On Preventative Physical Therapy

I have encountered a few discussions recently regarding the implementation of an annual physical therapy exam. The original source of this thought likely traces back to the legendary Shirley Sahrmann who has talked at length about this concept. The foundation of the argument appears to stem from the belief that preventative medicine is cost effective (which it is) and that physical therapy improves outcomes at a reduced cost (which it does for a lot of reasons and disorders). While both of these aspects are fairly valid, combining them to suggest that everyone would benefit from seeing a physical therapist (or any provider) annually and that this exam would reduce healthcare costs is a bit of a stretch.

First, we also need to acknowledge that the term “preventative” medicine is a slightly inaccurate. No disease or injury can truly be “prevented”; despite optimal care and an ideal patient, there will always be some risk. For movement based disorders physical therapy services can absolutely reduce risk and improve performance in many domains. We should also continue to screen for systemic disease. However labeling what we offer as prevention may create unreasonable patient expectations and unrealistic beliefs in a providers utility. Both of which can influence outcomes. But for now, until we devise a better word we’ll go with “prevention”

For most healthy individuals, receiving an annual physical therapy examination would be meaningless and it would come at cost. If an individual moves well and is disease free there are few benefits to them receiving examinations by a PT (or any provider) annually. This is similar to the issue encountered with the overly-capricious use of diagnostic imaging. If the pre-test probability is low then the test/image isn’t going to be useful and may result in false positives (See Bayes’ Theorem of conditional probability). Which leads to more testing, clinical visits and further costs. This issue occurs with imaging and tests that actually possess strong statistical power, which many of our movement based exams lack. Thus the false positive rate for an annual physical therapy exam may potentially be even worse!

We also must consider the bio-psychosocial ramifications associated with these potential false positives. One of the issues with over-utilization of imaging is that provides a tangible “proof” to patients that they are “broken” and often remain attached to those results. It can be quite difficult to break that cycle once it starts. Another example of this are those who visit a chiropractor monthly ad infinitum for tune-ups. What is actually being improved and is manipulation necessary even if the technique results in cavitation? Most (rightfully) would consider the notion of regular chiropractic visits to be unreasonable. Seeing a physical therapist annually despite being asymptomatic would be as well.

Even the utility of annual medical exams/physicals have even been investigated recently. With the majority of the evidence suggesting that they may actually increase costs without reducing much risk. This further analysis of risk reduction is also likely why the ACSM has recently adapted their recommendations and removed ETT/medical exams for many patients even those with risk factors. The old ACSM guidelines created bottlenecks in access to care, and delayed the initiation of exercise which affected outcomes. With the provider gap that currently exists in this country, the delivery of care needs to be as efficient and effective as possible. Annual visits to a physical therapist could also potentially impair access to care for those most in need of rehab services.

When deciding on policy change it must always be asked, does the intervention reduce risk and associated healthcare costs more than the cost of providing it? While I agree that access to physical therapy services needs improvement this annual model needs to be further analyzed. I suggest that maybe a “regular” physical therapy exam combined with other providers should be implemented. The frequency of this exam could then be modified based a number of health-related factors (congenital diseases, family history) and adapted to any novel changes (weight changes, acute injury etc). From our end we also need to start tracking outcomes data more consistently to help improve the effectiveness and efficiency of our care (which I have been working on improving with my software “Outcome Manager” set to release in the coming months) and develop more accurate tests and measures.

Again, as always the truth defies simplicity.

On Crossfit

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I wish more PT/physios would realize the potential in owning a box or gym and operating a clinic contained within. Instead of commenting on the issues with training and programming that Crossfit or any other training model has, we should be looking at ways address them while incorporating them into practice models. I’m more of an academic at this point in my career (and likely going forward) but it would seem that having a more fit and motivated patient population would be ideal. Having multiple revenue streams, a greater potential for direct access and collaboration with fitness professionals to ensure a smooth transition post rehab are all decent perks; not only for clinicians but patients too. These are all items that are frequently mentioned as lacking in most clinical models and barriers to outcomes Why more of us haven’t explored this business model is beyond me and appears to defy logic.

The primary point I am getting at is that owning a gym, box, Pilates studio, fitness centers etc should not be the exception rather the norm. As would owning your own clinic vs working for one of the large PT chains. We complain about revenues and reimbursement, yet we as a profession choose to work in situations where our earnings are limited with sometimes ridiculous work demands and paltry compensation. What other profession practices in this manner?  Of course there is significant capital required to operate your own business with increased risk, especially early in one’s career. But this sort of model is ideally developed over time and possibly in partnership with a few like-minded clinicians (not necessarily PTs) to divide the risk. At the end of the day one will never earn as much as they can working for somebody else. Until we as a profession realize this, from a practice standpoint we will continue to remain significantly impaired in our ability to move forward.