This weekend after attending the Combined Sections Meeting of the American Physical Therapy Association, I had the opportunity to extend my western vacation and travel to Orange County, CA to visit my friend and his family. His father had recently seen his rheumatologist because he had developed fairly severe joint pain in his shoulder over the past several months. Thankfully more severe pathologies were ruled out and he was diagnosed with mild rotator cuff tear and some osteophytes. His rheumatologist prescribed two exercises – 1) Finger wall walks to about 45 degrees of flexion and 2) bent over passive shoulder circumduction. Per his description, his physician stated that “this isn’t a chronic problem and you will be better in 6 months”. He was perfectly happy with this diagnosis and gladly demonstrated his exercises to me. When I examined him quickly – it was noticeable that he was losing active and passive motion in a capsular pattern, had asymmetrical weakness and obvious scapular dyskinesis. When I suggested he see a PT to address some of those issues he shrugged it off (albeit asymmetrically and painfully), saying that he will see how these exercises help him first.

What is wrong with this picture? How does a patient with obvious need for continued treatment fall through the cracks, and be perfectly content with it? As I see it, there are two intermingled factors that need to be addressed to avoid the perpetuation of this pattern.

1) Overcoming Physician-First Care. Building the PT Brand

I am certainly not opposed to patients seeking care from their primary physicians, rheumatologist or orthopaedic specialist when they are having joint pain of unknown origin. These professionals can rule out some of the more serious pathologies with laboratory tests and diagnostic imaging. These clinicians can offer treatment that as physical therapist and rehabilitation specialists, we cannot provide. However, it is a problem when physicians always act as gatekeepers to rehabilitation specialists. Although the legality of physicians acting as gatekeepers has been rightfully done away with in most states, most patients still view an MD as a mandatory first stop on the way to further treatment. This perception must change. This is not a battle over scope of practice, direct access or increased patient access. Those are secondary issues to a much larger problem – poor patient care. Without changing the culture of medicine, patients will not seek the care they need and deserve. When it comes to rehabilitation, and preventing or reversing disability, physical therapists need to be viewed as the clinicians of choice.

As was the case with my friends father, it is a problem when patients blindly accept ‘rehabilitation’ advice and treatment from medical professionals whose training is not primarily in rehabilitation. When a patient is ‘prescribed’ an exercise, stretch, strengthening regimen, they should think “I should see a PT for this, they are the experts in rehabilitation [exercise, stretching, manual therapy, etc.],” but most often this is not the case. If their physician said “You should see a shoulder specialist,” most patients would not bat an eye at scheduling a next available appointment that is weeks away to get that care. PTs need to be seen as the specialists in reducing disability, whatever shape that disability takes.

Now there are many culprits for this inaccurate (or at the very least, unfocused) branding of the physical therapy profession. It ranges from publicly glamorizing passive modalities or novel, yet wholly ineffective, devices as the core of PT interventions (yes – referring to the recent Dr. Oz episodes). It comes from exercise prescriptions from clinicians who are not experts in rehabilitation. It comes from third party payers who cap the services that we can provide, regardless of patient need. I do not have an answer as to how to solve these issues, but there needs to be a united rehabilitation voice to start challenging the current concept of patient care.

I have heard over and over from patients that they know exactly what PT means – Pain and Torture. It is time to change our PT Brand. Some of the conversations this past week at CSM were very encouraging; however the reality of our misbranding was painfully obvious after the 5 minute conversation with my friends father.

2) Pulling Back the Curtain – Empowering the Patient

Many times it is not possible for a patient to discern good from bad care, especially in the short-term. In fact, many things that patients view as good care, are often bad care and vice versa. A colleague of mine made a great point during her presentation about care after Total Knee Replacement. Patients will often times deal with the pain associated with knee flexion stretches after surgery, because they think that the more range of motion they have, the better their outcome will be. This is a fact served to them by the media, by the surgeons and by the medical device companies themselves. Millions of dollars have been invested to develop a new prosthesis that allows 3 more degrees of motion. However, there is little evidence to support improving range of motion beyond 110-115 degrees, unless the individual wants to return to higher level sporting or functional activities. Although many patients are willing to subject themselves to sustained painful stretches to maximize range of motion, most patients I have treated adamantly oppose and do not tolerate electrical stimulation and aggressive quadriceps strengthening, which has been shown to have a much higher relation to physical performance than range of motion beyond functional ranges.

My goal for this year is to provide information to help empower the patient. Make them a more savvy consumer of their healthcare and an improved advocate for their well-being. Although this is not a trivial goal, there is a place I think we should encourage all patients start. Start by asking  “Why?” Why this exercise, why this test, why see this specialist. Now, of course a clinician could provide any baseless answer to simply satisfy the question, but a good clinician won’t. A good clinician will offer a direct answer and support that answer with evidence. So encourage your patient to ask “why”. Maybe the next time they ask their primary care physician why they are doing passive shoulder circumduction, the physician will say “Hmmm, you should probably see a physical therapist for that question.” Okay – maybe not, but its a start.

I am interested to work with my colleagues to help bring Physical Therapy to the forefront of patient-centered medicine. Please let me know if you have any ideas where to begin!

— JZ

(photo credit – UDPT –