Partnering in Rehabilitation to Improve Outcomes
As the clinical director of musculoskeletal spine and sports rehabilitation medicine at MossRehab, Christopher Plastaras, MD, is an expert in spine care. This level of specialization brings him some of the most challenging cases. When he needs a second opinion or additional insight that only a functional manual therapist can give, he turns to his colleague and fellow clinician, James Poston, PT, OCS, CFMT.
As a rehabilitation hospital with robust inpatient and outpatient services and clinicians with shared values, MossRehab is uniquely suited to creating an environment where physiatrists and physical therapists not only share clinical spaces but collaborate on cases in real time.
Learn more about how these specialists combine their skill sets to improve outcomes for patients at MossRehab.
Read the Transcript
Here is a transcript of our conversation with Dr. Plastaras and Jamie Poston:
Please note, this episode was recorded prior to the COVID-19 pandemic. Since then, MossRehab physicians and therapists have adopted the appropriate physical distancing for patient and staff safety.
Welcome to another episode of MossRehab Conversations. The discussion this time, a model for collaboration in therapy as developed at MossRehab by attending physiatrist, Christopher Plastaras, MD, and certified functional manual therapist, Jamie Poston. Dr. Plastaras is clinical director of musculoskeletal spine and sports rehabilitation medicine at Moss, co-chair of the Einstein Spine Institute, and he serves as a clinical associate professor of rehabilitation medicine at Jefferson University. Jamie Poston is a board certified orthopedic clinical specialist, a member of the Einstein Spine Institute governance board, and he is primary faculty with the MossRehab orthopedic physical therapy residency program.
Well, first of all, I'd like to thank you both for joining us today. The first thing I'd like to ask is, Dr. Plastaras, how did the two of you first start working together?
Plastaras: Jamie and I started working together around July of 2018 when I joined MossRehab as the clinical director of the musculoskeletal spine and sports program. I started seeing patients in the same office as Jamie, at the MossRehab center city location at 23rd and Market, here in Philadelphia. And the physical setup really kind of pushed us together, where our clinic exam rooms were really right adjacent to each other, so we would almost run into each other coming out of exam rooms. And when we saw patients individually, and then we thought like, "Hey, I wonder what the other guy would think?" So I saw someone with a pelvic obliquity, I thought they had something going on with their sacroiliac joint, and I wanted someone with what I would describe as gifted hands, from the manual medicine perspective, to take a look and just corroborate what I found. So I asked Jamie, I'm like, "Hey, Jamie, would you mind just taking a peek at this person with me?" And that's kind of how it all started and it's really progressed very nicely.
Would you say that this is a unique situation?
Plastaras: Yes, I think it is quite unique, where a physical medicine rehab specialist gets to practice right in the same physical space as a physical therapist. So most medical practices have separate clinic space, and it might be in the same building as the physical therapy location, but often there's a wall that separates us. Or even if it is on the same floor, sometimes the exam rooms, the places where the patient care happens, are still on two separate sides of the floor plan. So when we're really right adjacent to each other and what I call rubbing shoulders and rubbing elbows, it really is a nice setup that really invites collaboration for patient care.
Jamie, what do you think makes this relationship work so well?
Poston: Well, first I have to agree and say that this is very unique. In my years of practice I haven't had this opportunity. And I do think that it's quite different from even across the hall, whether there's a physical wall or a metaphorical one, if you're not in the same organization, you're not sharing space, I think the opportunities for the frequency of collaboration are reduced. So just having that rapid sort of response of, "Can I get your opinion on this? Can I get some more information?" Or, "What do you think about this patient? This is what I'm seeing or feeling," on such a frequent basis, it really reduces the timeframe in between noticing something clinically that you weren't expecting, and have either a concern or an idea about how best to foster a positive outcome for the patient, and implementing that strategy. So if that was something where I needed support from a physician in terms of ordering a brace or writing a letter of medical necessity for the proper equipment for support, or modification to the patient's workstation, for example, that can happen in real time, that patient can leave that session with that support.
Well, do you think that that would apply to any other type of physical therapy?
Plastaras: Yeah. So I have Jamie here and we're speaking about our collaborative care, but Jamie has a small army of very skilled physical therapists that work in his practice. Each has a slightly different skill set, so we have a therapist that's skilled in the Parkinson's big therapy and neuro rehabilitation, as well as the vestibular rehab. So I often pull her aside and say, "Hey, can you look at this eye motion with me? Can you help me figure it out?" So that's really been great.
Poston: In addition, we have two physical therapists that are certified in the McKenzie method, and I often pull them aside and say, "Can you look at this lateral component? I think this is a mechanical derangement. What do you think about this?" Or, "Watch how the patient's doing this exercise. Are they doing it right?" I've had instances where a patient comes in with an acute cervical radiculopathy. I pull Mitch aside and, "Hey, can you help me figure out the directional preference of which neck motion he should be taking?" And really within five minutes, he figures it out and the patient leaves without any arm pain. And talk about a satisfier, that sort of collaborative approach in those really meaningful just a few minutes of key insights, looking at how the patient is moving, really is important.
Plastaras: The other thing that I wanted to touch on is sometimes I'll run a case by Jamie and say, "Is this someone that's right for you?" And he says, "That's perfect. I might need to get one of the McKenzie specialists in or the pelvic floor specialists in," or he might say, "Sounds like there's a lot more pain behaviors going on there. That sounds like a patient that might be right for our MossRehab take-back program that specializes in the chronic pain population." So that collaboration with the physical therapist, I'm able to bounce cases off them and help me make the right choice of which therapist might work best for that patient and their condition.
So this collaboration then does in fact help improve clinical outcomes?
Plastaras: Absolutely, absolutely. From the patient's perspective too, they've now got confirmation of two clinicians coming at it from different licenses, but a similar approach, that have now verified each other's work and agreed on a plan of care, all within the same session for the patient.
How long have you been doing this together? And in that time, have there been cases that come to mind now that you can point to where you saw real benefit from the relationship?
Plastaras: We've been working together for almost two years, and I can think of several patients where Jamie and I have worked closely in collaboration with the patient and it turned out as a better outcome for the patient. For example, one young woman, she was a nurse, she was at a baseball game, an exuberant fan fell on top of her and she sustained a pretty bad neck injury. And she had seen a lot of other providers and a lot of physicians, physical therapists, chiropractor, you name it, acupuncture, cupping, and she came to me with this persistent neck pain. And one of the first things that I reviewed with her was actually breathing. During my exam I was like, "Boy, just the way you're breathing, you're just kind of breathing all up in the chest." And I just went over deep breathing, diaphragmatic breathing, and that stuck with her, that I took time with her to go over her complex situation and kind of sort out the details, and my relationship with her started there. And as I worked with her, I said, "You know what? You really seem to have this problem with your cervical facet joint, or zygapophyseal joint, and it's giving you this persistent neck pain. Let me have you work with someone like Jamie with these skills as a certified functional manual therapist." And so, Jamie, what did you find when you saw her?
Poston: Yeah, so on my initial exam with the patient, amongst other things, I found quite a bit of abnormally lax ligaments throughout her cervical spine. She had excessive motion through there, so much so that it warranted me stopping Dr. Plastaras in the hall and saying, "Hey, I just wanted to run through what I'm feeling with this patient. And boy, is she really lax." So much so that when I mentioned it to her, the patient sort of confirmed, saying, "Oh yeah, when I left my radiology office to get my neck x-rays, they wanted an autograph, saying how unusually flexible, my neck was bending backwards." I wanted to look at her to make sure she was okay. And I said, "It was really lax when I worked on her, so much so that I felt a little bit unsafe trying some of the techniques, and I really had to exert some extra caution. So this is going to take a little bit more complex care and may take a little longer.
Plastaras: So, next sequence here is looking at those x-rays. So I pulled Jamie aside, because again, we're working side by side, I said, "Hey, look at these x-rays. You're finding the cervical facet here at this level a problem, let's look at the images together. Look, it's really moving a little bit more at that segment. There are the others, we think that's clinically relevant." And as she progressed in her rehabilitation program and Jamie progressed her to a little bit more of a strengthening program that she started to do as part of our gym membership, that for me to actually see her doing those exercises, and I was able to nod along, like, "Yeah, great," and that collaborative feel that she got, that she knew that I was on board with what Jamie was giving her, I was seeing it happen, I was endorsing that with nonverbal hellos and, "Keep it going," so that's how that close proximity of the rehabilitation program really turned out well for her. And she really has come a long way and doing much better than where she started when we first met her.
So then it seems that working together really had a big impact on the care plan for this patient. Jamie, tell me, how did working with a physiatrist provide insight into your work with the patient?
Poston: It really enabled me to see part of the clinical examination evaluation process that Dr. Plastaras undertakes, as well as to understand the patient's take on what's important to their care in real time. So their impression of what's important, based on their communication with the physician, is something that I can have a different take on because I may have been in the room for some of that. Or I've had a bit of a casual conversation off to the side before stepping into the room with the patient about what Dr. Plastaras's goals are for the patient, his impression or his concerns, if there's an outstanding clinical issue you have to determine, where he might say, "I'm not clear if this one condition is driving it, or if it's this long standing pain that she's always had just re-flared up. So I'm looking for you to help clear that up as well as provide a direction for treatment."
Now, you formed this relationship on your own initiative. Do you think that it's unique to MossRehab?
Plastaras:I think anytime a physical setup is available where you have two providers that are rubbing shoulders, it automatically fosters better clinical care. So we are fortunate at MossRehab in that Jamie, as a physical therapist, myself as a physiatrist, we're both employed by the same entity, and so we're usually allowed to be working in the same clinical space and we don't have to worry about any red tape. I've worked at other institutions where that red tape is there and the doctor and the therapist find all the different kind of silos, if you will, from the organizational structure. So that's really an advantage of being under the same rehabilitation umbrella.
So, hearing about this, if there are physicians or therapists or administrators at other institutions who are interested in establishing a model such as this, what advice would you give to them?
Plastaras: I would say it really does help to begin with a clinical relationship where you have a similar view of patient care. And I think there's enough similarities of background and training that really foster the same vision as we look at a patient and how we want to work with that patient and help them. So that similarity in training and approach, I think, is the fundamental cornerstone of that working relationship. To get back to maybe hospital administrators and folks like that, what can be done is when designing the physical space, you actually plan the floor plan out so you have areas that the physical therapist can work in an open space with tables that is really right adjacent to more private clinical exam rooms where, when you come out of the exam room, that you're sharing the same touchdown space, for example, or you're working right next to each other on the computer. That sort of situation really does foster collaborative care between two practitioners. So really it comes down to planning out the physical space.
I want to thank you so much for taking the time to provide all of this information for us, and also especially for creating this model and this good example. It's been a pleasure speaking with you.
That was MossRehab Attending Physiatrist Dr. Christopher Plastaras, and certified functional manual therapist, Jamie Poston. Go to mossrehab.org to learn more about the work being done in this field, and be sure to subscribe or check back at our website for other discussions with pioneers in physical medicine. I'm Bill Fantini, Thanks for joining us on MossRehab Conversations.
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