Physical Therapy Service

Physical Therapy
“I come to you”
At-Home, In-Office, At-Fitness Facility


The Physical Therapy service that I provide is delivered to you at your home, at your office, or at your fitness facility.  I come to you.

It is cash based Physical Therapy.  
Cash based service allows me to provide direct one on one high quality service.   Traditional health insurance based Physical Therapy is burdened with administrative requirements which take time away from the services that I provide.  Removing the requirements from health insurance plans provides a unique opportunity to take control of your problem. 

Depending on what your expectations and goals are you can have a Physical Therapy visit last as long as you want or as short as you want.  Depending on what your expectations and goals are you can have as many Physical Therapy visits as you want or as few visits as you want.  We have control. 

Are you looking for Physical Therapy service that provides?

•good enough healthcare
•all the healthcare you need to get back to what you want to do
•healthcare that is all the way well care

Together we can take the time to identify, clarify and measure your expectations and goals.  We can become a team without hassles from a health insurance company.  When the goals and expectations are agreed upon as Steven Covey said, we “can begin with the end in mind”.  If we do not come to agreement on your expectations and goals, I will assist you in finding a more appropriate healthcare professional team member to help. 

The expense of this type of healthcare is not necessarily more expensive than insurance based healthcare it is differently expensive. 

•The expense/cost can be less than traditional insurance based Physical Therapy.  National benchmarks for traditional health insurance based Physical Therapy is typically10 Physical Therapy visits per episode of care.  I have honed my craft to a point where the average number of visits per episode of care is 3 visits.  Using a standard outcome measure that is used by over 7 million Physical Therapists my score for improvement per visit ranks in the 97th percentile I provide effective and efficient service. 
•If you have a health insurance plan with a high deductible, and are healthy, using cash based fee for service makes sense.  I provide statements to you which you can submit and apply to your out of network deductible. 
•All of the time during the visit with me is one on one with me.  If you are going to pay for skilled Physical Therapy visit it makes sense to spend all of the time with the Therapist, as opposed to a PT Tech or exercising on your own during the PT clinic visit.
•If you have used all your allotted visits allowed by your health insurance plan for the year and you need additional Physical Therapy, using traditional insurance based Physical Therapy will be higher than using cash based Physical Therapy services.  You will be responsible for the entire bill including co-pay. And, the time spent with the skilled Physical Therapists typically is only 15 minutes/visit. 
•If you do not have health insurance the quality and efficiency of cashed based fee for service Physical Therapy is better than traditional insurance Physical Therapy.
•If you prefer privacy and convenience of At-Home, At-Office, At-Fitness Facility,  I can help.  Scheduling times are available early morning, evening, and weekends.  On-line access is available. 

Give me a phone call for a free consultation +65 9733 0932.  I will provide details of benefits and costs of cash based Physical Therapy and a worksheet you can use to determine what your health insurance benefits and costs for Physical Therapy would be.  You can than compare to determine if using cash based Physical Therapy makes sense.

Services provided:

•Orthopedic Physical Therapy
•Second opinions regarding Orthopedic Physical Therapy
•In home/office/vehicle ergonomic evaluation
•Assistance in ordering adaptive medical equipment, and home modifications to address movement system dysfunction
•Education on treatment/prevention or movement system disorders, and wellness
•Gait evaluation gait training motion analysis

If you combine, time saved, less time in pain, less time traveling to clinic, greater knowledge and understanding of your problem and being empowered to self-manage the problem, At-Home, At-Office, and At Fitness Facility Cash Based Service can be a real bargain.

Fluid Replacement Controversy: Too Little – Too Much
In 1996 the American College of Sports Medicine (www.acsm-msse.org) position stand on exercise and fluid replacement recommended that during exercise athletes should start drinking early and at regular intervals in an attempt to consume fluids at a rate sufficient to replace all the water lost through sweating (i.e. body weight loss), or consume the maximal amount that can be tolerated. Since 1996 studies have documented athletes can over drink, leading to water retention, weight gain, and in a few cases death from exercise associated hyponatraemic encephalopathy. Hyponatraemia is water poisoning; there is far too much water and too little sodium in the body. Symptoms associated with hyponatraemia include nausea, vomiting, head aches, cramps, convulsions, leading to coma. A study in 2002 documented that 13% of the Boston Marathon runners suffered from hyponatraemia. Hyponatremia is defined as a serum sodium level of less than 135 mEq/L and is considered severe when the serum level is below 125 mEq/L.

In July 2006 the International Marathon Medical Directors Association (www.aimsworldrunning.org) published a position statement “Update Fluid Recommendation”. The IMMDA presents 6 practical recommendations one of which is drinking to thirst will protect the athlete from hazards of both over and under drinking.

This recommendation of “drinking to thirst” is contrary to the common interpretation of the 1996 ACSM guidelines that drinking according to the dictates of thirst leads to “dehydration”, which impairs exercise performance and promotes risk of ill health. Frequently, I have heard the recommendation that you should start drinking early in the race even though you are not thirsty; because in order to stay hydrated you need to drink early and often. Dr. Tim Noakes argues that this practice increases the risk of drinking too much water and slower runners are at greater risk for hyponataemia, as they have more time to consume more water
(2007).

In Feb 2007 the ACSM published a replacement position stand on Exercise and Fluid Replacement. The goal of drinking during exercise is to prevent excessive (>2% body weight loss from water deficit) dehydration and excessive changes in electrolyte balance to avert compromised performance. The ACSM no longer recommends that during exercise athletes should start drinking early and at regular intervals in an attempt to consume fluids at a rate sufficient to replace all the water lost through sweating (i.e. body weight loss), or consume the maximal amount that can be tolerated. The 2007 guidelines recognize that drinking too much
fluid can also be dangerous. Athletes should weigh themselves before running and write the results on their race bibs. If anything goes wrong, emergency workers can use the weight information to tell if the patient had consumed too too little or too much water. The ACSM cites data water quenches the sensation of thirst before body fluid replacement is achieved, so thirst should not be the only determinant of how much fluid is consumed. 

Dr T Noakes critics the 2007 ACSM position stand on Fluid Replacement relative to using body weight as a measure of dehydration. Dr. Noakes suggest body weight is not an accurate measure of body fluid and electrolyte volume during exercise. He suggest that the controller of the balance between body fluid and electrolytes particularly sodium is the thirst mechanism. Dr. Noakes has concluded there is no conclusive evidence that athletes who drink sparingly during exercise develop specific medical conditions and the ability to sweat profusely while exercising in the heat is on of the most important determents of human evolution. Research by S Schwellnus (2007) found no relationship between dehydration and cramping. During his study athletes measured their levels of electrolytes, body weight changes, and found those who cramped were no different from those who did not cramp. 
He suggests cramping is likely related to meuromuscular control at the spinal cord level in response to fatiguing exercise.

The bottom line according to Dr. Noakes is drink according to the dictates of your thirst during exercise, and do not ignore thirst. This approach works for every creature on planet earth even the slower runners. According to Dr. Noakes when athletes drink according to thirst, the risk that they will over drink is minimized, and there is no evidence that they are at any significant disadvantage from the 3-5% level of dehydration that develop as a result.

The ACSM and the IMMDA disagree on whether thirst should be the guide regarding fluid replacement, but they agree that considerable variability exists among individuals, and blanket advice to widely variable population of individuals seeking simple answers is out of place. Athletes should be encouraged to explore, understand, and be flexible to their own needs. Look for multiple signs suggesting dehydration including thirst, body weight, volume and color of urine, and rectal body temperature. 

Dehydration Causes, Symptoms and Tips to Stay Hydrated

Our Body of Water
The majority of the body is made up of water with up to 75% of the
body's weight due to H2O. Most of the water is found within the
cells of the body (intracellular space). The rest is found in the
extracellular space, which consists of the blood vessels
(intravascular space) and the spaces between cells (interstitial
space).

What is Dehydration?
Dehydration occurs when the amount of water leaving the body is
greater than the amount being taken in. The body is very dynamic
and always changing. This is especially true with water levels in
the body. We lose water routinely when we: 
>breathe and humidified air leaves the body; 
>sweat to cool the body; and
>urinate or have a bowel movement to rid the body of waste
products.

In a normal day, a person has to drink a significant amount of
water to replace this routine loss.

Causes of Dehydration: Diarrhea.
Diarrhea is the most common reason a person loses excess
water. Diarrhea consists of unusually frequent or unusually liquid
bowel movements and excessive watery evacuations of fecal material. Persistent diarrhea is both uncomfortable and dangerous, as a significant amount of water can be lost with each
bowel movement. Worldwide, more than four million children die
each year because of dehydration from diarrhea.



Causes of Dehydration: Vomiting
Vomiting is the act of forcible emptying of the stomach, in which
the stomach has to overcome the pressures that are normally in
place to keep food and secretions within the stomach. The
stomach almost turns itself inside out - forcing itself into the
lower portion of the esophagus (the tube that connects the mouth
to the stomach) during a vomiting episode. Constant vomiting can
be a serious cause of fluid loss and it is difficult for a person to
replace water if they are unable to tolerate liquids.



Causes of Dehydration: Sweat
The body can lose significant amounts of water when it tries to
cool itself by sweating. Whether the body is hot because of the
environment (for example, working in a warm environment),
intense exercising in a hot environment, or because a fever is
present due to an infection; the body uses a significant amount of
water in the form of sweat to cool itself. Depending upon weather
conditions, a brisk walk will generate up to 16 ounces of sweat
(one pound of water).



Causes of Dehydration: Diabetes
In people with diabetes, elevated blood sugar levels cause sugar
to spill into the urine, and water then follows, which can cause
significant dehydration. For this reason, frequent urination and
excessive thirst are among the symptoms of diabetes.



Causes of Dehydration: Burns
The skin has an important role to play in the fluid and temperature
regulation of the body. If enough skin area is injured, the ability to maintain that control can be lost. Burn victims become
dehydrated because water seeps into the damaged skin. Other
inflammatory diseases of the skin are also associated with fluid
loss.



Causes of Dehydration: Inability to Drink Fluids
The inability to drink adequately is another potential cause of
dehydration. Whether it is the lack of availability of water or the
lack of strength to drink adequate amounts, this, coupled with
routine or excessive amounts of water loss can compound the
degree of dehydration.



What Are the Signs and Symptoms of Dehydration?

The body's initial responses to dehydration are thirst to increase
water intake along with decreased urine output to try to conserve
water. The urine will become concentrated and more yellow in
color. As the level of water loss increases, more symptoms can
become apparent, such as increased thirst, dry mouth, cessation
of tear production by the eyes, cessation of sweating , muscle
cramps, nausea and vomiting, heart palpitations, and
lightheadedness (especially when standing). With severe
dehydration, confusion and weakness will occur as the brain and
other body organs receive less blood. Finally, coma and organ
failure will occur if the dehydration remains untreated.



How is Dehydration Diagnosed?
Dehydration is often a clinical diagnosis. Aside from diagnosing
the reason for dehydration, the health care professional's
examination of the patient will assess the level of dehydration.
Initial evaluations may include:
Mental status tests to evaluate whether the patient is awake,
alert, and oriented.
Vital sign assessments may include postural readings
(blood pressure and pulse rate are taken lying down and
standing). With dehydration, the pulse rate may increase and
the blood pressure may drop because the intravascular
space is depleted of water.
Temperature may be measured to assess fever.
Skin will be checked to see if sweat is present and to assess
the degree of elasticity. As dehydration progresses, the skin
loses its water content and becomes less elastic.
Infant evaluation: infants may have additional evaluations
performed, including checking for a soft spot on the skull
(sunken fontanelle), assessing the suck mechanism, muscle,tone, or loss of sweat in the armpits and groin.

Pediatric patients are often weighed during routine visits, thus a body weight measurement may be helpful in assessing how much water has been lost with the acute illness.
In some cases, blood tests to measure potential electrolyte abnormalities and urinalysis may be ordered to determine the level of dehydration in the patient.



How is Dehydration Treated?

Fluid replacement is the treatment for dehydration. This may be
attempted by replacing fluid by mouth, but if this fails, intravenous
fluid (IV) may be required. Should oral rehydration be attempted,
frequent small amounts of clear fluids should be used. 

Clear fluids include:

>water,
>clear broths,
>popsicles,
>Jell-O, and
>other replacement fluids that may contain electrolytes.

Can Dehydration Be Treated at Home?
Dehydration occurs over time. If it can be recognized in its earliest
stages, and if its cause can be addressed, then home treatment may be adequate. Steps a person can take at home to prevent
severe dehydration include:

>People with vomiting and diarrhea can try to alter their diet
and use water-cure-protocol formula to control symptoms to minimize water loss.

>Acetaminophen or ibuprofen may be used to control fever.
Ibuprofen may irritate the stomach and cause nausea and
vomiting, so it should be used with caution in individuals
who already have these symptoms.

>Fluid replacements may be attempted by replacing fluid by mouth with frequent small amounts of clear fluids.

 If the individual becomes confused or lethargic; if there is
persistent, uncontrolled fever, vomiting, or diarrhea; or if there are
any other specific concerns, then medical care should be accessed. EMS or 911 should be activated for any person with altered mental status.



What Are the Complications of Dehydration?

Complications of dehydration may occur because of the
dehydration, and/or because of the underlying disease or situation
that causes the fluid loss. Complications that may occur include:
>kidney failure,

>coma,

>shock,

>heat-related illnesses (heat exhaustion or heat stroke), and

>electrolyte abnormalities.



Dehydration Prevention Tip #1

Plan ahead and take extra water to all outdoor events where
increased sweating, activity, and heat stress will increase fluid
loss. Encourage athletes and people who work outside to replace
fluids at a rate that equals the loss.



Dehydration Prevention Tip #2

Check weather forecasts for high heat index days. When
temperatures are high, avoid exercise, outdoor exposure, and plan
events that must occur outside during times of the day when
temperatures are lower.



Dehydration Prevention Tip #3

The young and elderly are most at risk of dehydration. Ensure that
older people, infants, and children have adequate drinking water or
fluids available and assist them as necessary. Encourage
individuals who are incapacitated or impaired to drink plenty of
water and assure they are provided with adequate fluids.
During heat waves, attempts should be made to check on the elderly in their homes. During the Chicago heat wave of 1995, more than 600 people died in their homes from heat exposure.



Dehydration Prevention Tip #4

Avoid alcohol consumption, especially when it is very hot, because
alcohol increases water loss and impairs your ability to recognize
early signs associated with dehydration. 



Dehydration Prevention Tip #5

Wear light-colored and loose-fitting clothing if you must be
outdoors when it is hot outside. Drink plenty of water and carry a
personal fan or mister to cool yourself.



Dehydration Prevention Tip #6

Break up your exposure to hot temperatures. Find air-conditioned
or shady areas and allow yourself to cool between exposures.
Taking someone into a cooled area for even a couple of hours
each day will help prevent the cumulative effects of high heat
exposure.



Dehydration Prevention Tip #7

Know the signs and symptoms of heat cramps, heat rash, heat
exhaustion, and heat stroke. Preventing dehydration is one step to
avoid these conditions.



Dehydration At A Glance

>The body needs water to function.

>Dehydration occurs when water intake is less than water loss.

>Symptoms range from mild to life-threatening.

>Prevention is the important first step in treating dehydration.

>The young and the elderly are especially susceptible to
dehydration.

How is dehydration diagnosed?

Dehydration is often a clinical diagnosis. Aside from diagnosing the reason for dehydration, the health care professional's examination of the patient will assess the level of dehydration. Initial evaluations may include:

Mental status tests to evaluate whether the patient is awake, alert, and oriented. Infants and children may appear listless and have whiny cries and decreased muscle tone.


Vital signs may include postural readings (blood pressure and pulse rate are taken lying down and standing). With dehydration, the pulse rate may increase and the blood pressure may drop because the blood is depleted of fluid. People taking beta blocker medications for high blood pressure, heart disease, or other indications, occasionally lose the ability to increase their heart rate as a compensation mechanism since these medications block the adrenaline receptors in the body.

Temperature may be measured to assess fever. While it is common to measure temperature in the ear (tympanic) or by mouth (orally), a rectal thermometer may be used to assess core body temperature if the patient appears warm, but no fever is noted tympanically or orally.

Skin may be checked to see if sweat is present and to assess the degree of elasticity (turgor). As dehydration progresses, the skin loses its water content and becomes less elastic. The amount of sweat is often felt in the armpit or groin, two areas that tend to have moisture normally.

The mouth can become dry and the health care professional may look at or feel the tongue to see how wet it is.

Infants may have additional evaluations performed, including checking for a soft spot on the skull (sunken fontanelle), and assessing the suck mechanism, loss of sweat in the armpits and groin, and muscle tone. All are signs of potential significant dehydration.

Pediatric patients are often weighed during routine child visits, thus a body weight measurement may be helpful in assessing how much water has been lost with the acute illness. This is very rough estimate because all scales are not the same, and for infants and children, it is important to know what clothing they were wearing when the original weight was taken.

Laboratory testing

The purpose of blood tests is to assess potential electrolyte abnormalities (including sodium, potassium, chloride, and carbon dioxide levels) associated with the dehydration. Other tests may or may not be ordered depending upon the underlying cause of dehydration, the severity of illness, and the health care professional's assessment of their needs and resources available.

Other blood tests may be helpful in determining the level of dehydration. Hemoglobin and red blood cell counts may be elevated because the blood is more concentrated with water loss from the intravascular space.

Kidney function tests including BUN and creatinine may be elevated, and this is one way of measuring the severity of dehydration.

Urinalysis may be ordered to determine urine concentration; the more concentrated the urine, the more dehydrated the patient.

Body Alcohol Content (BAC)

If a human body's blood alcohol content (BAC) exceeds 300mg/100 ml, it has reached a point where a person crossed over from harmless intoxication to alcohol poisoning.

No drinker knows when alcohol poisoning set in.

Downing more than 8 drinks in a row would cause your BAC levels to exceed 500mg/100ml, which is fatal.

At such levels, the alcohol affects the human brain's control over the person's consciousness, heartbeat and breathing. It also impairs the gag reflex, increasing the risk of victims choking on their own vomit and suffocating.

Constant vomiting will lead to dehydration, which causes irregular heartbeat, kidney failure and decreased blood supply to the brain, leading to coma.

Breathing will also become irregular and the person's blood pressure will fall dangerously low, depriving the brain of oxygen, which can cause come or severe brain damage.

In some hospitals, oxygen therapy, where pure oxygen is pumped into the lungs through a machine, is carried out to increase the supply of oxygen to the body. Any obstruction in the airways will also be cleared to ensure normal breathing.

Even if a person survives alcohol poisoning, he/she could suffer irreversible brain damage and memory loss.

It is not always easy to tell if a person has reached a dangerous level of intoxication. Drunk people often display the same symptoms such as unconsciousness, slurred speech and vomiting. All these are due to cellular chronic dehydration.

Some signs that set alarm bells off:-
mental confusion,
inability to wake from unconsciousness,
constant vomiting,
seizures,
fits,
slow or irregular breathing,
low body temperature and
bluish skin color or paleness.

Women need to be more careful and aware of alcohol poisoning as they suffer more effects from alcohol than men and generally at a faster rate too.

Teenagers, who have a smaller body mass, are also more vulnerable to the effects of alcohol because they have not built up a tolerance for alcohol. They are also less able to judge their own levels of intoxication.