been more of a collaboration of outside offices and trying to find a way to discuss and work with a patient with, of course, appropriate HIPAA clearance. I think that having a massage therapist on hand in an office is very valuable, but I think that opens up a can of worms of how you deal with reimbursement. And that's another topic in and of itself. But when you're able to collaborate, I think it's much more efficient.

Whitney Lowe:

Yeah. What are some maybe just a clinical case example or two of ways in which you think our two professions would work most effectively together? And I've certainly seen this because I've worked in a number of physical therapy clinics across the years and just saw some what I've felt like to be in many instances, enhanced results when the two of us did what we do best together, especially in various post-surgical cases and things like that.

But what are some examples of ways that you think the patient outcomes are really enhanced by the different approaches?

Lane Blondheim:

Sure. I have two basic ones that turned out really well. The crux of the improvement though I think was the communication between the therapists and the patient. That trilogy of communication would have to be particularly excellent.

One is a patient with fibromyalgia who also had lumbar radiculopathy. She psychologically had a lot of stress, was completely concerned and focused on her problem as if it was a series of forest fires. And that one significant problem between myself and a massage therapist, we were able to listen to the patient, help her delineate some of her problems. But from a more clinical aspect, we were able to actually put hands on areas of her spine that did have trigger points, areas of her hips and glutes that had trigger points that mimicked her radicular symptoms.

We were able to reduce the interference of the symptoms in the physical therapy clinic with some exercise, a little bit of modality and some hands-on soft tissue at joint mobilization. But I think she really got a lot better when she went to see the massage therapist, had spent 30 to 45 minutes at a time with this person doing nothing but we'll call it regional intervention, particularly like her electro thoracic spine down to basically her knees. And they had more time at clinic because they did not have the constraints we have as physical therapists.

As I said, any business productivity is a big situation. And we have to deal with insurance reimbursement, can be problematic. Insurances will limit how much manual therapy we can actually intervene on a patient with on a consistent basis.

But a massage therapist has the gift of time and for them to be able to change the vascular flow in that region to allow the patient to experience changes in the tissues and talk about it. And they use non-catastrophic verbalizations with the patient, gave her hope, gave her insight. We echoed a lot of those things in the physical therapy clinic with what we were doing with activity and function and the bit of manual therapy that we were doing.

And I think the whole turnaround from the psychosocial to the time on the table with the massage therapist and working on function and the bit of manual therapy we did was a wonderful formula for her.

Whitney Lowe:

Yeah.

Lane Blondheim:

Similarly, a total knee replacement patient, lots of swelling, lots of bruising. Again, our big constraints in the clinic that I was at was spending a lot of time working through the hip musculature, working through the calf musculature in a manual fashion.

We work a lot on function. We work a lot on strengthening, a bit on the manual interventions. But in collaborating with the massage therapist, they were very capable of making sure that we kept the iliotibial band free by working with the glutes and the fascia lata for example. Reduced their swelling, helped improve vascular flow all up and down the leg.

The remaining bruising was on their thigh from their tourniquet time and the surgery disappeared much quicker. They were more comfortable and then therefore they were able to turn around and they work harder on their function at clinic. So, just wonderful to have those several visits with the massage therapist with both of these patients to have wonderful impact.

Whitney Lowe:

Yeah. You've mentioned this a couple times and I know this is a bit of a potential rabbit hole too. But this is an issue that comes up a lot in our field, a lot of the discussion around should we try to get more involved with learning more about insurance reimbursement to make massage more accessible to different people?

And a lot of the folks that I've talked about in different fields, in your field and in the chiropractic field, do they have to work with insurance? A lot say they would love to not have to do that. And it seems like the people who have it don't want it, the people who don't have it want it kind of thing sometimes, at least to some degree.

And I'm curious to hear your take on whether or not you think that the reimbursement process through insurance is something that has interfered with the ideal treatment protocols in many instances because that is one of the things that I do hear from a lot of the PT practitioners that I listen to.

Lane Blondheim:

I'll say that it certainly does force us to have to think a lot harder about how we're going to treat a patient through the insurance company versus just purely treating patients.

Whitney Lowe:

Yeah.

Lane Blondheim:

Insurance companies rightly in some ways and not as rightly in others force diversification in how one intervened. Not to get mired in treatment codes and such but doing therapeutic exercise, neuromuscular reeducation, manual therapy, therapeutic activities, ultrasound, electrical stimulation, et cetera. That's how we bill. That's how we get paid usually based on a timed effort.

The timed efforts have evolved and I will not go into that because it can be quite a nightmare in a rabbit hole. We just don't want to have time for it. But the more diverse you'd bill, the better opportunities you have for complete reimbursement. If I had my druthers on some days and doing nothing but manual therapy on my patients for 2, 3, 4 units per visit, it would be fabulous to spend a full hour or more with a patient doing nothing manual therapy. And I can get away with that every blue moon for a patient.

But insurance companies seem to have an algorithm where they will stop paying for certain procedural codes after either a bulk number of them or after a period of time. And sometimes they will audit you sometimes without you knowing. As a practitioner, they'll get documentation, they'll look at your coding and they'll see if they think it was appropriate for you to actually perform those different procedural modalities with the patient.

So, massage therapists, if they decide to get into the insurance game, they're going to have to have extremely well-backed rationale as to why they're doing what they're doing. So this will force a lot of documentation and it will force them to realize that they may only be able to get paid from insurance for just a few visits until they decide that that's enough manual therapy for that patient. That's enough massage. You have to go do something else now.

Whitney Lowe:

One of the things that I think is a big limitation in that arena, and I'd love to hear your take on this too, is that we obviously have a serious lack of appropriate research in our field supporting the various different approaches and things that we do. And that's one of the things that I think a lot of the reimbursement issues get wrapped up in. The insurance companies say, "Well, there's no evidence to support the use of this particular procedure." So, is that something that you think is an impediment for that process?

Lane Blondheim:

I really do. From massage therapy research and the manual therapy researches from osteopaths and physical therapists and certainly from the chiropractic world, our sample sizes are too small or our methods are not specific amount to make it stick.

Such research institute has a history of a low number of samples, 11, 7, 20 something. Whereas you go to a pharmacological or a surgical intervention series and you see hundreds, thousands of patients. And there's definitive numbers that provide that information to say that, "Yes, if I do a lot of quadriceps exercise, I can help protect the knee and improve kneecap mobility and function and reduce comorbidities that are associated with gait or lower extremity strength."

And the extrapolation on that is much easier to have things like that justified for example strength training. But when it comes to manual therapy, we can look back on a long history of how manual therapy is helpful, but the research methods and the stories of it don't have enough definitive proof that the insurance companies and such will believe it.

And one generalization that has come out in the last few years again is that manual therapy and massage, mobilization, well, it's really not needed to treat your patient. It feels good but your outcome at the end of a year, at the end of six months post a surgery or post-diagnosis of a musculoskeletal problem is the same as if they just do exercise and take a few anti-inflammatories.

The argument that does thread through is the patient's quality of life and their quality of functional improvement is better with the intervention of manual therapy or massage. But your comorbidities that your patient have, your age ranges, it's so diverse that they won't take it as more of a definitive intervention.

Whitney Lowe:

Yeah. And I think too, I've always felt and one of the biggest challenges that we have had in terms of getting, for example as you noted, bigger sample sizes in a lot of these kinds of approaches and also looking at research models themselves, it's particularly difficult when we admit and recognize that in a lot of instances, a big factor in terms of the success of a treatment of manual therapy regardless of massage or physical therapy or who's doing it has a lot to do with who the practitioner is and how they develop a rapport and relationship with their clients or patients.

And for that reason, it's pretty hard to then standardize treatments across the board for hundreds of people if they're not getting seen by the same person. And then as a question, is it more about that person or is it more about the method or the technique or what is it that makes this work?

Lane Blondheim:

Right, that's absolutely true. And I do agree that the relationship between the therapist and the patient is probably one of the strongest bonds and one of the reasons why patients get better. If you can convince them as a therapist that you have their best interest at hand and you have them to use a hurdle term that I have to use way too often, have them buy into their treatment where they understand it, they want to perform with it, they want to be a part of that process, they do so much better.

If they don't have that acceptance and that assimilation of what you're trying to do with them and they can have a big hand in their care, it's not nearly as efficient and it's not nearly as slew then it may not work at all.

Whitney Lowe:

Yeah, yeah. I want to take a little bit of a slightly different tack here now and get some input from you on another issue that I hear about a lot. It comes up a lot in our massage therapy trainings and that is understanding adequately scope of practice issues around things like can we give our clients exercise recommendations or is that practicing physical therapy? And that's a thing where there seems to be a fair amount of gray area misunderstanding. I'd love to hear your take on that in terms of scope of practice issues.

Lane Blondheim:

This comes across my radar so many times. And a lot of physical therapists will say, "Well, if they're going to teach somebody a little bit of a stretch and that." So, they start teaching them poor recruitment and how to squad, how to do other functional or more detail-oriented activities that physical therapists do on a daily basis. Then the massage therapist is infringing on the scope of a physical therapist and working outside of their scope.

I always try to look back at the basics of what people are taught and their programs. Both are taught anatomy, some level of physiology, origins, insertions and actions of musculature. And then they go into their more specific treatment modes where massage therapists do massage therapy. They focus primarily on soft tissue. They're not taught to manipulate any joints of the body including the spine and any matter other than basic range of motion of the large joints such as the shoulder, the elbow, et cetera.

And physical therapists are taught more focused manual therapy techniques on some things such as manipulation of thoracic spine, gliding of large joint structures such as the shoulder or the syndesmosis joints of the wrists and ankle. And physical therapists are taught more about different modes of exercise, isokinetic, isometric, et cetera, types of exercise in order to glean changes in the human body where massage therapists are not.

So, if one looks at it from that standpoint, massage therapists really are limited in where they can go. I have in the past dealt with massage therapists who have developed complete exercise programs for a patient say a lumbar dysfunction, which I don't think is appropriate. I think that this is where collaboration between our two fields is really important.

And physical therapists can step back and say, "As much as I want to say, I'm good with my hands. I'm going to have to defer to a massage therapist who has a different opportunity for time and likely a different sense of palpation, an opportunity to work with muscular structures and connective tissue at fascia on a regular basis."

And massage therapists are going to have to say, "Well, I could teach a couple of things like a stretch or a couple of gross exercises that may help them. But I'm going to have to stop there and I know it's a gray area."

Whitney Lowe:

Yeah. I know there's a fair amount of also challenge from what I understand too of understanding those gray area points between physical therapy and exercise training like strength training professionals who say, "Well, we are trained to do exercise. We're trained to do." And they start working in rehabilitative contexts around that too. So, how does that work?

Lane Blondheim:

Yeah, it's a bit of a mess but I can say that currently personally right now, I'm working in a clinic here at South Bend where I have to say it's a suite location. I'm right next to Notre Dame. And we get scholarship athletes in the clinic.

And so, I have to collaborate with their trainers for endurance and strength for their sport, whether it's crew or track and field or soccer or whatever. So, as their physical therapist, I am going to work on the fine details of stability, small muscle strength and integration of one body area to another. And then turn things back over to their strength and conditioning coaches, trainers to make them better at their sport.

So having an open bit of communication with those individuals sometimes via email, sometimes on the phone, occasionally in person, I'd be able to make sure that I don't over-train that person or step on the toes of a strength and conditioning specialist who is much smarter than I am, at least formally if not across the board, at making sure that person is able to perform at their highest. But they need me to connect the dots from their injury through stability and coordination so that they can then make that person the amazing athlete they are on the field.

Whitney Lowe:

Yeah. So, there's a couple of things too along those lines that I wanted to touch on. One of the things I'm sort of looking at, we spoke earlier about some of the misconceptions that maybe some of the public has about what we both do, what physical therapists do, what massage therapists do, what occupational therapists do or all these other professions. Are there kinds of things you think that we could maybe jointly approach or how would we jointly approach educating the public about getting better awareness about what we do and how we can work together more effectively?

Lane Blondheim:

That's a great question. I think that's a tough call. We have patients that come to see us that think all we're going to do is rub on. Or if we do take the time to do some soft tissue work on and so on, I'll get called on the suits. And one of the things that has worked for me in terms of delineating our professions is by establishing the plan of care with the patient on their first visit.

So even as a massage therapist, what I did massage therapy, on their initial visit after assessing them and doing some special tests and trying to more focally figure out where they have a problem, I'd say, "Okay, here's what I'd like to do and here's how I'd like to do it. And here's the idea about how long I think it's going to take us to get you feeling a little bit better based upon what I'm going to do with you today."

So from an individual patient, I think it's easier to start the education that way. And I will often introduce some of the things we may do such as massage and say, "Well, similar to what a massage therapist may do, I'm going to work for some of your musculature." And let them know that we have some common DNA as practitioners, but that's going to be the only realm that we're going to work at that we have our common DNA and the rest is going to be modalities exercise and maybe other tangents of manual therapy like joint mobilization or neural mobilization.

But as a massage therapist, establishing that plan of care with a shorter list of techniques, and I don't say that quite appropriately because that's not exactly true because of the different layers of what massage therapy can do with their hands. I don't think that's quite a fair statement but I don't know how else to say it at the moment. Absolutely I'll take any clearing up that you have, I mean that from neuromuscular education, Rolfing, et cetera.

But I think it's a little bit different when I can say we're going to do exercise function as well as some techniques that we're going to do soft tissue. And have you ever had a massage before? So similarly to the massage you add, we're going to work for your different tissues and then come at you with these other perspectives of intervention.

I think also in my referral to massage therapists, it separates what we do from a massage therapist. There's some wonderful sports massage therapists and another I'll call them clinician generalist massage therapists in this area where I can say, "I would like you to go see this guy because he's very focused and he can work with you on this shoulder region or hip region. And he's going to do quite a fine job in doing that. And when you do your home exercises that we've provided for you, I think you're going to notice a big difference."

And they see that we are two separate entities and seemed to work with it better. So, in terms of the grand scheme of things for discussing with the public, it may have to be grassroots. I mean, I know we both work 5k, 10k marathon run and we'll stretch people after a run. We'll do some soft tissue work on their calves and their hamstrings and such. And it really looks like there's no difference.

Even with people who are trained by you are standing next to me at a marathon and we both do a Thompson test or we do an anterior glide of the tibia, a Lachman's test or something on a patient or on a runner because they have a problem. They're going to have a hard time seeing a difference between one of your educated folks and your average physical therapist.

So, it's kind of hard when we go to those walk, run kind of things to delineate. But I think at those, it's where we go after we assess.

Whitney Lowe:

Yeah.

Lane Blondheim:

Both of us could directly refer to a physician but in terms of some injuries and issues, that you've got bad charley horses come to either one of us, we think you have a joint issue. Well, with the more proliferation of direct access, so physical therapists to the public across the country, depending on state practice acts, we can see them in a clinic the next day. And we can do other interventions just as a massage therapist.

But telling them how we're going to get to our plan of care and listening to them and being able to refer them out to either one another or a physician I think is how we're going to delineate it.

Whitney Lowe:

What is the current state of direct access in the different states? How many states have direct access for physical therapists?

Lane Blondheim:

I think and it's changing, I think it's 30 states of the country have direct access in some form or another. Such as in Indiana, we have direct access for 42 days from the time they walk in the door for everyone but Medicare.

Whitney Lowe:

And just to clarify for the individuals who are listening who don't know what we're speaking about here, direct access essentially is meaning an individual can come directly to that physical therapist without having an intervention with a physician or someone else first.

Lane Blondheim:

That's correct. With a physician because most insurance companies require a physician to allow us to bill their insurance and actually treat them. And in some states, we're prohibited from any kind of contact with the patient other than conversation unless we have a physician's referral.

Whitney Lowe:

Yeah.

Lane Blondheim:

But in places like Indiana, we can treat people for private pay or we can treat them through their insurance if they walk in the door. Treat them like any other patient, full evaluation, et cetera, and take care of them. We can't do that with Medicare because Medicare is federal. And other federal payers, we can't do direct access as well.

But we can do whatever they need ranging from exercise to dry needling to manipulation on the spine with our direct access. Other states have other limitations on the direct access, maybe an evaluation only. Some have provided direct access to their therapists such as in Michigan, they just didn't write anything in their practice act about requiring a physician's referral. So they've had direct access since I think the '60s.

Whitney Lowe:

Oh, wow, okay.

Lane Blondheim:

Yeah, because they just sort of didn't write it in their practice act. Yeah.

Whitney Lowe:

Was that an oversight over intention?

Lane Blondheim:

That's a great question. I wish I could pick some brains on that one because I think it was brilliant if they just did it on purpose.

Whitney Lowe:

Yeah.

Lane Blondheim:

So anyway.

Whitney Lowe:

Yeah. We have quite a few listeners outside the United States. Do you know what the state of direct access is for physiotherapy in other countries?

Lane Blondheim:

I think in Norway and Israel, they have a good form of direct access and I think it's based on how the practitioners report things. Their system of medicine is more socialized. Now, acquaintance of mine lives in Israel and his wife is a physical therapist. And they get paid the same thing whether they drop a hot pack on somebody or spend an hour doing detailed manual work on it.

Whitney Lowe:

Oh, interesting.

Lane Blondheim:

Yeah. And the therapists go in and they basically do what they should do, what they have to do and make the patients better. And similarly, I think Norway with their medical system, they have some like basically it's a per diem pay. And you just do your job and you get paid per diem, per patient, per treatment.

Whitney Lowe:

Yeah.

Lane Blondheim:

You just do what you have to do to make them better. And in a way, I think that's very supportive of the patient and the therapist. I think their number of visits is insane at over 200 visits in some cases.

Whitney Lowe:

Oh, wow. Yeah.

Lane Blondheim:

So if you have a stroke, you have a child with a problem, you have a musculoskeletal problem, you can have somebody who's going to take care of you. They're not going to make huge dollars per visit, but their living is not going to suffer.

Whitney Lowe:

Yeah. Well, last thing I want to ask your wisdom about is I want you to predict the future a little bit for me. So, I'm curious, from your perspective, what you think are some of the big challenges coming up in the future in the world of physical therapy? And then also maybe for us in terms of interprofessional education or working together or learning more about each other, what are some of the big challenges that you see coming down the pike?

Lane Blondheim:

I think the biggest challenge we have is lack of communication regardless. If we as practitioners can make sure we talk to each other, we don't look down on each other, one does not have to look up to the other one, I think that's going to be a boon for all of our professions. We can work more seamlessly and make our communities and our individuals and our communities better overall.

Insurance companies are difficult to work with. They want to save their dollars. They want to make their profits as any business does. But with the insurance companies being so strong and their lobbies so strong in restricting payments, et cetera, even for those of us who really truly believe that we're making a good difference in choosing the best practices to help our patients be better, further reduction in reimbursement per year is not always the best thing.

So, many PTs are going into private practice with a cash-based system or they're becoming trainers. Have these wonderful gyms and I think that's awesome. However, it sort of dilutes what it is that we're trying to do in terms of health care professionals.

And as massage therapists, if more massage therapists do decide to take insurance, they will have to wrestle that bear. They will have to figure out where their limitations and their strengths are with the insurance companies and realize they're being funneled into how they treat their patients.

How much effleurage can you do? How much deep tissue can you do? Can you do some fascial techniques to make sure the median nerve is not bound up around the bicep? Or are you prohibited from doing any of those activities whatsoever?

Whitney Lowe:

Yeah.

Lane Blondheim:

So, I think our biggest obstacles will be insurance and it will be communication. So, if we can lobby things, if we can discuss things amongst ourselves, I think that we'll continue to provide amazing care for our constituents out there that require good health care.

And we need to just keep educating our physicians, our public, each other, ourselves. We need to tell ourselves that we're only as good as we are. How do we get better? We have all these teammates on other sides of the aisle besides therapists, chiropractors too, strength and conditioning specialists, et cetera. We can all make these opportunities for these people to stay better and be healthier.

Whitney Lowe:

Yeah, wonderful. That's a great place for us to wrap that up. And Lane, thank you so much for taking the time to talk with us today and share those perspectives with the listeners. There's some really valuable insights I hope everybody took away with that.

If people would like to perhaps get in touch with you or just touch base, is there a convenient, easy way where people find or connect with you?

Lane Blondheim:

Well, let's see. I have an email address which is probably the easiest way to do that. And my professional email address is lane.blondheim@athletico.com, L-A-N-E dot B-L-O-N-D-H-E-I-M at athletico.com. I have a professional Facebook page which is Lane Blondheim, PT, MT, massage therapist. And yeah, those are probably the easiest ways to catch me and I'll return messages and keep in touch with people if they have any questions, whatsoever.

Whitney Lowe:

That's great. Thanks so much. And again, I just want to clarify, Athletico is A-T-H-L-E-T-I-C-O, is that correct?

Lane Blondheim:

That's correct.

Whitney Lowe:

Okay, great. Yeah.

Lane Blondheim:

Yeah.

Whitney Lowe:

Great. Lane, thanks again so much for being with us here on The Thinking Practitioner. We certainly appreciate your marvelous insights there.

Lane Blondheim:

Whitney, thank you so very much. It's great to be in contact with you again. And I hope we'll talk to you and some of your listeners sometime in the near future.

Whitney Lowe:

All right, that sounds great. Please do remember, The Thinking Practitioner is supported by ABMP, the Associated Bodywork and Massage Professionals. ABMP membership gives professional practitioners like you a package including individual liability insurance, free continuing education and quick reference apps, as well as online scheduling payments with PocketSuite and much more.

ABMP's CE Course's Podcast and Massage and Bodywork Magazine always feature expert voices and new perspectives in the profession. Such as my partner Til and myself, Thinking Practitioner listeners can save on joining ABMP at abmp.com/thinking.

This episode is also sponsored by the Academy of Clinical Massage where our mission is to help you become a better practitioner working with pain and injury conditions. It's challenging to find high-quality training in your location when you need it and we bring exceptional orthopedic massage online training programs to the comfort of your home through our innovative online programs, so you can learn anytime, anywhere and immediately help more of your clients.

This year, we have completely revised all of our online programs so you can learn more about these at academyofclinicalmassage.com. Thanks again to all of our listeners and to our sponsors. You can stop by our sites for our video show notes, transcripts and extras. You can find that over on my site at academyofclinicalmassage.com and also on Til's site at advanced-trainings.com.

If you have questions, comments or things you'd like to hear us talk about, just record a short voice memo on your phone. You can email it to us at info@thethinkingpractitioner.com or you can look for us on social media. Under our name is my name Whitney Lowe and also Til Luchau.

You can rate us on Apple Podcast. It does help other people find the show. And you can hear us on Spotify, Stitcher, Google Podcast or wherever else you happen to listen. So please do share the word, tell a friend. And thanks again for joining us, everyone. And we'll talk to you in the next one.