Self-Referral to Physical Therapy

I have written a lot over the past few years on my success with Direct Access and patients coming to see me first for musculoskeletal pain vs going through a physician referral.  The literature is coming out with more and more evidence to support my (and I’m sure you other PTs) anecdotal statements.  

Here are a few links from my page here.  Also, check out article in the past that shows we have the knowledge to manage these patients. A recent article in Health Services Research here looked at the comparison of self-referral vs physician-referral episodes to outpatient physical therapy.   If you get the opportunity, you can listen to the authors speak through APTA podcast here.  I also recommend reading the APTA Media Release here as our President and others (who are more renowned in our field!) remarked on the study. I do not have access to the full article so cannot delve but so deep but I find the results very promising for our field. 

Basic findings were those who self-referred had:

–fewer PT visits.

–costs the system less for services.

–overall utilization of other resources for this problem were less. 

We all know this but good to have it in the literature.  Quality of care, with the least cost needed, is what we are striving to provide! Don’t we want this with anything we do on a daily basis?  

I educate my patients all the time in regards to not only having the knowledge to treat you (or refer out if not acting mechanically) but also availability to care in terms of time-frame is more accessible (and quicker usually) coming to me first.  I will include this data now to push more cost-efficient our services are compared to the typical gatekeeper route.  

Physical therapy is growing and consumers are more aware of the benefits now vs anytime in the past.  We are also improving out education and post-graduate work (OCS, Fellowships, etc) to advance our knowledge even more.  It is our job as clinicians to do our part to provide these results to the public, one patient at at time if need be!

This study should also help the state levels make better decisions in terms of getting Direct Access for states who do not have it, but also improve the Direct Access time-frame (i.e. Virginia can only see for 14 business days).  

Good study for the profession, keep it up!

A few good links on back pain

New York Times gives a quick overview here of back pain including data on surgery failure and side effects of medication. Basically it goes back to simple exercise, being active and most will heal on its own. We should be there for the rest.

Allen Besselink here hereoffers great insight on back pain and benefits of Direct Access to treat it. I agree with every bit.

Clinical guidelines via Annals of Internal Medicine here herefor your source on what physicians are taught. Good for new therapists out there and even for your patients.

SMT & HEA > medication for neck pain, yes! But, more publicity for DC Care?

I came across a post via NY Times Health Blog about a new study on effectiveness of Chiropractic care, simple exercise/advice and medications for neck pain.  As you can expect, I jumped right in to read.  You can check it out here yourself before you read this.  I will not summarize it per say but do want to give my two (actually 3 or more) cents on how this affects our profession.

#1.  Chiropractic Care…manipulation…works!

For those who practice Spinal Manipulation Therapy (SMT), you probably disagree with most higher level evidence, Cochrane reviews (example here), that there is no more benefit of manipulation over mobilizations for neck pain.  This individual study did not compare the two in particular but is a great win simply to show improvement with manipulation.  Now the study looked at chiropractic care (not to get into very much detail on their manipulation styles, techniques, etc.) so I will just refer to the result as manipulation.  Should we as a profession do more SMT? 

#2.  Medication doesn’t work comparable to SMT and exercise/advice.

Nothing more needs to be said.  If you just get this from this article, please share it with your patients.  Some of those skulls are just thick though…

#3.  Home Exercise with Advice (HEA) works!..but…

The article has a supplemental sheet so the reader can know what exercises were performed (find here). This is great and made it easy for the patients to follow. Don’t get me wrong, research has to be fairly general and cover all bases when it comes to exercise (as you know we have millions of exercises out there…) but wow, I really do not the ones in this study!  Some are good, such as retraction and rotation, but who really lies off the edge of plinth and does cervical extension. And maybe I’m biased, but I do not like side-bend or flexion; particularly the way it is shown.  Or better yet, lets just move our necks in any direction possible.  No-brainer. 

To sum, I like this study but am disappointed for our profession for many reasons.  

–Annals of Internal Medicine is a highly reputable journal for physicians and guides their choices for patient care.  They can now either refer to DC care, print off these exercises for their patients, do not recommend medication and boom, we are not needed.  I do not know the numbers (someone out there probably does), but we need to get more physical therapy research into big time journals for other healthcare providers to recognize us.  

–NY Times Health Blog is big time.  I don’t know how many people go to this site for information, but I know for sure its much more than any physical therapist’s blog.  I am sure millions of people read that blog! The consumer can find information out more and more on his/her own and honestly, this site is a great start (I check it out regularly).  With Chiropractic and Neck Pain in the title, this shuts us down even more.  We are making significant gains in terms of being musculoskeletal specialists, but still not first to go to when pain arises. With neck pain affecting an American ~70% sometime in their life, don’t you think they will continue to undergo DC care?

–Exercises  = blah. To be honest, if I wasn’t a physical therapist, I would think “our part” in this study is lame, unchallenging (I mean just move your neck in any direction right?), and simply undermines our profession.  We do not need a doctorate as everyone knows to sit up straight, correct?  The exercise and advice is what we do!  And again, wow, not exciting.  What I get from this article is DC care is awesome, stay away from medication, and oh yeh, keep your head moving.  

Take Away Notes from 3.5

I started practicing 3.5 years ago.  I know very short period of time for you veterans out there but I feel this period of time is perfect between being a hungry student and a set-in-my-own-ways physical therapist.  Plus, 5 years and seems so far away. 

I would like to reflect back over this time and share a few take away notes from my personal experience. There are probably hundreds of notions worth considering on but to celebrate 3.5 years, here are 3.5 reflections.  Enjoy and if you get a chance, let me know your thoughts and experiences so we can all learn from each other!

#1 Touch

Personal Touch.  As I mature as an individual and more picky with my choices in life, I know that I like the personal touch that seems to be leaving any industry due to technology and cut-backs.  This is no different from picking your healthcare provider, especially someone you will see multiple times a week for possibly many months as in our field.  Being able to provide an exceptional service that goes above what someone expects separates you as a clinician.  This can be something as simple as not interrupting the subjective history during initial examination (as it has been shown that physicians interrupt every 14 seconds), or taking the time out to simply educate your patient with something other than your office’s ‘handout’, or just calling the patient the day after initial evaluation to check in on them.  I’m sure you have more to share but you get the point.  Give in abundance. 

Physical Touch.  My wife tells me that no one can ever take away your education.  I agree and think the same in terms of manual, physical skills.  This is what we do day to day in not only assessing during an exam but more importantly treating.  This is an expertise and trade that only a few possess.  As much as the research dethrones the palpatory, physical exam; just you can’t go without it.  Sometimes it can be just as diagnostic as more expensive imaging.  Keep our profession fresh!

#2 Treatment vs Diagnosis

If you have read this blog in the past, you have probably seen multiple posts about sensitivity/specificity, etc values during several clinical, “special tests”.  Not so special actually if you look at the numbers.  I am still highly intrigued and interested in ‘diagnosing’ and knowing the probability that a certain pathoanatomical structure is of fault but honestly, I am starting to get more away from it.  Maybe its because the more I look into it, the more I find inconsistent and various interpretations that makes it frustrating; but probably more in that patients just want to get better.  We learned more diagnosis and exam in school, but not treatment so I guess everyone is on the same page here. Patients come to you to get better, lets continue to be good at this part of our field and not spending all our time with a “physical therapy diagnosis” (what is this really?).

#3 Nutrition

During one of my oral exams in PT school, I was asked by a professor if I should provide nutritional advice for a home health patient if you were seeing them for a wound.  I commented yes and spoke about importance of protein, etc (I don’t exactly remember my answer but you get the jist).  Well, I was “wrong” and told that this is not my specialty and ask for nutritionist consult.  Wow, do I not follow these guidelines now.  As an adjust healthcare provider with multiple backgrounds in exercise and nutrition from undergrad studies, patients can certainly benefit from my knowledge.  Who has the money anyway to go to a nutritionist?  Maybe it is because I work in a rural, social and economic deprived area without healthy choices to eat but you would be amazed at what patients think is healthy, or simply do not know.  Continue to educate about nutrition, it will pay off.

#3.5 EBP

You have probably read in the past that I am a component of evidenced-informed medicine, not necessarily evidenced-based medicine.  This meaning you are aware of what the literature says, but not necessarily follow it to a T. If you practice the latter, well, you probably will not work or get a paycheck because you will be hardly able to do anything “correct”!  The reason I put this as 3.5 is that you should strive for 50% evidence in your practice daily.  I do mention everyday EBP such as “combination of manual plus exercise yields best results, etc.” but also incorporate my own experiences as well as patient’s status in front of me. Students always ask if what I am doing is EBP and I don’t always have an answer.  Sometimes it just works and for now, you have to go with what you got.  

Hope everyone has a happy and healthy New Years! See you in 2012!

Harrison

Direct Access

With many PT blogs putting this video on sites promoting Direct Access, I figured I would also share with this community.  I see quite a few Direct Access patients and get excellent results.  Just wish more patients knew about it and more therapists implement it…  Share this with your colleagues. 

 

Also, check out VPTA’s Virginian on page 9.  There is a case report utilizing Ottawa Ankle Rules through Direct Access written by myself and co-authored by David Love, PT.  

Click on picture below. Hope you enjoy and continue to promote Direct Access!