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 There are many many outdated, disproven, and flat out bad theories running around out there.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
Quackwatch

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...

Cory

5 comments:

Therapeutic Wealth said...

Every PT is different from another so it is best that you know where to go to. Try asking your relatives and friends, maybe they know someone that can provide the service you are looking for. Some PTs are well-known from referrals of their previous patients.

Tim Richardson, PT said...

Cory,

Very well thought-out post. You seem to be a caring therapist.

However, I would take the payers perspective and ask you, using a cost/benefit analysis, is there one treatment approach that will provide similar or superior outcomes at lower cost?

More is usually better - especially from the patient's perspective who is getting rehab.

The therapist (and the patient) can usually say 'why' we should pay for therapy that appears to aleviate pain and improve function.

However, in an environment of scarce healthcare dollars (and 48 million uninsured Americans) can we make the argument for any treatment variation?

Tim
TimRichPT@PhysicalTherapyDiagnosis.com
www.PhysicalTherapyDiagnosis.com (blog)

Cory Blickenstaff said...

TW,

Thanks for chiming in!

I agree that referrals from trusted friends, relatives, and associates is a good idea when looking for good service of any kind. That won't necessarily provide an answer to undesirable variation in treatment though. Some well pointed questions to the trusted referrer could help.

Unfortunately, lots of people feel they are being given excellent service simply because they provider is friendly, charismatic, uses lots of bells and whistles, etc., but they may not be providing effective well reasoned treatment in the least bit.

Cory

Cory Blickenstaff said...

Tim,

Welcome to moving forward!

A cost/benefit analysis sounds like a good idea, but in practice would be difficult to implement effectively (both improving care AND reducing cost). Our outcomes research, while growing more robust, remains woefully inadequate to provide the information needed to place many treatments head to head. For example, I've seen it estimated that the CPR for lumbar manipulation for low back pain applies to around 10% of that population and it hasn't been compared to other interventions in that same population. So, you may try to pay based on performance statistics on the providers per patient, per diagnosies, etc, but this approach is woefully indadequate to account for variation in setting, patient population, etc. For example, I may see all post surgical rehab patients with relatively established lengths of care while my competitor sees a chronic pain population with multiple comorbid diagnoses. Is it reasonable to hold them to my statistics for their payment? Of course, this hasn't stopped many of the insurance carriers from setting apparently arbitrary limits based on just these types of things.

I think your question is a good one, and I think that treatment variation can certainly be justified. However, variation in clinical reasoning (maximally utilizing both reasonable supported theory and data provided by outcomes evidence) is a different story.

Effective encouragement of self reliance tends to resolve the "more is better" problem in my experience. Why do so many clinics have gyms full of weight equipment? Do many patients have those at their disposal at home?

Cory

Anonymous said...

Hey Cory,
Just saw you were in Linked In. I haven't been able to follow much conversation or you over at SS ever since they gave me the "banned" status. Glad to have "found" you again!

This topic is something that always bothers me. I feel for consumers. Seems as though word-of-mouth is currently the main mode for choosing a physical therapist.

The introduction to the CSM session I did with JW and Mike actually provides a possible solution to the current state of affairs... you can take one guess what would be involved. :)

Here's the link:
http://www.slideshare.net/SelenaHorner/csm-2009-why-outcomes-are-relevant

Tim, from a payer's perspective, we are one of the cheapest alternatives for low back pain regardless of how we practice. Drugs, medications, injections, diagnostic testing, surgery... we are quite cost effective - have to also figure in the risk - infections, side effects.

~Selena