play one of these little graphic things,
and then we'll kick it off.
Sounds good.
All right, let's do this thing.
All right.
All right, welcome to Orthostatic,
a podcast created by the
Academy of Orthopedic Physical Therapy.
Keelan Ensky is on the show today.
Keelan, welcome to the program.
Thanks.
Appreciate it.
Thanks for having me.
What's your background?
You've done a bunch of
different things in your career.
What do you get to do?
I'm not going to say what do
you have to do.
I'm going to say what do you
get to do now in your PT career?
Yeah.
It's kind of a mixed role that, uh,
kind of has evolved over time.
Uh, first and foremost,
I still get to treat patients,
which is great.
It's something I would never
want to fully leave behind.
It may not be as much as I used to, but,
uh, I,
I still see patients almost not
exclusively,
but probably 90% with hip
related pathologies of different types,
non-surgical post-surgical.
Um, I administrate,
I'm an administrator for
our residency programs.
We have five within UPMC and
day-to-day I'm in charge of
the orthopedic program.
And, uh, um,
I have a little bit of a
role with our clinical innovation,
which is anything from
telehealth to some of the
things that are coming down the pipe,
particularly in orthopedics
and sports medicine, physical therapy.
And then also a role,
I still am an adjunct
faculty at the University of Pittsburgh.
And for the most part,
for the residential DPT program,
I teach most of the hip-related content.
All right.
So you're the guy.
You're the guy for this.
This is right down the road.
We're talking about
navigating orthopedic surgery recovery,
something you're clearly familiar with.
I wanted the audience to know that.
So let's talk about big
picture key factors in
successful post-surgical
recovery in orthopedics.
And this can be anything
from clinical to education
to communication.
If someone were to say,
what are these key factors?
How would you answer?
You said one of them.
Communication.
And that's communication
with the therapist,
the physical therapist, the surgeon,
the patient care team members.
It's just crucial to understand, uh,
you know,
on our side from the therapist
perspective,
what procedure is performed
because not all the
procedures are the same.
They're categorically maybe similar,
but there are variations
that could greatly affect
the rehabilitation.
Um,
communication between us, the patient.
It's crucial we monitor their response,
not only for things that
maybe are signs of things
not going the right way,
but also we use that
response to some of our
criteria to progress people
through the rehabilitation protocols.
Along with that, compliance.
I think
I think we all know that.
Right.
And, and, but when we say compliance,
it's not just consistency
that they're doing things,
but the quality of which
they're doing things as well.
Not always time that is part of it,
but it's also, you know,
are they doing things correctly,
the right order, et cetera.
And we're,
we're the primary drivers of
that other than the patient themselves.
Sure.
And is there a third that
you might throw in there on
top of communication and compliance?
Yeah,
and they probably fall within that
kind of subdomains of it,
but it's constant
reevaluation and review of goals.
So reevaluation,
how are they doing objectively?
Are they following the expected trajectory,
which there's another variation there,
but also review of goals.
Are we meeting that
patient's goals within what
is expected at that point?
And sometimes that's reeling
them back in and then let
them know what your goal is great,
but is it realistic for
where you are in the
rehabilitation process?
And that can be a
challenging conversation at times.
Right,
but a conversation that should be
had in the earlier I imagine you have it,
the better that
understanding has a chance
of being achieved.
Earlier and often.
Correct.
All right.
So your very first C,
and I don't think we even planned on that,
but that was three Cs, right?
We had compliance.
So how do PTs collaborate with surgeons?
Because now you're
mentioning in terms of communication,
all the different people in
our neighborhood or on the rehab team,
right?
How do PTs collaborate or
how do you suggest they
collaborate well with
surgeons to ensure optimal
recovery outcomes?
Yeah.
And that, and you know,
and that can be a challenge.
I'm fortunate in our system.
You know,
we're an academic medical system.
A lot of the surgeons that I
work with are down the hall
or I happen to know them.
I've been doing this for a while,
but irregardless, you know,
that open line of
communication and really I look at us,
our role is so valuable in
communication because we
are the primary and most
frequent touch points for
the patient for us to
advocate what is going on
with the patient to the surgeon.
Uh, so frequent communication.
You do have to get to the point at times.
They're very busy.
So you have to speak their language,
give it to them in summary fashion,
kind of really put an
emphasis on the important
points of what is going on.
So the other part of that is we over time,
particularly as we've been
kind of shifting to an
emphasis on milestones in rehabilitation,
we help develop those milestones.
I mean, that's what we do.
We look at how an individual
is moving forward.
and the quality of their
movement and where they are
in these goals.
And we're the experts there.
So taking that and being
able to communicate with the surgeon,
how we can integrate that
into the protocols for progression,
we play a valuable,
we are the primary drivers
of that part of the process.
And again, I think, you know,
consistency of, you know,
when we communicate with
our surgeons and speaking
their language is invaluable.
Yeah.
Understand those things.
So let's talk about things that are common,
right?
Frequently asked questions is one thing,
but how about,
what about common
challenges that you see
patients facing after an
orthopedic surgery?
Doesn't really matter what
it necessarily is,
but what comes to top of
mind when we talk about
common challenges?
Yeah.
And it actually,
there are two things where
we talked about that kind
of fall in there and then,
and then they're part of a
kind of bigger picture.
And when we talk about
compliance and goal management,
Sometimes the long game is the challenge,
right?
Because some of these surgeries,
most of these surgeries
have some component of time
that is involved,
even if they're doing
perfectly fine and they're
the textbook case that you want to see.
The challenges often are
getting the patient to
invest in their own success.
Right.
And not trying to rush the process,
but also not giving up at
some point and saying, hey,
this is where I'm at.
You want to be realistic.
But at the same time, you know,
the constant reinforcement
of where they are,
bringing reality and having
those discussions very
often because it is our
patients either check out
or they'll just jump ahead
of you at times.
And both of those kind of
fall under compliance and
gold management as well.
Yeah.
We want things to be personalized.
You mentioned not skipping ahead,
not lagging behind or
checking out completely.
What are some tips or
suggestions you give to
colleagues or students if
you're interacting with
them in terms of having
that recovery protocol developed,
but also personalized for this person?
So when we say personalized,
we might have similar surgeries,
but not everything is the same.
And we're similar humans,
but not everything's the same.
So what are suggestions to
really develop a protocol
and personalize it to that
person's recovery?
Yeah,
that's true because you're always
trying to, which can be somewhat,
it is clinical and feel
very clinical when you look
at best practices, hierarchy of evidence,
all the things that we
consider that must be
considered with a
rehabilitation protocol.
But at the same time,
that matters to the patient,
but what really matters are their goals.
So really keeping this
somewhat clinical approach,
very clinical approach,
delivered in a patient-centered fashion.
So what I attempt to do,
and there's challenges with this at times,
is to anything that we're
recommending and bringing
back to a goal that they have.
Maybe it's a short-term
objective to get them to
where they want to be tomorrow,
reducing pain,
allowing more range of motion,
or bringing that back to
the long-term goals of, let's say,
return to sport or return
to just any daily activity,
playing with their grandchildren,
anything like that.
Anytime we can bring back
what we're delivering in a
clinical fashion and is appropriate to
who in a patient centered
fashion to address a goal
or an objective.
I think that's how we keep
it personalized.
And we had sometimes those
goals change for the patient.
And if that changes,
we have to incorporate that
into our plan of care when
we're looking at, again, that long game.
Yep.
Well,
let me ask you this follow up to that
question.
And I struggled with this a
lot as a student and going
into my clinical rotations,
which was how do I figure
out how deep to go in terms of education?
Some people want to know nothing.
Just tell me what to do.
I show up and do it.
Some people want to know
every single anatomic detail.
What do you typically
suggest for new graduates
or students on how to
figure out how much information is good,
how much is overload and
how much is not enough?
Yeah, and it is very different.
I'll get my high school
athlete in here who may be
interested in the anatomy and such,
or maybe their interest is, hey,
I want to get back to activity,
or maybe I'm treating one
of our surgeons post-operatively.
They probably want much more detail.
They probably already know more.
They want more information.
And really in that initial conversation,
you know,
some people say if there's a
prehabilitation component,
that's a perfect time to
have this discussion.
Or within that first session,
through that initial conversation,
you can directly ask them, hey,
how much detail do you want about this?
If it's too much, let me know.
Or sometimes you just get a feel for it.
There are some soft skills in that regard.
But I would, if anything,
recommend that you get a feel for that.
Because if you give them too
much information, again,
they may check out on you.
You don't give them nothing.
Could be insulted, right?
You're not telling me enough here.
Sometimes see that on press gaming scores.
So that is really on you to
get a sense and early on
just how much information
that individual wants and
look for cues of you're
giving me too much.
I'm going to check out on you.
Or I need to know more.
Yeah.
And again,
try to do that early because
then it's going to set that
relationship up.
It's probably gonna be a
fairly long relationship
during the rehabilitation process.
Yeah.
My experience was I just
assumed I needed to know the answer.
I needed to figure that out.
And then when further on, I went,
I realized it's okay for me
to ask and say, Hey,
is this too much information?
Is this not enough?
Yeah.
And that actually helped me
build sort of therapeutic alliance too.
It showed I was worried
about them having not enough or too much.
I definitely made the
mistake early on of
sometimes providing what I
would want to know, but I'm very curious.
I mean, all of us are, you know,
this is what we do.
So maybe that's not as much
as they want to know.
Maybe they don't want to
know every detail about the surgery or,
you know,
why you're doing every single
thing that you're doing or
that you're recommending.
So it's really,
you got to get that read
early on and use that to make, you know,
basically make that
rehabilitation process most effective.
Yeah,
and you went and went with a nice
little podcast segue as you
talked about pre and before.
So how would you describe or
how would you explain or
educate the role of
pre-surgical physical therapy?
Why is that so important?
Why does that matter?
And I think it's popped up
or it's gained some
notoriety in the last couple of years,
this sort of pre-surgical
preparation by the physical therapist.
Yeah, it's a hot topic.
you know, the term prehab.
And, you know, it's interesting to,
you know,
it makes all the sense in the world that,
and we tell people this, hey,
the more information you have going in,
the more you know about
your rehabilitation process,
the surgery itself, you know,
you hope they're getting
some of this from the
surgical team as well.
And that varies.
You know,
the easier it's going to be for you,
the less stressful it's
going to be for you after surgery.
And,
And perhaps we're
recommending interventions
that will set you up,
whether it's strength, range of motion,
whatever it may be,
to do better or recover
more quickly after surgery.
And we do that with all good intentions.
The studies are interesting.
The overall trend is, yes,
it is linked to outcomes that are better.
It gets a little more
challenging at times.
There's a little more robust
information out there for
joint replacements, other surgeries,
you know, I do hip arthroscopy,
lower level of evidence.
But part of this is just a
challenge of what is
prehabilitation or
rehabilitation before surgery.
What does that entail?
It's not consistently defined.
It's more education.
Is it actual exercise?
And what are the outcomes
we're looking for?
Is it their strength after surgery?
Is it their patient report outcomes?
Just the sense of them telling, you know,
I felt more comfortable.
So I'm all for it and we endorse it.
And I think overall,
all the literature that's
available endorses it as well.
We have a long way to go to kind of,
for as much as we can,
standardizing it and
knowing really what we need
to be really hitting in
pre-surgical physical therapy.
The only thing I will say is
that we have payers that are endorsing it,
and they're not going to
most times if they don't see value in it.
So if I think of our joint
replacement surgeries,
our insurance companies,
many of them are covering a somewhat,
a variably defined pre-surgical episode.
And they wouldn't be doing that,
as you mentioned,
unless there was some
research and some evidence
that that was actually
going to help recovery and ultimately,
right, from their KPI is lower cost.
And that's a great thing to do.
But if it's helping the human first,
that's where we're in.
Yeah, you know, when you can cover,
check both boxes,
which doesn't always happen,
it's always a wonderful thing.
Yeah.
All right.
So you did mention other resources.
Research is always fantastic.
But is there if someone's
nodding along and listening
to this and saying, okay,
I want to learn more about this.
Are there other, you know,
resources or places that
you'd suggest physical
therapists to go to maybe
dig a little deeper?
yeah you know and it's it's
a great question oh and the
timing is perfect because I
just submitted uh myself
and uh dave chorizers my
co-authors just submitted
our uh our manuscript for
this uh one go-to you know
because there is literature
out the literature changes
somewhat quickly for some
of these fields uh or some
of these subdomains of a
post-operative
rehabilitation and it can
be somewhat daunting or intimidating
And you can get some mixed messages.
But one resource that the AOPT provides,
and right now it is
literally in the revision process,
it's part of their
independent study course series.
And that is the
Post-Arthro-Management
Orthopedic Surgeries.
you know now if you go into
the website I believe it is
listed under enrichment
only because it is we're
transitioning to a we will
be or they will be
publishing a new series and
what they attempt to do is
get authors and often it's
a clinical team so you'll
have a physical therapist a
clinician uh you may have
mixture of academic uh
representation in there and
often more often than not a
surgeon representative co-writing these
providing a summary in a reasonable amount,
you know, a one-stop shop, if you will,
at the time of the surgery,
from what we look at,
what they look at from the
surgeon's perspective,
the rehabilitation
protocols associated with it,
gaps in the literature kind
of put together.
It's an opportunity for
continuing education as well,
and many residency programs
also use it in their curriculum.
i think that's a I i would
find and I'm not sure I did
write one of the monographs
but I use the monographs
that other authors when I
get outside of my comfort
zone is references as well
and they're great they're
being updated I think for
early next year I believe
is is the target
publication date that's a
first stop recommendation I
have for anybody at any level
Talk about that interesting
format for a second.
I mean, you helped write this,
so you got firsthand knowledge.
You were paired with a
physician colleague.
That had to be fun.
That's a different way of doing it,
is making sure there was
collaboration across
professions when creating this resource,
which is primarily directed at PTs.
Yeah,
it is a great opportunity to really
see what they see.
Sometimes I don't understand
why they're telling... I'm
not always in the office.
I'm very rarely in the
office when these
discussions are being had with patients.
And then collaborating with them,
I can see it.
I can see, this is what you do in surgery.
These are the concerns.
We know what they're doing,
but we don't know
everything that goes on around that.
And at times...
Getting a even just a
glimmer of what they are
looking at in their
clinical decision making
and why they make recommendations.
And then also it just it
evolves into good discussion.
You get to share points of
view and sometimes maybe
they will change what
they're doing based on what
you're saying.
That has definitely happened
and vice versa.
And it's just great to get
that perspective.
And it's often we just
depending where you're practicing,
you may not get that
opportunity very often.
Right.
and you get to take
advantage you know sort of
highlighting the format for
this independent study
course you get to take
advantage of that
collaboration a lot of
times uh they say you know
the the biggest problem
with communication is when
we think it has occurred so
why are they doing that
they don't understand me
it's like that when this
comes together we're closer
to achieving more
understanding I think
that's one of the main
benefits of an independent
study course like this is
that it wasn't written just
by a physical therapist it
had cross professional collaboration
And the editors were very
particularly in the
specifically in the upcoming edition.
They said, you know,
can you include what
physicians sometimes think
about when they when they
think about why?
Why is the physical therapist doing this?
I'm thinking this.
But why?
Why are they thinking this way?
And it kind of they're not
always clashing points.
I think you're thinking alike.
You're just communicating it
in a different way.
And there's some great kind
of interaction there.
Right.
I think clinicians,
physicians and PTs would
find it useful to look at
that and kind of get a
sense of the viewpoints and
why sometimes we see these
recommendations or these
points of conversation that
we often have during the
rehabilitation process.
Yeah.
The more we know,
going back to that series on TV.
Now we're going to put you on the spot,
Keelan.
We have a segment on the
show called Words of Wisdom.
Wow.
What would you want to leave
with the audience about this topic?
Is there a parting piece of
advice or wisdom?
Yeah.
You know, what I would tell anybody,
wherever you are, you know,
and I feel like this is
what I tell myself every
day is that you really have
to expect that change is going to occur.
You know,
whatever is here today is going
to change tomorrow, if not tomorrow,
next week, next month or next year.
Every time that I think I've
had this great monograph we put out.
Um,
when it gets knocked down by the
editorial process, uh, so, you know,
we said the clinical practice guidelines.
So you look at it like,
these are great recommendations.
I got the C level recommendation.
That's actually better than we had.
It was an F in 2014.
Now it's a C maybe someday
we'll get to an a,
but what you have to really,
you have to realize the
evolving nature of this.
And it's always going to change.
Surgeries always change our
rehabilitation associated
with those surgeries.
It's going to be an ongoing change.
So you should be satisfied
when you see that,
if we want to call it an improvement, uh,
or that evolving process,
but just know it's going to
evolve into something different,
hopefully better tomorrow,
or if not tomorrow, soon.
Yeah, this is, I was taught in PT school,
just add one word onto the
end of what you're sharing.
This is what I understand to be true now.
That word right now, now says,
so we understand now,
and that leaves you sort of
off the hook when and if
and when information changes.
It's your disclaimer.
It is my lifelong disclaimer.
So that's fantastic.
Keelan,
thanks for putting the time and the
effort and the research
into that independent study
course that you mentioned
coming out very soon from AOPT,
available at orthopt.org.
And thanks for taking the
time to talk with us today
on orthostatic.
Thank you.
Thank you for having me.
I appreciate it.