REP 6 - Into the prevention sphere
Being out of school for just over three years, I consider myself to be a young physiotherapist. To this day, I still remember how excited I was to talk about prevention during our community health unit at McMaster University. I should have recognized right then that it was going to become a passion of mine.
Even back then, there were so many questions that came up as we discussed the topic. It seemed like physiotherapists knew the benefits that they could offer patients. What exactly those benefits looked like, however, was still a big question mark.
When I left school, I began work as a physiotherapist in a private practice and in a gym setting. At first, I primarily saw athletes. But before long, I began seeing their family members and friends.
During my time in the gym setting, I experienced significant growth in my skills regarding the true benefits of exercise-focused physiotherapy. In fact, there was one patient who changed my life and my career.
I started working with a 65 year-old woman who experienced degenerative meniscus issues, as well as likely underlying arthritis. Her pain had gotten so severe that she was often pushed in a wheelchair when she went out with her family. Her doctor gave her bilateral cortisone injections and told her to go to physiotherapy.
I decided this was our chance to really focus on strengthening her knees. We did a gradual progression using classic exercise principles. Over time, her knees got stronger.
Her pain didn’t flare back up again for about six months and when it did, it was only in the left knee. She went in for another shot. Shortly after that, with continued strengthening, her pain went away.
This patient still experiences odd times where her knee feels irritated, but she’s avoided surgery and hasn’t needed another cortisone shot.
I knew that she needed to continue exercising, but it was becoming clear that she no longer had physio-specific goals outside of maintenance. I was unsure where to send her and knew that a supervised exercise program would probably be the best spot for her. So I created one myself.
Here is where my questions started to pop up:
- Could this be covered as physiotherapy, because I knew that when she stopped moving, her pain will inevitably return?
- How would this work?
- Would there be a need for reassessment?
To answer these questions, I turned to the College of Physiotherapists of Ontario, as well as the Canadian Physiotherapy Association to find answers.
Their responses were helpful but this area seemed so vague. There were no clear guidelines. So in order to ensure that I wasn’t doing anything wrong, I decided to make the program a private one.
It worked as a small group exercise program would in any other gym setting. I ran it, but as an exercise instructor. But this got me thinking. As physiotherapists, we have a huge role to play in the world of health promotion and disease management.
The people who were attracted to my class had health complications that prevented them from wanting to go into a typical program. I had people who had had a stroke, diabetes, severe arthritis and chronic obstructive pulmonary disease (COPD) who all worked out together and accomplished such incredible things that my eyes tear up just thinking about what they achieved.
So why can’t we as a profession, do this? I decided to go back to McMaster in September of 2015 to investigate this question.
I am now working with Dr. Ada Tang at the School of Rehabilitation Science on the use of high intensity resistance training to stave off disability and decline in persons with preclinical disability and pre-frailty.
My work focusses on targeting individuals before an incident has happened and trying to improve function before it is too late.
I delved head first into the literature and, in conjunction with my clinical (though limited) experience, I saw this huge and well-validated potential. Exercise was like a miracle drug. How many medications help with the prevention and management of 35 different chronic conditions? None. But exercise does.
In my PhD studies, I was able to get the background on the effectiveness of these prevention programs. Millions of dollars have been spent on research trials validating this concept.
In the public sector, we are beginning to see more and more examples of exercise-centered programs (although often times, capacity can be an issue). Other kinds of these programs, like fall-prevention programs and cardiac rehabilitation programs, are becoming more popular and referred to.
But there are limitations. Working within regular 9:00am– 5:00pm hours prevents some people from attending. Often, wait lists are long. I started thinking about how wonderful it would be for us to have a resource like this in the private sector.
More and more physiotherapists are landing in private practice and it would enable myself, a physiotherapist, to get involved in community prevention; to help people manage their chronic conditions with exercise.
That is when STAVE OFF came into being.
I had originally started STAVE OFF as an information website. I would post the workouts from my private exercise program and share the new things that I was learning as part of my PhD. But I wanted it to be more. I wanted to take what I was learning and translate it directly into a business model; a physio-gym, you might say.
Now, STAVE OFF is a 4000 sq. foot facility. I have three treatment rooms that I rarely use outside of assessments and I have a gym facility. My rehabilitation takes place there.
Here, I am able to help people exercise to stay healthy, and improve pain and other symptoms associated with chronic conditions. The workings of this business model are still transforming and I’m learning as I go, along with my fiancé and business partner.
We have started an arthritis management program. As part of this program, we have an initial assessment with a physiotherapist where we get an extensive past medical history, use validated outcome measures, and work with our clients to create client-centered goals. Then they move into a group exercise program.
This program is private pay– it is not physiotherapy billed back to extended health benefits. Maybe one day it can be.
I have consent from each of my clients to de-identify them to create a case report form with pre and post data.
I’m using the skills I am learning in my PhD to create an argument for the coverage of these programs in the private sector. It is a three month program; at the end of which we do a second physiotherapy consult to consider next steps and help with transitions.
We work with our clients to try to achieve their best outcomes. For persons without benefits, this is also a cost-effective strategy.
When STAVE OFF opened, that is also when I reached out to the Canadian Physiotherapy Association and Ontario Physiotherapy Association (OPA). As I said before, I believe that we as physiotherapists have a huge role we can play in the health, wellness and prevention sphere – but we haven’t really delineated what that is going to look like yet.
I also believe it is my responsibility to act as an advocate for my profession. It’s why I am writing this blog. It’s why I continue learning.
Because I had so many questions about what it will look like operating a business focused on not only rehabilitation from acute injury, but also prevention and management of chronic conditions, I thought others probably would too. I wanted to be part of the solution. To help myself and other physiotherapists who are passionate about entering into this space.
I believe that now is an important time to act. With the Exercise is Medicine movement gaining traction and a focus on prevention coming to the forefront with our aging baby boomer population, we need to advocate that physiotherapists can be a very important part of that solution.
I wanted to begin the conversation. One way that I am doing this is to help present a Health, Wellness and Prevention panel at the InterACTION conference this spring hosted by the OPA. I have brought together a pretty incredible group of women in various aspects of academia and practice to begin to open up the discussion. A group of voices can be more powerful than one, but it takes one to get it going.
So please, share what you think below and let’s continue this conversation:
- How do you think we as physiotherapists can be involved in the health promotion or the disease management sphere?
- What is our role?
- How can we advocate as a profession for our role in this space?
- Where are the boundary lines?
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