In 2012 The Institute of Medicine (IOM) broadly criticized the U.S. healthcare system and reported this industry wastes roughly $750 billion per year. That’s about 30 cents of every dollar spent on healthcare! Let’s compare healthcare to shopping for a home. You walk into a real estate agent’s office and sit down to look at homes. The agent tells you that the house prices aren’t posted and that these prices will vary, depending on which real estate agent you choose and on your source of payment. If you want your house inspected—each inspector will look at different things and have a different blueprint to work from. Oh, and one last thing—you need to get a safety check, but different agencies follow different safety standards and implement these in different ways. Can you imagine what this would feel like? I am willing to bet you do because this is often how a healthcare experience feels!
Pain changes everything! There is sufficient evidence supporting the theory that pain is associated with impaired cognitive function.13-15 Translation—pain can affect decision making! This is why healthcare providers should be held to a high standard and why evidence must help guide decision making in healthcare.
Physical therapy is an incredible profession—yes I am biased. We treat individuals of all ages, from newborns to the elderly, who have medical or health-related conditions that limit their abilities to move and perform the activities they love. The profession has evolved into a direct access role and many people are now seeking help from their PT before considering more invasive treatment options. This is a huge responsibility for PTs because this means the flow of healthcare often starts with us. Having an evidence-based practice has never been more important!
The goal for physical therapy is to develop a plan for returning to your highest level of function. PT can be expensive, so you don’t want to waste money, time and appointments at the wrong place or with the wrong providers. People often ask—how do I know what good PT is? When this happens, I usually provide a diplomatic statement about the profession and then start to talk about why my services are unique.
To be honest, when providers get this question, it’s an easy opportunity to sell ourselves and our services. After many of these conversations I realize my answers are likely the same as everyone else and perhaps I am guilty of contributing to all the confusion. When I find myself following patterns of the masses, I usually take the opportunity to pivot and consider a different approach. Rather than trying to convince you to come and see me, a dialogue you are likely accustom to if you have visited multiple PT’s, this article will provide all my readers with a “Blueprint” for what quality PT looks like.
Please understand, it is often easier to criticize than create. The goal of the article isn’t to promote a platform for negativity or to put down other healthcare providers; however, we all took an oath to put patients first and above all—to do no harm.
I’m a huge fan of the Choosing Wisely Campaign, an initiative that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures. In response to this initiative, The American Physical Therapy Association (APTA) created a list of common therapy treatments that people should question. I have provided some of these below. The full list can be found here:
http://www.apta.org/PTinMotion/News/2014/9/15/ChoosingWiselyRelease/
Using hot packs and ultrasound as a means to provide long-term outcomes in musculoskeletal conditions.
Evidence shows the use of superficial (hot pack) or deep heat (ultrasound) is not a musculoskeletal treatment that will help patients make meaningful progress. While some evidence shows heat can provide short-term pain relief, it should be used to facilitate an active treatment program. Another thing about hot packs—you can buy them yourself! There is emerging evidence that passive treatment strategies can harm patients by reinforcing fears of moving with pain, prolonging recovery and increasing costs. These treatments can also increase the risk of exposure to invasive and costly treatments like injections or surgery. In other words—we need to stop teaching patients they need us to “Heal” them with our tools. The benefit of passive treatment—short term pain relief. The cost—running the risk of depriving a patient of their self-efficacy!
A hot pack sounds like a good option and is usually sold as a way to promote healing and prep your tissues for exercise, however, you can do this on your own as this is not a SKILLED treatment. An ideal PT session may consist of a few sessions of manual therapy and the majority of time should be spent on educating you about your condition, the underlying problems as well as exercise and activity progression.
Strength-training programs that don’t challenge older people.
Under-dosing exercise for older patients can minimize function and delay recovery. PT’s need to match the frequency, intensity, and duration of exercise to the individual’s abilities and goals. If people find their daily activity is more challenging than their exercise routine—this is a red flag! When I mention the words “Power training” to my older patients they look at me like I am crazy. What isn’t crazy—evidence shows power declines sooner and faster than strength as we age.10-12 One of the easiest examples of this was a complaint I got from a retired hall-of-fame NFL quarterback. He said he was embarrassed at how long it took him to get out or a chair! How about getting across the street before the light changes! Power is simply force with a time component. My point- strength and power training is important throughout the lifespan and should be trained accordingly.
Now let’s really dive in! Here are some other signs of poor quality care!
Your PT is not being performed by a PT!
I’m sure many of you are nodding your heads right now, saying “I know what you mean.” Many PT models consist of a very limited amount of time with the PT and then you are passed off to an aid. If you are paying for quality care—a teenager will not provide it! One example that comes to mind—I was working with a patient who told me their previous PT was “so good” that he could see 4-5 patients at the same time. My heart broke but to be honest—this isn’t uncommon. During my first internship I was treating 3-4 patients at once and thought I was awesome for being able to do this. The truth—if you aren’t being observed during your treatment, it isn’t skilled care!
No changes in your treatment plan
The definition of crazy – doing the same thing over and over again but expecting different results. Somehow, many people have been following the same routine for weeks, months and even years without any change in pain or function. A crucial component of rehabilitation is progression—meaning you need to move forward!
No plan to get you back to doing what you love
Addressing pain is an important part of therapy but improving function is crucial. Most people don’t make appointments for therapy just because they have pain—it’s usually because their pain is preventing them from something they love. If your treatment plan or exercise routine has nothing to do with your goals—something is wrong!
Over-treating
This is a big one! The unfortunate truth is many clinics have a goal of seeing patients for a certain number of sessions. A common model is 3 times a week for 4 weeks, with a goal to reach at least 12 sessions per patient. Another ugly truth is the existence of bonus models where PT’s are encouraged to see more patients in a day. I will make no apologies for exposing this information. Like I said—pain changes everything and providers need to be held to a higher standard! Let me be clear—there are many factors that determine a course of care. For example, manual therapy, which is supported by evidence, may be an important part of your treatment plan. There are often times when this should be repeated within a week to maximize the results. Another important point is progress. If you are being seen in PT twice a week, receiving a skilled manual treatment AND are noticing some progress between visits, then this plan has merit. However—does it make sense to establish a practice pattern where everyone is seen 2-3 times a week for as many sessions as allowed by insurance! NO- there is nothing evidence-based about this!
Telling you a story that we have magic treatments
Again, addressing pain is an important part of therapy. Where this usually goes wrong—people think passive treatments like manual therapy, dry needling and instrument assisted soft tissue mobilization (IASTM, also known as scraping), is what will get them better. I think a historical perspective is key here! There are many treatments that have popped up over the years and all have evidence to support them. Here is the key to understanding this—evidence supports passive treatments for SHORT TERM PAIN RELIEF. None of these treatments should be viewed or sold as curative. They should be used sparingly and as a means to promote exercise and activity progression! How do you know when enough is enough—when the treatment doesn’t provide any change between your visits.
Another very important point about manual therapy is how it is presented as a treatment. The best available evidence does not show any change in joint position following a manipulation! This means you are not out of alignment and we are not putting you back into alignment! A joint manipulation can be a very effective pain treatment, but the resulting pain reduction is a response from your nervous system—not a change in joint position. Not convinced? Look at your hand carefully—I mean really look at it! Look at your knuckles- their shape, size and specifically—their alignment! Now, pop that knuckle. Notice any change? Well, an x-ray before and after a joint manipulation will show the same thing!
PT is an evidence-based approach to help people develop a plan to get back to their optimal level of activity! A crucially important point—your treatment should accomplish one very important task—improving your self-efficacy! Rather than relying on someone else to “fix you”—use PT’s to help you understand the underlying problems and learn how to fix yourself! Please—share the knowledge!
References(some taken from APTA) and can be found here:
http://www.choosingwisely.org/clinician-lists/apta-use-of-heat-for-musculoskelatal-conditions/
- Ulus Y, Tander B, Akyol Y. Therapeutic ultrasound versus sham ultrasound for the management of patients with knee osteoarthritis: a randomized double-blind controlled clinical study. Int J Rheum Dis. 2012 Apr;15(2):197-206.
- Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Phys Ther. 2009 May;89(5):419-29.
- Robertson VJ, Baker KG. A review of therapeutic ultrasound: effectiveness studies. Phys Ther. 2001 Jul;81(7):1339-50.
- Graham N, Gross A, Goldsmith C, Michlovitz S. Heat and cold for neck pain: A systematic review. Physiother Can. 2009;61:73-73.
- French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004750.
- Gebremariam L, Hay EM, van der Sande R, Rinkel WD, Koes BW, Huisstede BM. Subacromial impingement syndrome–effectiveness of physiotherapy and manual therapy. Br J Sports Med. 2014 Aug;48(16):1202-8.
- Davis AM, MacKay C. Osteoarthritis year in review: outcome of rehabilitation. Osteoarthritis Cartilage. 2013 Oct;21(10):1414-24.
- Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;(2) CD004258.
- Mechanisms and potential role of high velocity power training. Ageing Res Rev. 2017;35:147-154.
- Vandervoort AA. Aging of the human neuromuscular system. Muscle Nerve. 2002;25(1):17-25.
- Skelton DA, Greig CA, Davies JM, Young A. Strength, power and related functional ability of healthy people aged 65-89 years. Age and ageing. 1994; 23(5):371-7.
- Mckinnon NB, Connelly DM, Rice CL, Hunter SW, Doherty TJ. Neuromuscular contributions to the age-related reduction in muscle power: Mechanisms and potential role of high velocity power training. Ageing Res Rev. 2017;35:147-154.
- Moriarty O, McGuire BE, Finn DP. The effect of pain on cognitive function: a review of clinical and preclinical research. Progress in neurobiology. 2011; 93(3):385-404.
- Wiech K, Tracey I. Pain, decisions, and actions: a motivational perspective. Frontiers in neuroscience. 2013; 7:46.
- Hess LE, Haimovici A, Muñoz MA, Montoya P. Beyond pain: modeling decision-making deficits in chronic pain. Frontiers in behavioral neuroscience. 2014; 8:263.