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Leadership and Culture as Keys to Successful Acquisition

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By Michael Durand, MBA, ATC

Growth through acquisition can prove to be a successful strategy. However, it is not without its challenges. In the growth of our organization, which has 13 locations, nearly half of our clinics were acquisitions and the rest were de novo. The success of our acquisitions is tied closely to the transition of leadership and culture. Highlighted below are acquisition scenarios that we experienced in our company’s growth. In each scenario, we had different leadership strategies in place to transfer our organization’s culture to the new acquisition.

“Acquisition A” was early in our history. The acquired clinic was a single owner and practitioner who had plans post-acquisition to focus on a related business outside of traditional physical therapy. The geography, patient demographics, physician referral base, and other considered factors all fit with our existing practice. A newly hired physical therapy manager replaced the former owner without overlap or transition. We failed to consider the leadership transition, which we could have implemented with the exiting owner. Also, the newly hired physical therapy manager was not fully ingrained in the culture of our organization. Because of these two factors, the acquisition was destined to fail, and we were forced us to close our doors within a few years.

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Following the difficult lesson in acquisition A, we implemented a new strategy for acquisition B. A strong internal leader who was ingrained in the culture of our organization took over for the exiting owner who was bound to continue at the clinic for six months post-transition. Though we felt we were more prepared in this venture, we did not anticipate the impact and value of the exiting owner through the transition. The exiting owner did not fully support our organization’s culture with the remaining staff. The result was an “old guard versus new guard” clash, and, subsequently, many of the acquired clinic staff opted to move on. In the short term this was a challenge. Thankfully with strong leadership, a firm sense of the organization culture, and “new blood,” acquisition B has survived and thrived.

We ventured into a third acquisition—acquisition C—with experience. Throughout discussions with the current owner, we spoke frequently about the culture of our organization and our goals of incorporating our culture into their clinic during the transition. We were able to impart our organizational values and show the value of creating a unified leadership for the existing staff. For this acquisition, we not only had new leadership ingrained in our culture, but we also had a previous owner that “bought in” to the direction we were taking the clinic. Throughout the transition, both leaders were consistent in the message they delivered to staff. This consistency led to a successful transition, desired staff retention, and positioned the clinic for immediate growth.

Although there are several factors to consider when incorporating a growth strategy through acquisition, few are as critical to the success of these ventures as the leadership and culture transition.

Three valuable lessons we have learned through our acquisitions have been:

  1. A leader from within your organization must transfer your organization’s culture to the acquired location.
  2. Cooperative leadership between the acquiring organization and exiting ownership will lead to a smoother transition.
  3. Understanding and capitalizing on the value of the exiting owner, in combination with the energy and drive of the new leadership, will jumpstart the growth of the practice and create a successful acquisition.

Michael Durand, MBA, ATC, is director of business development at Physical Therapy & Sports Medicine Centers and managing partner of Strategic Therapy Partners. He can be reached at mike.durand@ptsmc.com.

Navigating the Course

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Mergers, acquisitions, and other exit strategies.

By Iris Kimberg, PT, MS, OTR

Orchestrating the sale of your practice is not unlike the process of starting or growing your practice. It requires intense focus on your end goal, coordination among many professionals working on your behalf, and a firm belief in your ability to navigate the course as it unfolds. Since the sale will impact your professional and private life after the sale, you must structure it to meet your end goal.

Fifteen years after I sold my own therapy practice and 15 days after I helped a physical therapist sell his practice to an employee so he could move back to Australia, I am still in awe of how a therapy entity can be sold. After all, we cannot guarantee that a patient will walk through our doors, we cannot guarantee that a physician will make another referral, or that a therapist will stay at work. Yet, if a practice is built to last and if value is integrated into every aspect of a practice, it is an asset that commands whatever price the marketplace will bear. Anything that increases the volume or the security of future revenue will increase the value of your practice. What makes your practice valuable to you should also make it valuable to a buyer.

In the past, practice owners approaching the age of 60-plus and thinking of retiring were the most likely private practice sellers. Today there is a new face for practice sellers. These include therapists of any age who have grown their practices as far as they can and want “out;” therapists who are selling from a position of strength (for example, their practice is booming, and they want to capitalize on that); therapists who are selling from a position of weakness or desperation; and therapists who need to sell for myriad reasons, death in family, breakup, or dissolution of partnership.

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Make sure you understand why you are selling so that you are clear to potential buyers. Be sure about your goal in selling and be flexible about how you might reach that goal. If the goal in selling is to secure enough money to retire: Don’t count on it, although many therapists look to recoup their initial investment and be compensated for many years of hard work and endured risk. Others want to end the burden of ownership, but continue working as a highly compensated employee. Typically, the ways to reach your overall goal of selling include an outright sale (stock or asset purchase), a structured buy in/buyout plan, or a merger with a local competitor.

To achieve your goal, you will need to assemble a team to navigate the course, yet I cannot emphasize enough how vital a role and voice you should have in the process. While everyone’s focus tends to be on the asking price, and, later on, the gap that is often between the asking price and the offered price, many other facets to any practice deal exist. Life after your practice sale needs to begin well before the ink is dry and the deal is done. How you structure the deal will impact how your life will be after the deal.

Your accountant will play a vital role in your practice sale. The strength and quality of your financial statements is a direct reflection of your practice and should include profit/loss statements/balance sheets from the past three to five years with information backed by filed tax returns. Your accountant should help you break down your clinical costs so that gross profit percentages can be determined. Prospective buyers will want an accurate aging report (AR), and projections for the current year.

Your accountant may or may not be equipped to help you with your practice valuation; if he is not, seek out a professional who is. Your accountant should discuss with you and your attorney the consequences from a tax perspective on structuring your deal as an asset or a stock sale. This is crucial and will directly impact your tax liability. Unfortunately, what is advantageous for a seller from a tax perspective may not be advantageous from the buyer’s perspective; fair negotiations are important.

There must be an open and ongoing dialogue between your attorney and accountant for structuring the purchase agreement. Your attorney should make sure you have a good nondisclosure agreement in place before you release any details to potential buyers. Your attorney should help you evaluate any letter of intent from a potential buyer, and review, revise, and sometimes create the purchase agreement. Your attorney should help craft an employment agreement (if that is part of your deal) and evaluate any non-compete clause you will undoubtedly have to sign. Sometimes lucrative employment contracts offset a less than optimal purchase price. Other times a poorly negotiated employment agreement may not compensate you adequately, especially when you may be working less or differently during the non-compete transition period.

Be realistic, be flexible, be clear about what you want for yourself, and what you want your role to be post sale. Most therapists think their practice is worth more than it actually is, so be prepared for some initial disappointment. If you plan on staying on only for a “reasonable transition period,” then who you sell to is less important. If you want to stay on post-sale as an employee, then you need a high degree of compatibility between you and the new owners. The negotiation of your employment agreement (terms, salary, etc.) becomes almost as important as the negotiation of the purchase agreement. Your non-compete clause must be reasonable in order for it to be enforceable. Carve out any nuances that you believe are important. You must always be allowed to earn a living, but there are a finite number of nonclinical, academic, or management positions in our field. Do not wait to begin exploring what is next until the day you walk out the door.

The emotional component to a practice sale is rarely addressed or discussed. Regardless of the purchase price and the joy you may envision after a sale, most owners post-sale have some degree of identity crisis. You are probably more attached to your work identity than you realize. Answering “yes” to the question: “Can this practice exist without you?” is easy. Answering “How will you exist without your practice?” may be harder. Even though you may be selling of your own accord and on your own terms, you are likely to feel a sense of loss. Who we were versus who we are today comes into play. One therapist described it best: “It is like I lost my wallet. Suddenly, I don’t have a job title, a desk, or a name plate!” Re-inventing yourself post-sale, much like growing and selling your practice, is a process. Capitalizing and leveraging the skills you have amassed over the years will assist your successful transition.

Iris Kimberg, PT, MS, OTR, is a PPS member, private practice consultant, and owner of NYtherapyguide.com. She is also on faculty at Columbia University and can be reached at infonytherapy@aol.com.

Surviving the New Payment Model

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The right technology helps physical therapists report and document patient care accurately and efficiently.

By David McMullan, PT

Earlier this year, legislators passed HR 4302, “Protecting Access to Medicare Act of 2014,” which once again temporarily addressed the flawed Sustainable Growth Rate (SGR) formula for Medicare Physician Fee Schedule. This latest legislation brings the physical therapy industry closer to a new payment model that will offer significantly more value to patients while mitigating Medicare and insurance fraud and abuse.

Historically, the physical therapy industry has operated on a fee-for-service billing model. Because the process is subjective, there has been room for interpretation. Ongoing treatment and procedure codes are based on time, and do not consider patient improvement or how time is spent with the patient. As a result, overbilling and inaccurate coding—either intentional or accidental—are common in the physical therapy industry.

To remedy the flawed program in 2007, Medicare introduced the Physician Quality Reporting System (PQRS) to gather quantitative data on the quality of the care being provided to patients. PQRS uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. While well intended, this voluntary program has low participation, particularly in the area of outpatient rehabilitation. Despite the bonus potential and/or penalties tied to reporting, the majority of physical therapists opt out of this program because of its onerous reporting requirements.

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In 2013, Functional Limitation Reporting (FLR) was introduced, shifting the emphasis from providers to patients and patient outcomes. Similar to PQRS, FLR is a quality-reporting initiative that gathers data on patient status and outcome. While PQRS is focused on risk, the emphasis of FLR is on function (i.e., how a patient’s functional limitations have changed as a result of the therapy that they received). Unlike PQRS, FLR is mandatory; therefore, if a physical therapist does not report, he or she will not be paid.

While elements of PQRS will remain, it is apparent that the claims-based reporting option is going away and will not be an option in 2015. However, FLR appears to be the stepping-stone to the industry’s new payment model, which will focus on patient outcomes and not the amount of time physical therapists spend with each patient.

In 2016, a new payment model is expected to be introduced, which will have new evaluation codes and a more simplified coding system. Coding will follow a patient’s current medical status, how severe or involved the patient is, and the amount and intensity of treatment that is required to move a patient from their current level of function to their optimal level of function. It is anticipated that the evaluation component of this new model will mirror the physician model that utilizes evaluation management (EM) coding. Using this model, physicians bill different value codes for an evaluation based on the complexity of the patient condition and evaluation procedures required. For example, if the physical therapist performs a battery of tests and the treatment is very involved, coding is billed at a much higher-level evaluation code. However if the patient’s condition and assessment were straightforward, requiring only limited assessment tests that are problem focused, physical therapists would bill at a lower evaluation code.

The EM coding model has been around and worked in the physician world for some time. While most people realize that the current physical therapy payment model must change, providers fear that they may be paid less. While providers certainly will not be paid more under this new model for giving good care, being efficient, and obtaining good outcomes for their patients, they should not be negatively impacted by the change. In contrast, however, for those blatantly abusing the system, the new payment model will make fraud related to overbilling difficult. Providers will need to show how involved they were with the treatment, patient status from start to discharge, and demonstrate the value of care that they are providing patients—otherwise they will not be paid.

The Role of Documentation Technology

Providers may have trepidation about the new payment model, particularly if they are taking liberties when billing. For these providers the impact of these billing standards will be significant, and lead to a 15 to 20 percent decrease in revenues. Having the right tools in place will help physical therapists accurately report.

Gathering data is essential to the success of this new payment model. For the outpatient rehabilitation market, providers need a standardized outcome tool to benchmark against. Such a tool most likely will be a combination of something the patient completes, an overall sense of improvement/satisfaction with the care they were provided, and something more quantifiable on the provider’s side, such as where the patient started, how they improved, how many visits the improvement required, and the cost involved.

From a technology perspective, capturing the appropriate documentation and data elements will be essential to a provider’s success. Documentation technology will play a pivotal role in a provider’s ability to record and report the functional status of a patient at the outset of care, throughout the care model, and at the end of care.

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When considering documentation technology, look for a solution that offers alerts. Providers are required to report at specific intervals—at the onset of care and then every 10 visits—or they will not be paid. In addition to alerting the physical therapist to report on FLR, the documentation system should also alert the scheduler at the front desk to the impending deadline so that they can put an additional reminder on the physical therapist’s schedule. Visual alerts and dashboard make reporting on a timely basis easier for physical therapists.

The ideal system should also assist providers with documentation. Similar to a clinical decision-support system, it should guide clinicians to the appropriate coding and billing selections. For example, built-in logic can guide providers along the way, ensuring test measures have been completed and offer code recommendations based on the type of visit and other pre-determined justifications. The system should provide clinicians with the power and guidance to bill appropriately given the amount of time spent treating patients and the intensity of the service provided in combination with current medical condition and functional status of the patient already documented within the system. The use of algorithms and logic will make documentation easier for clinicians, thus enabling them to spend more time on treating patients and less on reporting.

As the industry continues to move toward a new payment model, clinicians will likely see an expansion of the current FLR requirements. The ability to report accurately ensures claims are processed and paid efficiently. Documentation technology with built-in logic will keep you on top of these changes.

David McMullan, PT, is vice president of Product Management for SourceMedical. David has more than 20 years of outpatient rehabilitation health care experience. He can be reached at David.McMullan@sourcemed.net.

The Peak of Change

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Navigating through the ceaseless changes in health care.

By John Sievers, MPH, MHA

This spring, I vacationed with my family in Mesa, Arizona, where we took advantage of the numerous hiking trails winding through Superstition Mountains. Our most story-worthy adventure involved a trail that leads to the top of Flat Iron Mountain and boasts a varied difficulty rating between “moderate” and “intense.” Getting to the top required that we leave behind a clearly marked trail—because it ended halfway up the mountain—and navigate the rest of our journey by trial, error, and instinct. More than once my family and I had to back-track and pursue another path, but the reward was well worth the effort; the view of Phoenix from atop Flat Iron Mountain and the sense of accomplishment that came from making the journey was truly unbeatable.

This experience is not unlike navigating the ceaseless changes in health care, specifically as they relate to the many business models for physical therapy service delivery. There are stretches of time when it seems like we are on a clearly marked trail, headed in a sure direction—then without warning the trail disappears, and we are left to find our own way to the top.

As frustrating as this may seem, we have only just begun the climb. Physical therapy delivery models face a wealth of change in the near future, including payment methodology, physician alignments, development of provider networks, and the consolidation of health care systems.

The general agreement is that the health care industry’s current state is not sustainable, and while most recognize that the next five years will look nothing like the last five, how to position and pursue the best course of action is still not a clearly marked path. With the specific details and timing of change unknown, physical therapy owners are hesitant to craft a clearly defined strategy. They recognize that they are facing huge decisions for the future of their company, but are reluctant to act amidst so many fluctuating variables.

Looking ahead, three industry trends are likely to take root in the coming months, which will affect the future environment for nearly all physical therapy centers.

Changing Trends in Health Care

  1. Payment will decline. Medicare and commercial payors face increased rate regulation, tougher medical loss ratio requirements, and the establishment of health insurance exchanges, which increases transparency and forces premiums downward. Given these pressures across the major payor classes, payments to facilities will suffer.
  2. Alternatives to fee-for-service payment will become more prevalent. Commercial payors, Medicare, and state agencies will continue to refine alternative payment concepts that transition from fee-for-service towards pay-for-performance, episode-based bundled payments, and population-based reimbursement.
  3. Increased availability of provider-specific information on the price for a specific health care service. As health care costs continue to rise, purchasers will focus on strategies that can bring costs under control. These pressures have facilitated a movement by many purchasers to engage consumers more fully in their health care decisions, including taking on a greater share of their health care costs. In their efforts to manage costs, health care purchasers—including large employers—recognize consumers need information on both health care price and quality.

As these trends evolve and begin to affect practice owners, the most critical change may be the degree and pace of transition from volume-based payment schemes to value-based alternatives.

Even facing this change, many facilities will choose to stay the course and hope for the best, especially in markets where net payment is favorable and owners are still enjoying strong profit margins. Regardless, the options you elect to implement or reject will go a long way in determining the future sustainability of your company. As you consider what route to take for yourself and your facility, keep in mind the market variables, which change as frequently as the market itself.

MARKET VARIABLES

Payment Rates in Your Market
  • Analysis of net revenue per visit both current and trending
  • Evaluate payor mix and individual contractual fee schedules
Current Profit Margins
  • Review of year-over-year patterns and future forecasting
  • Determine potential to reduce expenses—both fixed and variable
Consolidation among Physicians & Health Systems
  • How will organizational restructuring of referral sources affect your facilities?
  • Assess potential impact of Accountable Care Organizations (ACOs) and bundle payment arrangements
Ability to Capture Market Share
  • Your ability to maintain and grow same store volume
  • Effect of high deductible insurance plans and Health Savings Accounts (HSAs)

Fortunately, despite the changes and the variables within them, you have many options to position yourself and your physical therapy facility to gain a competitive advantage. While every possibility needs to be weighed against your long-term personal and business objectives, I recommend that independent physical therapy facilities consider expansion and growth strategies, mergers and acquisitions, integrated network alignment, or succession planning.

BUSINESS MODEL DELIVERY OPTIONS

Expansion & Growth Strategies
  • Focus on increased case volume and payment
  • Determine cost/benefit of offering new service lines
  • Offer carve-outs with self-insured and commercial insurers
Mergers & Acquisitions
  • Target local/regional market competitors
  • Potential to create greater value for future monetizing transaction
  • Leverage economies of scale with respect to billing, software, and human relations.
Integrated Network Alignment
  • Evaluate various options available in your market
  • Determine competitive advantages that local networks could offer
  • Assess Professional Services Arrangements (PSAs) with health systems
Succession Planning
  • Determine best course of action to monetize ownership
  • Target current employees for potential succession strategy
  • Develop 2 to 3 year plan of action to transition

The bottom line is to prepare for everything. You cannot know when your paved trail will end, you cannot determine which obstacles will cross your path or when, and you cannot always know the variables you will have to address when considering how to position (or reposition) your facility. Take time to review market trends and studies and align your practice with a group that has in-depth understanding of what is going to affect health care change and how it will wind its way to you.

The journey ahead will transition facilities to compete and there will be difficult stages along the trail. But it is still possible to reach the top. There is always an alternate route—find one that makes it possible for you to keep pressing forward.

John Sievers, MPH, MHA, is vice president of Physical Therapy Business Development at Nueterra. He can be reached at jsievers@nueterra.com.

Video Analysis

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Using contemporary technology to improve clinical assessment.

By Brian Hoke, PT, DPT, SCS, CGFI Andrew Altman, PT, MPT, ATC David Volkringer, PT, MPT, and Katie Johnson, PT, DPT
What is the common element in the following events: a soccer player lands a jump, a pitcher throws a ball, a long distance runner makes contact with the ground, and a golfer makes impact with the ball on the tee? They all take place in less than one second, and the movement that occurs cannot be accurately assessed with the unaided eye. The integration of video technology solves this clinical dilemma by capturing the motion and allowing the clinician to replay the motion at a much slower rate to analyze posture, joint positions, and symmetry. Video technology has evolved greatly from the days of the first tape-based systems. Some will recall the VHS and Sony Beta technology of yesteryear, with its large recording units and cameras. The cost of the equipment was high and slow motion playback was often “fuzzy” with poor definition. Fast forward to modern technology for video capture and playback, and the user is provided with several video options that are more compact, affordable, and produce a much higher definition playback for slow motion clinical analysis. In our physical therapy practice, we use video capture
  • to analyze landing patterns that reveal a higher risk of anterior cruciate ligament (ACL) injuries
  • to analyze the throwing motion in baseball
  • to analyze the swing path and body positions during the golf swing
  • to analyze gait patterns for walking and running

ACL Injury Risk Evaluation

In the United States alone, there are more than 200,000 ACL injuries annually. Of these, approximately 65 percent will undergo reconstructive surgery. This has consequentially created an increase in the numbers of rehabilitative cases seen in the physical therapy outpatient setting. As a result, there has been much attention toward designing a physical therapy training program that will not only result in predictably good outcomes, but also one that is able to test and predict the level of injury and or re-injury.

There have been many efforts toward determining various risk factors that lead to ACL injuries, and high valgus moments, especially with anterior tibial forces, have been determined to result in strain and increase the risk of rupture of the ACL1,2,3,4. A Drop Jump Test objectively measures the athlete’s ability to control lower limb axial alignment in the frontal plane.

To perform the video analysis, the patient jumps off a box on to the ground and then immediately jumps in to a maximum vertical jump. The camera captures the jump in four specific phases; just as the toes are touching the ground (pre-landing), the landing (deepest position), the take-off in to the maximum jump, and the maximum jump.

The knee valgus angle can also be measured to objectively document the higher risk athlete who demonstrates greater valgus angle on landing.

Clinically, we have found that the video analysis of the drop jump test is a standardized, time-efficient measurement tool that can be performed easily in a physical therapy office.

Biomechanical Throwing Analysis

High-speed video analysis can be a valuable tool to assess a baseball player’s faulty mechanics as they perform the movement of throwing. A portable system is necessary to video at a baseball field, which can be analyzed and reviewed at your physical therapy practice with the player, coach, and parents. To perform a good quality video analysis for a baseball pitcher:
  1. The player should wear clothing that affords good exposure of the throwing arm, trunk, and legs. Have the player shirtless or in tight clothing so that all land marks and joints can be identified. Sliding shorts or bike shorts are useful to video the lower trunk and hips.
  2. Mark necessary landmarks with small retroreflective markers such as ScotchLite® Adhesive Tape. You can also use a permanent felt-tip marker.
  3. Film three to five pitches from three different views: second base view (behind pitcher), home plate view (front view), and open side (left handed pitcher would be from first base and a right handed pitcher would be from third base.)

During analysis, identify the biomechanical faults observed in the thrower’s motion to decrease the athlete’s risk of injury and/or improve a thrower’s performance and development of maximal pitch velocity. After reviewing your analysis with the athlete and other key individuals, such as parents, coaches, and sports agents, it is not uncommon for them to recommend the analysis to other players and coaches.

Gait Analysis for Walking and Running

During walking the foot is only on the ground for six tenths of a second, and when we run stance phase is as short as 2/10 of a second.

Integrating video into the evaluative process enables the clinician to observe the gait pattern in a frame-by-frame manner and find the exact moment in gait where the subject reaches maximal pronation. At this point we are able to use an angle tool to compare the difference between the left and right subtalar joints. As a result of the analysis, the plan of care may include strengthening for the lower limb decelerators, a footwear recommendation, or orthotic therapy. A marked difference between the left and right sides may also lead the clinician to look further up the kinetic chain to determine if there is a reason behind the difference, such as a limb length discrepancy, pelvic asymmetry, or scoliosis.

Vertical displacement of the center of mass is another predictor of running efficiency. Decreasing vertical displacement improves performance by using less energy to go up and down and spend more we have for moving forward. We use the video software to find the lowest and highest points during the subject’s gait cycle and use the calibrated line segment tool to determine the distance that the runner travelled up and down.

Video capture and playback software enables the clinician to slow down movements that are too fast for the naked eye to see and educate the athlete regarding their biomechanical faults or movement inefficiencies and identify excessive or inadequate motion that can be altered to improve performance or reduce the potential for injury.

Golf Swing Analysis

Down-The-Line Golf Swing Video Capture

Down-The-Line Golf Swing Video Capture

Face-On Golf Swing Video Capture

Face-On Golf Swing Video Capture

Video analysis of golfers’ swings is a common practice by teaching golf professionals and on sports coverage of televised professional golf events. For the clinician, a brief analysis of a golfer’s swing can assist in detecting faults that can increase the risk of injury and also impair a golfer’s performance.

The video analysis of a golfer’s swing is typically done from two views: “face on” and “down the line.” The “face-on” view (Figure A) is done by filming facing the player as they swing. This provides useful information regarding proper weight transfer during the swing as well as lateral sway of the hips and pelvis during the swing. The second view is “down the line” (Figure B) filmed by standing behind the player facing their target. This view is extremely helpful in analyzing the golfer’s posture, swing plane, and rotation of the hip and pelvis.

What You Need to Get Started

Knee extension of trail leg leading to Reverse Pivot swing fault

Knee extension of trail leg leading to Reverse Pivot swing fault

Takeaway and swing path

Takeaway and swing path

To begin video analysis, you will need a camcorder, preferably with the ability to record in high definition, a tripod to keep the camera steady while filming, and a computer with a memory card reader or USB cable to connect the camera to load the video for analysis. For the analysis itself, you may choose from many user-friendly software packages. Some of the more commonly used programs available for purchase are Dartfish, Sports Motion Analysis, and Coach’s Eye. There are also very useful public domain programs for the clinician, such as V1 Home and Kinovea.

Capturing and printing the video frames that reveal the most useful information can be helpful and providing video images to the patient is a marketing opportunity. People love to see themselves on the video since it is a perspective that they cannot otherwise obtain, and they will often share this information with other athletes and coaches. When the patient has been referred by a physician or coach for the video analysis, make sure the referral source also gets a copy of the video images, as well as a concise summary of the significant findings.

Summary

The integration of video analysis into clinical practice can open the door to more accurate analysis of functional movements, particularly in the high velocity movements of common sports. The information obtained can assist the clinician in identifying factors that increase the risk of injury, cause the body to move into abnormal patterns of compensation, and impair optimal sports performance. From this information, corrective measures can be developed, and subsequent analysis can further assess the effectiveness of treatment interventions. In addition to providing an extremely valuable clinical tool for the clinician, this novel service can also be a new source of revenue for the clinical practice. This is particularly true in the absence of injury, where the goal is injury risk reduction and improved performance. If people in your community value this service, it can provide significant cash-based revenues.

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The following are examples of four common swing faults that can be demonstrated on the video and linked to specific problems that can be addressed by a physical therapist:

Reverse Pivot: If a golfer allows the trail leg to move into knee extension during the backswing (Figure C) and subsequently fails to make proper weight transfer to their lead foot in the downswing, they will hit “off their back foot.” This can often be corrected with core stabilization of the lower trunk musculature, lower extremity postural stabilization exercises in a flexed knee position, and better proprioceptive awareness and balance ability.

Improper Swing Path: If the golfer swings the club outside the ideal swing path on the backswing, they will repeat the path on the downswing imparting a left to right sidespin to the subsequent ball flight (“slicing”). When this is observed in the video analysis, it may reflect a lack of thoracic rotation or inadequate shoulder external rotation range of the trailing shoulder.

Loss of Golf Posture: In an ideal golf swing, the golfer maintains a consistent spine angle from takeaway to impact with the ball. This creates consistency in bringing the club head back to a “square” position as the club is brought through the impact zone. When the loss of golf posture occurs, the golfer fails to maintain a stable spine angle (Figure B) during the swing, becoming more upright during the golf swing. This can be related to inadequate strength and stability in the hip and pelvis and can frequently be corrected with core stabilization exercises for the gluteals and lower abdominal musculature.

Shortened Swing Arc: A golfer’s swing arc is related to the power developed and ultimately the distance that the ball travels. When the golfer fails to bring the club back fully in the backswing there is a loss of power and distance. The video analysis provides an easy tool to observe the length of the arc of a golfer’s swing (Figure D). Tightness in the posterior shoulder of the lead arm, loss of hip internal rotation of the trail leg, and limitation of trunk rotation can all lead to a shorter backswing.

 

Brian Hoke, PT, DPT, SCS, CGFI, is a PPS member, co-owner of Atlantic Physical Therapy, PC, in Virginia Beach, VA, and a Titleist Certified GolfFitness Instructor. He can be reached at hokeptscs@aol.com.

Andrew Altman, PT, MPT, ATC, is co-owner of Atlantic Physical Therapy, PC. He can be reached at aatlmanpt@aol.com.

David Volkringer, PT, MPT, OCS, is a physical therapist with Atlantic Physical Therapy, PC. He can be reached at dvolkringer@gmail.com.

Katie Johnson, PT, DPT, is a physical therapist with Atlantic Physical Therapy, PC, and a former Division 1 soccer athlete. She can be reached at katieannj@gmail.com.

 

Notes

1. Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr. Mechanisms of anterior cruciate ligament injury. Orthopedics 2000; 23: 573-8.

2. Boden BP, Torg JS, Knowles SB, Hewett TE. Video analysis of anterior cruciate ligament injury: abnormalities in hip and ankle kinematics. Am J Sports Med. 2009;37(2):252-259.

3. Ford KR, Myer GD, Hewett TE. Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exerc. 2003;35(10):1745-1750.

4. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am. J. Sports Med. 2005; 33: 492-501.

5. Zebis MK, Andersen LL, Bencke J, et al. Identification of athletes at future risk of anterior cruciate ligament ruptures by neuromuscular screening. Am. J. Sports Med. 2009; 37: 1967-73.

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