Physical Therapy: Art and Science of Practice

Introduction

Most spine specialists recognize that early mobilization (activation) of patients with neck or back pain is not harmful and is, in fact, necessary. Activity early in an acute course of neck/back pain shows 50% improvement of pain symptoms in greater than 90% of patients. For this reason, physical therapy is the first-line treatment and remains the backbone of spine care. Most patients suffering an acute episode of back or neck pain recover in less than 1 week, and greater than 90% of patients are back to work before 90 days. Yet, between 50% and 84% of patients experience a recurrence of low back pain (LBP) within 1 year after recovering from a previous episode. Therefore, in the face of recurrent pain, determining the most effective physical therapy intervention is beneficial for a surgeon's practice and the patient. This chapter provides insight into how this determination is made.

An unfortunate and too common analogy is that choosing a physical therapy (PT) clinic is like choosing a Starbucks; find the location closest to you and order. One franchise location makes the same coffee as any other location. The reliability of the Starbucks process produces a consistently similar quality product. This analogy would be correct if all physical therapists had high-reliability processes to create the similarly reproducible results as seen at Starbucks franchises.

The hypothetical clinical scenario required to mimic Starbucks outcomes would require all PT clinics to possess remarkable reliability in assessment procedures, formulation of diagnosis, and application of treatment. This putative process would then produce the same outcome from PT clinic to PT clinic. We all know these idyllic therapy outcomes are ridiculously untrue. Geography is usually destiny in the marked variability of outcomes for the same diagnosis. Methods vary from clinic to clinic and even within a clinic. Clinician X utilizes significantly different methods than colleague Clinician Y, each defending one's approach with the same phrase: “…but it works for me.” Meanwhile, neither is tracking outcomes to determine whether the same patient-centered results are being produced. The extensive variability within PT mirrors practice and cost variability throughout musculoskeletal medicine. PT as a mode of treatment and service delivery is a long way from the model employed by Starbucks. Nevertheless, some physical therapists strive to follow evidence-based assessment methods that lead to a valid reproducible diagnosis that, in turn, leads to reliable, predictably effective treatments that may be surgery sparing. Most important, these therapists can prove their effective and reliable methodology because they track patient outcomes and patient satisfaction scores in a problem-oriented record.

Readers of this chapter, as patient advocates, may ask themselves the following, taking this coffee-to-PT analog further. What if there were a “coffee shop” (PT clinic) that reliably produced a better cup of coffee? What if that cup of coffee cost less than others? And what if the overall experience of getting that coffee was superior to others? Would that be worth traveling somewhat farther to get? Would you refer a friend to that coffee shop? This analogy is the Institute for Healthcare Improvement triple aim: better care for individuals (quality and satisfaction), better health for populations, and lower per-capita costs. Later in this chapter is a process describing exactly how to find the PTs who can reliably produce the best outcome at a lower cost with high patient satisfaction. It is, in fact, these professionals who will do the most to improve the spine surgeon's outcomes, patient satisfaction, and practice throughput.

Efficient spine surgeons' practices depend not on their skill in the operating room alone, but upon the skill of the physical therapist their patients see in the preoperative or perioperative period. A well-trained physical therapist utilizes a reliable assessment method that leads to a predictably effective treatment. The physical therapist then trains the patient in an independent functional program of self-assessment and self-treatment for long-term prevention of recurrence. This often empowers the patient to succeed and decreases the probability of multiple return visits for PT. The surgeon's office is also spared multiple unproductive patient visits. Due to the greater amount of time a physical therapist spends with a patient (compared to a surgeon), a therapist may have greater insight to hidden barriers preventing successful outcomes. A well-qualified physical therapist who determines that a patient is not making satisfactory progress can also inform the surgeon about a patient's underlying biopsychosocial distress that may produce inferior surgical outcomes. Also, valuable mechanical information can be communicated to the surgeon by the physical therapist. For example, determining a reducible disc versus an irreducible disc is easily within the skill set of the mechanically trained physical therapist. Effective and efficient spine practices thrive on collaboration and free communication between all team members. Patients are best served by a collaborative effort with the best trained therapists in the spine surgeon's geographic location ( Figs. 110.1 and 110.2 ).

Guidelines for Selecting a Physical Therapist

The physical therapist with whom a surgeon chooses to collaborate must demonstrate skill in treating that surgeon's patient population. The therapist must possess a shared understanding of surgical indications and flags that may predispose patients to poor outcomes. In summary, the therapist must be a good fit for the surgeon's practice. The benefits of collaboration start early. Patients are seeking the spine surgeon's recommendations for all aspects of their care. Instructing patients to blindly find their own therapist can produce unreliable variability that can make surgical interventions less successful. Hildebrandt et al. demonstrated that preoperative programs that do not change subjective feelings of disability in the patient produce inferior outcomes. Simply referring patients to the in-house PT department at the spine surgeon's hospital/health system fails to guarantee quality treatment. Spine rehabilitation is not covered to the same extent in all PT programs and postgraduate training for PT also differs significantly.

Unless individual outcomes (not process measures) are measured by the therapist and used to inform practices, treatment efficacy provided will vary by clinic and even by clinician within the same clinic. Just like surgery, PT is not a standardized practice.

In order to judge the quality of a physical therapist, the spine surgeon is accountable for interviewing physical therapists to whom spine patients will be referred. By interviewing the physical therapist who will treat referred spine patients, the spine surgeon ensures that the patient is receiving the expected PT. Virtually all competent physical therapists want to collaborate with a spine surgeon. However, the physical therapists who are unwilling to accept an invitation for an interview with the surgeon often lack the skill set to treat the spine patient population. The physical therapists who do accept interviews should demonstrate spine-specific proficiency. Often, “bad actors” will be easily ruled out, utilizing an interview process. During this interview, the surgeon should identify several key data-driven factors. The more criteria the physical therapist meets, the better chance that therapist will provide highly effective and reproducible outcomes. Time spent screening therapists with the process described later will pay massive dividends by eliminating unproductive time in a busy surgeon's schedule. However, the spine surgeon may not have adequate preparation for such an efficient process. An alternative may be to choose the top one or two therapists in a practice and refer patients for a 6-month trial period, then request standard pre-post outcome data from each therapist (described later in this chapter). Occasionally, a surgeon's practice is in an area that has limited choice of PT clinics. This scenario is a golden opportunity for the spine surgeon to influence the type of continuing education for a PT clinic. The spine surgeon can request specific PT continuing education training on behalf of the patient population to ensure continuous quality improvement in nonoperative/postoperative patient care.

The interview process is comprised of 10 questions:

• 1.

  Does the physical therapist have experience treating spine patients? How many does the physical therapist treat per month? Spine patients are often the least sought out patients by physical therapists due to the perceived complexity and lack of outcomes associated with treatment. Experience with spine patients is an excellent start and simply indicates a lack of avoidance of, if not interest in, this patient population. However, experience alone is not an indicator of treatment effectiveness. Continuation of questioning is required to determine effectiveness markers.

• 2.

  Does the physical therapist exclusively use active modes of treatment? Exercise and movement promotion are quintessential to the care of a spine patient. Passive modalities have little to no place in the care of the spine patient, with rare exceptions. Transcutaneous electrical neural stimulation (TENS) may possibly speed weaning from opioid pain medication use in the immediate postoperative period. However, further use of low-value (high expense without any validated outcomes) modalities is generally inferior to active treatment. Ultrasound and various other modalities, including electrical stimulation, laser, massage, and traction, are inferior to the long-term outcome of active treatment and are discussed later in this chapter.

• 3.

  Is the physical therapist able to cite the reliability of the clinical protocol being used? Methods of PT practice are available that produce more reliable assessments and outcomes than others. Reliability is the most important first step toward validity. Any diagnosis produced by unreliable assessment methods is doomed to ineffective treatments and subsequent poor outcomes. A surgeon or physician may be unfamiliar with the phases of “usual care” physical therapy that lack reliability. Physical therapists who utilize methods with greatest reliability will be able to cite their evidence-based practice.

• 4.

  Does the physical therapist track the outcomes for quality assurance? The collection of meaningful data is imperative to determine if a process or intervention is producing an effect on the outcome. Here are some common standardized patient-reported functional outcome measures for the spine: the Oswestry Disability Index, Neck Disability Index, Pain Disability Questionnaire, Roland Morris Disability Questionnaire, and Pain Disability Index. A more recent measure, the Patient-Reported Outcomes Measurement Information System, utilizes computer-adaptive testing and scales that may allow greater breadth of outcome gathering without the burden of asking too many questions. Patient-centered perceptions of function are the most meaningful outcomes to track. In contrast to measuring pain scores, measuring functional perceptions more closely mirrors and predicts return to work and surgical outcomes than merely collecting visual analog scale pain scores measured at random intervals. In this patient population, a significant improvement in functional rating signals real gains for the patient and often meets the increasing regulatory burden with regard to performance measures.

• 5.

  Are the outcomes tracked for at least 1 year? High-value treatment interventions are durable. This means that a clinically significant improvement in outcome scoring should be durable for up to 1 year. Clinical effectiveness often requires education and patient buy-in for a gym-based or home-based exercise program. Patient adherence can be measured directly or through the proxy of the therapist's chosen outcome measures (see item 4) deployed to the patient at regular intervals for up to 1 year. Long-term gains and surgical outcomes are tied to home program compliance. The process of tracking outcomes requires other resources in addition to the usual clinical operation costs. Allocation of resources for outcome data tracking may be a strong indicator of that therapist's commitment to improving the patient's health.

• 6.

  Does the physical therapist take action to remediate deficiencies identified during outcomes tracking? Data are just numbers until utilized for a purpose. Whether therapists utilize the data for clinical decision making is what makes it meaningful. Clinical reasoning regarding a particular patient's care must occur based on trends in the collected data. Plans identifying and treating unexpected or deviant trends must be developed by the therapist to ensure safe and efficacious patient care. Addressing clinical nuances, including comorbidities confounding results, should heighten your confidence in your therapists' ability to handle a diverse patient population. Correct utilization of data enhances the patient's experience and improves therapist-to-surgeon communication.

• 7.

  Does the physical therapist participate in a regular quality control, continuous quality improvement, or a grand rounds process among clinicians (within or outside of the clinic) to identify patients not meeting expected outcomes so that changes can be implemented? Continuous quality improvement in some form is the most important learning tool as long as the format is a clinical case presentation or interactive workshop/small groups. It is a mirror for the therapy practice to identify both best practices and deficiencies. Regular use of the process implies that the therapist is interested in communication and providing the surgeon and the patient with optimum outcome. This interdisciplinary approach improves the clinical experience for all clinicians involved as it centers care on each individual patient. The patient's treatment experience is enhanced when the knowledge base of senior/expert clinicians combines with innovative approaches and guidance of all stakeholders.

• 8.

  Does the physical therapist understand value? Can the physical therapist cite cost savings by reducing resource utilization (compared to community standard) while returning superior outcomes? This can be achieved through participation in a national registry (American Physical Therapy Association, Physical Therapy Outcomes Registry) or a national outcomes measurement tool such as Focus on Therapeutic Outcomes. Surgeons share responsibility with therapists to request access to deidentified claims data. This allows tracking of all regional entrances into the health care system. Comparisons of a practice's costs and outcomes against a regional benchmark is increasingly important. The cost of providing a service may not be readily accessible to all physical therapists. However, cost is directly related to the number of PT sessions that a patient receives per diagnostic ICD-10 code. Substitutes for the standard value formula (outcome/cost) exist. A simple formula is useful:

  $\text{Value}=\text{Outcomes}/\text{Visits}$

  Fewer visits and/or better outcomes increase value for patients and the value of that practice to the spine surgeons in their community. Newer time-driven activity-based costing tools are emerging as simple ways to make cost data actionable. Broadly speaking, the Value-Based Health Care Delivery initiative led by the Harvard Business School provides easy access to best-practice ideas while off-the shelf ideas may be accessed through a simple Internet search or through a national medical society.

• 9.

  Can the physical therapist present patient-level satisfaction scores? Collection of patient satisfaction questionnaires shows a dedication to patient-centered care. Improving the patient experience will reflect well on the surgeon who took time to identify a quality therapy practice. Conversely, poor patient experiences will be reflected in the surgeons' satisfaction scores as well. A willingness on the part of the therapist to identify areas of improvement is necessary in this increasingly data-driven marketplace. Patient satisfaction is a slippery slope and must be weighted in the face of other quality measures. Donabedian concluded that access, administrative technical management, clinical technical management, interpersonal management, and continuity of care are domains that define patient satisfaction. Satisfaction ratings improve if the patient's expectations are met. Dissatisfied patients are less likely to use professional advice, thus undermining both primary and secondary prevention. Often, the most effective treatments bring a temporary increase in pain symptoms before gains are realized. Gentle guidance from the surgeon that effective therapy often hurts, but will not harm , the patient is a benefit for the patient, the therapist, and the surgeon's office staff. However, a skilled clinician who is cognizant of the patient experience can proactively educate and guide the patient through exercise regimens that ultimately produce the desired outcome. Through the use of collected data, patient satisfaction improves; this will, in effect, recruit more patients to whom the physical therapist can provide a high-quality service.

• 10.

  Finally, the surgeon should ask himself or herself the following: do I trust this person? If the interaction with the physical therapist does not feel right, patients will notice this as well. The late physician Leon Wiltse was famous for making difficult concepts understandable. After pioneering the use of quantitative testing (Minnesota Multiphasic Personality Inventory) to optimize surgical outcomes, he boiled down years of clinical acumen with a speech as President of the Association of Bone and Joint Surgeons on his famous “look 'em in the eye” test. If you do not trust what you see when you look the therapist in the eye, choose a different therapist.