Friday, November 7, 2008

Part 2: Are All Physical Therapists the Same

In the first post I made an argument that treatment variability was not necessarily a bad thing all of the time. The caveat is, I feel, that variation in clinical reasoning should not exist.

In the first post I discussed how many therapists differ in their explanations of WHY they do what they do. This is bad variation.

In this post I'll talk about the 2nd caveat for appropriate variation, which is that the therapist should always have the consent of the person they intend to treat. You should not only expect, but should require that the plan to address your predicament addresses your goals and has your approval. Additionally, the more you are involved in establishing the goals the better chance you'll have of a positive outcome. It is, after all, your predicament and you'll have to be the one to get out of it so it makes sense that your involvement in the solution is paramount.

It also makes sense that you should be the architect of what a positive outcome will look like. This will be a source of much variation from one person to the next. You may have the same exact pain description as another person, but may have entirely different needs based on your life and activities. It is likely that goals will be much different between a professional athlete, who may need to regain the ability to jump high, and a stay at home mother needing to be able to pick up and hold her child, for example. The treatment between individuals will be much varied despite the similarity of their pain.

Of course, it is also appropriate for you to expect your clinician to be able to assist you in the process of determining your goals. They should be able to give you ideas of realistic goals as well as time frames and expectations.

What they should also offer to you is a plan of treatment or action to achieve your goals, and this is also where much variation exists. It is completely appropriate for you to expect your clinician to explain to you why it is they are using a specific approach in a way that makes sense to you. If you are not comfortable with that reason and you don't agree with the course of treatment, you have the right to refuse the treatment.

Of course, the other side of this coin is that your clinician has the right to refuse your request for a specific treament as well. I'll give an example of a common treatment that will hopefully clarify both sides of this issue.

Therapuetic ultrasound is one of the most traditional treatments used by physical therapists. It has been a part of our treatments for many years and continues to be used very commonly. Indeed, when many think of What is Physical Therapy they often think of ultrasound and exercise (see the link for my thoughts on that). The problem is that ultrasound has been studied a hundred times in a hundred ways and all the evidence points to the same conclusion: it is of no benefit beyond placebo. Despite this, many therapists continue to use it for a number of reasons, such as tradition, demand for it by physicians, demand for it by patients, influence by poor quality research from the companies that build the machines, etc. You won't find one of these machines in my clinic.

Now, knowing what I've told you about your right to consent and the lack of support for ultrasound, you know that it would be completely appropriate for you to refuse it as a treatment. On the other hand, many patients feel that ultrasound has helped them in the past (and I won't deny that it feels good and that occasionally a person feels better after a treatment. But it is clear that this is not the result of a treatment effect from the ultrasound. I plan to talk more about how this apparent paradox might be in the future.) and demand that this be included in their treatment. As a responsible clinician, knowing that ultrasound is only as effective as placebo, I have the right to refuse to dispense this treatment. In the rare event that this confrontation happens, most people are grateful for the honesty and understand my reasons for not providing this treatment. For the rest, I will politely inform them that I am likely not the person that will meet their needs if this is a requirement on their part. Until all of my collegues begin to treat in a way that is consistent with the research on ultrasound, this will remain an example of what I consider to be innapropriate treatment variability.

Friday, October 24, 2008

Opportunistic Marketing and Your Health

In my last post I said:

So, how can you, as a patient, know when you've been given a poor reason
for treatment? This is unfortunately not easy. There is so much mis-information
and opportunistic marketing out there that it's often hard to know who to

I have just finished reading a book by Michael Shermer titled "The Mind of the Market." It was an excellent read and I'd recommend it to anybody interested in human behaviour or even the economy (a hot topic!). This post is to expand on what is meant by opportunistic marketing.

There is a lot of information in the book about why we make some of the decisions that we do. One particular bit of information seemed particularly relevant to this blog, and I'll attempt to explain how. From p. 97:

Thousands of experiments in behavioral economics demonstrate conclusively that
most of us are highly risk averse.

How risk averse? According to research we are about twice as motivated by a risk of loss than we are a potential for gain. Further research has confirmed that most of us are actually wired to think this way. For every tendency in human behavior there is a matching strategy to capitalize on it by others.

Since we are typically more motivated by risk of loss many marketing strategies exist to point out to you exactly what you stand to lose if you don't buy their product, do as they say, follow thier advice, seek their care, etc. I'm sure you can immediately think of several examples. This strategy exists in healthcare too. Healthcare decisions often involve the need to motivate patients to action. This research clearly shows that it is more motivating to say "If you don't exercise you may fall into a state of poor cardiac health and risk heart attack and stroke" than it would be to say "Exercising helps you feel better, is good for you heart and lungs, and will make you feel more energetic!" Again, we are more motivated by a risk of loss than a potential for gain.

Unfortunately, opportunistic marketing exists in healthcare just as it does everywhere else. Thinking in terms of risk aversion, be on the look out for products or people who are trying to convince you that you have a problem, and the problem is a lack of whatever it is they are selling. The nutritional supplement industry is full of this type of thing.

Sometimes, however, it is appropriate to be told what risks your behaviors carry. For example, "If you don't stop smoking you risk getting lung cancer, having a heart attack, and/or having a stroke" would be very appropriate to hear from your physician if you smoke. This is appropriate because it has been shown to be true in quality research and the behavior is present.

You have to be on the lookout for mis-information though. This is not easy and we'll be getting into some ways of doing this effectively in future posts. For a start, any claim that is made to you by a healthcare provider should be able to be backed up in a science based way. At a minimum it should be plausible and optimally it should have specific research to back it up.

This is one of the big problems with people who are in pain, however. The research on specific treatments has been either a) lacking, or b) typically of questionable quality (although this is turning in the right direction). I commonly hear from both collegues and patients that you can find research that will agree with just about anything. That is true, but you can't find QUALITY research that agrees with anything. For research quality we often must rely on others help. I find this site to be of great help. But, in absence of quality research we must rely on plausibility. And this you can learn to identify. More coming soon....

Monday, August 4, 2008

Are All Physical Therapists the Same?

A question I'm asked a lot is "do all physical therapist treat the same way?" The answer to this question is NO, and that is both a good and a bad thing.

One reason it is good is that physical therapists are not technicians. Going to a PT is not like going to the mechanic with your car. When brakes go bad, there are only a certain number of problems and therefore only a certain number of solutions. On the other hand shoulder pain, for example, can be a result of many many things and there are many solutions to each problem. The physical therapists job is to find a solution that 1) is appropriate for the problem 2) appropriate for the person with the problem, and 3) is appropriate for the therapists expertise. As I've mentioned before, physical therapy requires a thoughtul evaluation process. This allows us to use our individual strengths to your advantage.

This variation is fine as long as 1) it makes sense WHY the therapist is using the treatment, 2) the therapist has the consent of the patient to proceed, and 3) the therapist is not treating in a way proven to be ineffective or unsafe.

This leads into many of the bad reasons for variety of treatments. And for this post I'll discuss the 1st: WHY the therapist is using the treatment.

The most common bad difference among therapists, and indeed all practitioners, and their treatments is why they are using them. You might go to one therapist and be told that your alignment is off and that is why you hurt. Another therapist might tell you that your fascia is restricted, and that is why you hurt. Yet a third might say that your muscles are tight, and that is why you hurt. Each one will treat you differently based on their reasoning for treatment. This is not good. There are many many outdated, disproven, and flat out bad theories running around out there.

When it comes to pain, any theory that is not up to date in pain science is questionable. There has been an astounding degree of advancement in this area and much is now known.

So, how can you, as a patient, know when you've been given a poor reason for treatment? This is unfortunately not easy. There is so much mis-information and opportunistic marketing out there that it's often hard to know who to believe.

The skeptical community can be quite helpful in this regard. I'd recommend looking at a few of the skeptic resources and searching for information. A couple that I'd recommend would be:

Science Based Medicine

You might be surprised at what you find out.

Expect qualtiy reasoning from your practitioners. That is a very fair expectation on your part.

More soon...


Tuesday, March 11, 2008

Exactly What is Physical Therapy?

What is Physical Therapy exactly?

Isn’t physical therapy just exercise? Can’t my chiropractor do physical therapy? Can’t I get physical therapy from a personal trainer or at the gym?

These are commonly asked questions. The answer to all of them is NO. I’ll get to why in a minute.

Let’s start broadly and then get more specific. Here is an official answer (warning: dry wording ahead):

Physical therapy is the application of evaluation and/or treatment to movement dysfunction as provided by a licensed physical therapist.

Great, there’s the official answer. Now let’s see what this means in practice.

Physical therapy is the application of evaluation…

As discussed earlier, PTs are movement specialists and we treat movement dysfunction in its many forms. In order to identify the dysfunction and its effect we must do an evaluation. This involves acquiring information through interview (including medical history), taking measurements and making observations about movement and of the health of the neural, muscular, and skeletal systems, and screening to rule out more sinister contributions that require another professionals expertise. Evaluation allows the physical therapist to assess the situation and come up with an appropriate plan to move forward.

…and/or treatment of movement dysfunction…

Once the evaluation is completed treatment is initiated, if needed. The treatment will vary based on the needs identified in the evaluation. Some of the many examples of physical therapy treatment include many forms of manual therapy (using our hands), movement therapy with its many variations, conditioning (exercise is a part of this), electro and thermal modalities, and education. These treatments are not physical therapy themselves but are some of the various ways in which a therapist may treat. In other words, exercise is not physical therapy and neither is ultrasound. For example, school teachers also use education for their jobs. Does that mean a school teacher is providing physical therapy when they teach? Of course the answer is no.

…as prescribed by a licensed physical therapist.

Physical therapy describes the skilled work done by a physical therapist. As you can see from the above there are many skills involved in providing physical therapy. Common misconceptions are that physical therapy is “just exercise” or something of that nature and this describes us by one tool that we might use. Let me highlight one problem that arises with this misconception.

In most states the term “physical therapy” is protected. In other words you can’t advertise that you offer physical therapy unless you have a licensed physical therapist on staff, just like you can’t claim to practice medicine without a medical license. Makes sense, right? The state of Oregon is one exception. Many chiropractors in the state of Oregon advertise that they provide physical therapy, physiotherapy, or physiotherapuetics (terms that confuse the consumer), or physical therapy modalities when in fact they do not, because the term is not protected there. They may offer exercises and modalities and other rehabilitation related treatments, but that is not physical therapy, as I just described above. It is chiropractic. It would be the same as a PT claiming they can offer chiropractic because they do spinal manipulation. That would be false as well as demeaning to the chiropractors. This is a frustrating state of affairs for physical therapists in and around Oregon because it belittles the complexity of what physical therapy offers and allows the chiropractic profession to do as they wish with our professional title including gain from its promotion, or belittle its meaning to that of an ultrasound machine or exercise ball.

Well, I got onto my soapbox there a bit, but hopefully you can now go back up to the 3 questions at the top of this post and understand why the answer to each is no.

Tuesday, February 26, 2008

What is Physical Therapy and Who are Physical Therapists?

Day to day in the clinic and around the community I frequently encounter misconceptions about what physical therapy is and who physical therapists are. I suppose this state of affairs is true of a lot of professions, but I find that these misconceptions often influence when and why a person might seek the care of a therapist.

Here are a few questions about who we are that I am often asked:
- How much school did you have to go through?
- Do you guys just treat athletes?
- What types of problems do you treat?

First and foremost, physical therapists are specialists in treating movement dysfunction. We have a variety of ways to deal with a variety of movement problems. These problems may consist of the issues that come with a stroke, a spinal cord injury, cerebral palsy, or from having had an amputation. There are many many disorders and diagnoses that might bring about movement dysfunction. Then there is pain. Pain often creates movement dysfunction as well. It can limit your amount of movement, decrease your tolerance to movement, and make functioning annoying, difficult, or flat out impossible.

Physical therapists are trained and licensed professionals. We must graduate from an accredited physical therapy program. A typical duration of schooling for a physical therapist is 6-7 years of undergraduate and post-graduate university training (and yes it did feel like a long time!). After graduation we must pass a state licensure examination. Each year we must update our training with continuing education courses.

It is a very rewarding profession and well worth the effort it takes to become one.

A very common question I am asked next is: "Isn't that a lot of school to learn about exercise?" In order to answer this I need to address what is physical therapy, which I will do in the next post.....

In the meantime, please feel to add any other questions you can think of about who are physical therapists and I will answer them.

Cory Blickenstaff PT
Forward Motion Physical Therapy


Welcome to my blog. My name is Cory Blickenstaff and I am a physical therapist. I own and operate a clinic in Vancouver, WA called Forward Motion Physical Therapy. I am a board certified specialist in orthopaedics and a certified strength and conditioning specialist. While physical therapists help a wide variety of people with a wide variety of problems, my particular interest is in helping people in pain. These people may be young or elderly, elite athletes or couch potatoes, dealing with new pains or with very old and persistent pain. They may have any number of medical diagnoses. I see people at many places on many spectrums. If they hurt when they move I try to help them.

This blog will often be about discussing issues involving physical therapy, pain, and its treatment. I will hope to keep it entertaining, bringing in seemingly unrelated topics and tying them in to what it is to experience and recover from pain.

Also of concern to me is protection of the consumer. Searching for effective health-care today is daunting. There are as many resources as there are people to ask and often times advice is conflicting. Oprah may say one thing while your physician says quite another and a chiropractor tells you a third. In this time of easy to access information there is a lot of opportunistic marketing around to prey on the unsuspecting health-care consumer.

The second purpose of this blog will be to examine some of these issues. We'll discuss some of the marketing ploys out there, how to recognize the deceitful ones, and where to find good information. Consumer protectionism if you will.

Feel free to comment on my posts and join in the discussion.

Cory Blickenstaff PT