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REP 28 - The grey areas of physiotherapy practice in health, wellness and prevention: the good, the bad and the “to be determined”

Anonymous

As a physiotherapist working in an extremely connected and evolving landscape, there are several challenges that come with navigating the world of health and wellness.

With the rise of social media, blogging and web presences, lines are starting to become blurred and different types of professionals are entering the rehabilitation space.

Personal trainers and fitness professionals are starting to market themselves as “rehabilitation specialists” or “Master’s fitness clinicians”. With large amounts of physiotherapists using modalities and manual therapy as their go-to forms of treatment, exercise professionals are beginning to fill the gaps. 

My newsfeeds are inundated with comments from personal trainers about failed therapy stints for their clients, as well as the easing of musculoskeletal injury through proper exercise prescription practices. 

“They don’t need a physiotherapist; they just need to be on a strengthening program.”

But as a physiotherapist in a rehabilitation space, I also ask myself “where does rehabilitation start and end?” Where do we fit into the health and prevention space? 

This post shares some of the good, bad and grey areas of practice I have observed working in a gym setting. These practices range from fraud, to inappropriate use of support personnel, to proper integration into a lifelong exercise routine, and everything in between. 

As I have attempted to navigate this space, I have come across some great practices and some not-so-great ones. 

I began my physiotherapy career in a gym setting. I had the entire gym at my disposal to help clients with exercise-based rehabilitation. I used a combination of manual therapy, mobility work and exercise prescription to help my clients and I saw incredible results. 

However, the more I worked in a gym environment, the more I discovered grey areas, or question marks that cause a clinician to stop and pause. 

Here are a few of my observations.

 

The good

As a physiotherapist in a gym setting, I witnessed an amazing opportunity for the continuation of exercise. Exercise became not a simple snapshot in time, but a lifelong endeavour. 

By performing rehabilitation in a gym setting, clients who didn’t feel comfortable eased into their surroundings. As they worked with a physiotherapist in this athletic environment, clients who had never before set foot in a gym gained confidence.

The therapeutic exercise program given by the therapist creates a solid foundation for confidence with exercise and allows for a person to continue on in that setting, if they so choose. Clients learn equipment recognition and the skills to use them, which lowers the barrier for entry for practicing regular exercise. 

As primary care providers, physiotherapists have an incredible opportunity to speak about healthy lifestyle practices with every person coming through their doors. Sleep, stress, nutrition and movement are all important aspects of the rehabilitation process not only for a patient’s current injury, but for future prevention. 

Physiotherapists are in a wonderful position to start these types of conversations, not only with clients, but with other members of the healthcare team.

Physiotherapists have the opportunity to collaborate with other healthcare providers to provide a comprehensive health management team. More physiotherapists are now referring clients to dieticians, nutritionists, osteopaths and other health professionals and are working closely with physicians to provide clients with the best quality of care. 

 

The bad 

As in every profession, there are physiotherapists who try to take advantage of this new grey area. 

While working at the gym, I was approached by a man who represented a “physiotherapy company” who asked if our staff would be willing to partner with them. Unaware that I was a physiotherapist, he proposed allowing clients to claim gym memberships through their physiotherapy benefits. 

He explained that the company would provide the registration number of one of their staff, who would periodically come in to do “assessments.” Our staff would then use the physiotherapist’s registration number to bill gym member’s physiotherapy insurance.

I made the man aware that I was a physiotherapist and asked for the name of the physiotherapist who was willing to share their registration number, he promptly left.

While I felt upset by the interaction, I could understand how a gym owner who might not have knowledge of the rules and regulations for physiotherapist insurance claims might be tempted to participate in this blatant fraud.

I’ve heard of other healthcare professionals connecting with gyms to create similar “deals,” which usually benefit the healthcare professionals more than the clients. 

They often go something like this:

“If you see me [the healthcare professional] x amount of times per month for treatment, then you can use the gym facility for free”. 

In this example, clients are still monitored by a healthcare provider, but largely without specific goals for therapy. This “deal” also includes inflated costs of treatment to cover the membership of the gym. I have seen this practice often in gyms, and it is often taken advantage of by clients with unlimited physiotherapy coverage.

On numerous occasions, I have been asked to participate in this “deal” and have promptly educated my clients about the fraudulent nature of this arrangement. 

Another “bad” I have observed is the inappropriate use of support personnel. Physiotherapists complete assessments, then delegate care to a personal trainer. 

In this example, personal trainers are in charge of generating and executing exercise programs. 

I have seen instances where physiotherapists do not conduct a re-assessment, and others where there is a periodic check in. These instances create opportunities for clients to get personal training covered under their insurance benefits. 

This is also fraud and is not endorsed by the College of Physiotherapists in any province. 

 

In these scenarios, physiotherapists place their licenses at risk and create doubt in the minds of the insurers who fund these programs. 

As a profession, we need to hold ourselves accountable and ensure that we are practicing in a way that is ethically sound. 

 

The to-be determined

I still have some questions about the prevention environment. From my experiences, there are a few “grey areas” that I would love clarification on how to navigate: 

  1. Exercise for management chronic conditions. Physiotherapists have learned ways to help people begin exercising after heart attacks, strokes, lung diseases, cancers and a whole slew of chronic conditions. But when do these programs start and end? For example, cardiac rehabilitation takes three months in the public sector, but guidelines recommend one year. What is the best model for physiotherapists to adopt that help persons exercise when they have symptoms which may limit their capacity to do so?
  2. Private physiotherapy in small groups. This is prevalent in the public sector because it is both physically and cost effective, with a recent systematic review concluding that group physiotherapy may be more effective than one-on-one sessions). However, this type of physiotherapy is not covered in the private sector. Where does chronic disease management end and group fitness begin?
  3. Risk factors. We are in an era where hypertension, diabetes and chronic low back pain are sky rocketing. Physiotherapists have tools to help combat all of these things. But what is the best way for us to get involved? 

 

Over to you

1. What thoughts can you share about the “to be determined” areas?

2. What are some of the other areas of practice that physiotherapists are interested in navigating but just aren’t sure how? 

3. Wellness coaches are becoming increasingly prevalent, but isn’t that essentially what a physiotherapist is as well? 

 

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Comments

As physiotherapists in a large rehab facility, we struggled with the same concern of how our patients, especially those with balance & mobility challenges,  could continue to exercise and promote their health and well-being after discharge from formal rehabilitation.  Our unique idea was to partner with community recreation organizations, combining the skill sets of physiotherapists and fitness instructors to deliver a task-oriented group exercise program, designed by physiotherapists and led by fitness instructors at the rec centre.   The ongoing support of physiotherapists is essential to teach and mentor the instructors by a training session and visits to the exercise class. We also eventually developed a licensing process wherein the community centres sign a license as another way to protect the quality and integrity of the program.  Research into the effects of the program has also been ongoing.

The program has expanded into other provinces, demonstrating the need for access to exercise for people living with disability in the community to manage chronic disease and sustain function and wellness over the long term. The program has also created new opportunities for physiotherapists to apply their skills in the community through advocacy, collaboration, education and mentoring - - a win-win situation for all.

As this description has been very short, I suggest visiting the TIME website for more information http://www.uhn.ca/TorontoRehab/PatientsFamilies/Clinics_Tests/TIME .

 

I was interested in reading your reflections on the 'grey areas' this morning. You may be pleased to know that these are actually not so 'grey'. After three physical therapy Summits on global health and one follow up being convened in South Africa at the WCPT Congress in July, our international surveillance teams have aligned the dots when it comes to:

* the leading health care priorities across the WCPT member organizations/countries (>102) (specifically, the largely preventable lifestyle-related NCDs in high- and increasingly low- and middle-income countries)

* the evidence-informed and evidence-based 'best' practices to protect health, promote health, reduce disease risk and optimally manage chronic conditions though lifestyle practices)

* the role of contemporary physical therapists; excluding dentists and pharmacists, physical therapists are the third largest established health profession in the world, and the leading (largely) 'non-pharmacological' health profession

* what has defined physical therapy for over 100 years is its largely non-pharmacologic lens, which uniquely positions us for at least the next 100 years to take a lead in 'health' care as well as maintaining our role in 'illness/injury/disease' care.

Our global Summits have concluded that physical therapists are uniquely positioned to not only first and foremost address the 'health' of every patient (not simply sign and symptom and reduction), but also to lead.

In Capetown, we are establishing minimal (accredit-able) health competencies and recommending to WCPT these be endorsed in their practice accreditation standards. We would be the first established health profession ever, to do this.

The Health Improvement Card endorsed by the World Health Professions Alliance, which the WCPT was instrumental in developing (yet the uptake has lagged) is included in our recommendations for standard physical therapist practice. Further, our Summits have concluded given our unique non pharmacologic lens as a leading established health profession, that the physical therapy profession and each physical therapist has an ethical responsibility to lead in advancing health protection, health promotion, and disease risk reduction. You will find our published proceedings of the first two global Summits on line; the third we are tightening up (is in front of me as we speak for final editing). Also, check out 'The Patient Promise' initiative.

The 'word' is spreading. I no longer only address physcial therapists around the world on this topic, but am leaving tomorrow to address primary care physicians in Dublin, Ireland, at their conference.

I thought I would take this opportunity to bring you and others up to scratch. Your energy and commitment is vital to this initative. Be encouraged, don't dispair, you are uniquely positioned professionally.

 

 

 

 

 

 

 

 

 

 

 

Great article. Just need to point out that "Registered Dietitians" are health care providers, while the term "nutritionist" is not protected as a synonym for a Dietitian in all provinces/territories. Physiotherapists should understand the legislation of protected terms for nutrition professionals in their region and ensure they are referring to a Registered Dietitian. 

Thank you for the clarification!

 

@CPA_Melissa

Good for you and your efforts they are needed.

Our profession brought this upon themselves.  When I went to the university of toronto in the early 1980's there was no exercise physiology program, I lobbied the faculty and they borught in a MSc exercise physiologist for a half year course.  Alot of time was wasted teaching silly things like positioning and bizarre electronic devices.  The manual therapy as taught by the Wendy Aspinalls was way to conceptual, remember Kaltenbourne (or however you spell it).

That is history and now we need to aggresively teach and practice exercise based practice.  I am leaving the profession soon and opening a fitness and wellness business in Tofino.  We will be emphasising exercise, nutrition, yoga, meditation, laughter and all will be evidenced based.

I know that physio's like Bahram Jam (spelling) is doing good stuff and we need more like him.  But our society has to wake up and quit looking for quick fixes to their MSK problems and start exercising.

 

 

 

 

 

 

The answers that physiotherapists can give to these questions related to people with chronic conditions and in the areas of prevention would go a long way to helping our governments deal with the sky-rocketing costs of health care.

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