The dependence on opioids is a problem in the United States. There has been much talk about alternatives to opioids, but despite the rhetoric, things don’t seem to change. I came across an article in the New York Times Health section that covered this topic specifically. The title caught my eye…“New Ways to Treat Pain Meet Resistance”. I thought I may be reading about some new, cutting edge approaches to the management of pain and ways to avoid opioid abuse. Instead, what I read is that physical therapy is considered an “alternative approach” by many and lumped in with a number of approaches without strong research to support their success in dealing with pain. I guess it really shouldn’t have come as a surprise. As a physical therapist with over 25 years of experience, I often hear about people that have NEVER been referred to physical therapy for their neck, back or joint pain. Despite copious amounts of research touting the benefits of exercise in reducing pain and disability, people are still quick to take the pill (or the shots), hoping that it will be the quick fix they are looking for and they won’t have to put in the hard work.
In the NYT article, the patient interviewed had neck and back pain from a motor vehicle accident. Although they didn’t delve deeply into his history, it appears that he was seen by a “pain specialist” who put him on a combination of muscle relaxants and opioids to dull the pain. It wasn’t until the patient started to have serious issues with dependence on the drugs that he was referred to any type of a physical therapy program. At that time he had to enroll in a 6 hour a day program (which involved physical therapy as well as other approaches) at a cost of $20,000. I might be biased, but maybe if the “pain specialist” had referred to PT first, there would have never been the need for an intensive detox program.
There are obviously cases where opioids are the best choice. Cases where people are having life altering pain or end of life illness and the only thing they can do is dull the nerves and block the pain. Where opioids are generally not needed are for patients with neck, back and joint pain. In most of these cases the pain is due to some inflammation, muscles spasms and inactivity. Getting patients to use an ice pack, some over the counter anti-inflammatories and getting them in a GOOD physical therapy program that utilizes the latest in evidence based practice, specific manual techniques in combination with custom, guided exercise programs is a much better approach than getting them hooked on drugs.
Gladly , the article does go on to discuss how effective physical therapy can be in helping patients eliminate pain and return to life. I know first hand how it can work…I have been helping people get pain free and return to their lives for 25 years!
If you or someone you know is suffering from chronic neck, back or joint pain and your only treatment so far has been medication, do yourself a favor and give physical therapy a try. We shouldn’t be considered an “alternative” treatment for pain…we should be considered THE treatment for pain!
Delayed onset muscle soreness (D.O.M.S) is one of the top reasons that people STOP a new exercise program. For patients in physical therapy, especially those that are not regular exercisers, it can be a scary outcome to the start of treatment. What happens and what causes it? Should you be concerned? This quick Q&A in the NYTimes Well blog does a nice job explaining some of the science behind it, but what you need to know is that it is very normal and it will go away. So if you are new to exercise and are getting soreness for a few days afterwards, don’t get discouraged and don’t stop doing that exercise in the future. Most likely you just over did it a little and getting back into the same exercises but with a reduced load or intensity will help you build up those muscles so you don’t have the same outcome in the future. We always warn our patients that it could happen (hoping it doesn’t)…but knowing about it helps stop the surprise of a few days of soreness for someone just getting started. Like the Marine Corp mantra states…”pain is just weakness leaving your body”…hoorah
The number of joint replacements performed per year continues to grow and it is anticipated that as the average life span continues, and people continue to remain more active than they have in previous generations that the number will continue to grow. As a matter of fact, there have been articles that have shown some concern as to whether or not there will be enough access to surgeons to actually perform this growing number of replacements!
The question we hear often from patient is “When do I know it’s time to get a knee replacement?” There is no single answer to this question as it varies for each person.
Signs that it might be time for a knee replacement:
- Your pain persists or recurs over time
- Your knee aches during and after exercise
- You’re no longer as mobile as you’d like to be
- Medication and using a cane aren’t delivering enough relief
- Your knee stiffens up from sitting in a car or a movie theater
- You feel pain in rainy weather
- The pain prevents you from sleeping
- You feel a decrease in knee motion or the degree to which you’re able to bend your knee
- Your knees are stiff or swollen
- You have difficulty walking or climbing stairs
- You have difficulty getting in and out of chairs and bathtubs
- You experience morning stiffness that typically lasts less than 30 minutes (as opposed to stiffness lasting longer than 45 minutes, a sign of an inflammatory condition called rheumatoid arthritis)
- You feel a “grating” of your joint
- You’ve had a previous injury to the anterior cruciate ligament (ACL) of your knee
If you have a number of these signs or symptoms, it may be time to start having a conversation with your primary care doctor for a referral to an orthopedist that specializes in joint replacements to start to look at alternatives.
Before you make the final decision, there are a number of conservative methods that can be very helpful in reducing pain and may extend the time before getting a knee replacement…or maybe even prevent it all together. There was a recent article in the New York Times that discussed a study that was performed trying to determine whether surgery, or conservative measures were best. In a number of the cases, physical therapy alone was very helpful in reducing pain and helping to avoid surgery, but in a number of other cases, it was the joint replacement that really helped fully restore function and relieve pain.
From the perspective of a physical therapist, even if you are planning to go the route of a joint replacement, having a course of physical therapy prior to the procedure can help to maximize your mobility and strength and really help improve the speed and outcomes of your post-surgical recovery.
Michael Vacon, PT is the Managing Partner of Blue Hills Sports & Spine Rehabilitation of Braintree and Weymouth and can be reached at firstname.lastname@example.org
The American Physical Therapy Association 2020 Vision Statement suggests that “physical therapists and physical therapist assistants will render evidence‐based services throughout the continuum of care and improve quality of life for our society.” Make sense right?? I know if I am having anything medical done, I would like “evidence” to be part of the thought process from the clinician rendering the services. Despite how much sense this makes, you would be very surprised to find out how many physical therapists are NOT using evidence in their clinical practice, but instead, just keep using the same old tired techniques. There has been studies done that show that 30‐40% of patients do not receive care according to current scientific evidence and about 20‐25% of care provided is not needed or is potentially harmful. Crazy, right??
So, what is Evidence Based Practice? Quite simply, it is using well researched, peer reviewed studies to shape your clinical practice. The goal is to have a standard approach to the evaluation and treatment of a variety of conditions to optimize the quality of patient care. A physical therapy practice that is using Evidence Based Practice will have therapists that” integrate clinical experience with conscientious, explicit and judicious use of research evidence in order to make clearly informed decisions to help maximize and optimize patient well‐being.” If you are being treated in a facility that uses Evidence Based Practice, you should see very little differentiation amongst the approach of the therapists…if you are seen by a different therapist, the treatment should remain very consistent as should the overall philosophy of treatment. The hallmark of a physical therapy office that is utilizing Evidence Based Practice is going to be better patient outcomes, but despite the abundance of good clinical studies to shape a practice, the vast majority of physical therapy offices still do not used an evidence based approach.
The term Evidence Based Practice has really become a buzzword…people tout that they do it, but the evidence in studies shows the opposite. One of the biggest problems that physical therapy faces as a profession is the very wide variability of practice patterns between physical therapists…and in most cases, physical therapists that work in the same office are using completely opposite techniques.
What confuses many people that get treatment for places that are not using evidence based treatment is that they do “get better” with a variety of treatments, but is this because the treatent was effective, or, was it because you just “got better” while getting a variety of treatments that actually didn’t have any effect at all? It would makes sense that there should really be just one way to treat a specific injury, right??
So what are some of the defining characteristics of an Evidence Based Practice:
Using the best research evidence: This means using relevant patient‐centered clinical research to help in the diagnosis and differentiation of injuries as well as the efficacy and safety of therapeutic, rehabilitation, and preventive strategies. The most updated clinical research suggests new ways to diagnose pathology and approach treatments. It also can often invalidate older ways of diagnosis and methods of treatment and replace them with more powerful, valid, or successful methods. At Blue Hills Sports & Spine we are very careful that everything we do is based on the latest, best clinical research.
Using clinical expertise: This means the ability to use clinical skills and past experience to rapidly identify each patient’s unique diagnosis, their individual risks and benefits associated with potential interventions, while skillfully integrating their personal values and expectations. Clinical expertise is something that is developed (of course), but a good center will quickly bring new clinicians up to the speed of older clinicians through clinical shadowing, teaching and good clinical discussion. At Blue Hills Sports & Spine, we ensure that every clinician is trained in the same techniques and in the same way. We have an approach and a philosophy to everything we do and we make sure that all our clinicians share that expertise.
How is Evidence Based Practice used at Blue Hills Sports & Spine Rehabilitation?
• When we do our initial evaluations on patients, we are making sure that we evaluate all the surrounding joints…the whole structure of the person. Although the pain is in one area, the cause could be someplace else. We always “treat the cause, not just the symptoms”.
• When we develop our treatment program, it is based on our findings from our comprehensive evaluation…we ask ourselves “why” for each treatment we decide to use…is this “the best, most effective means of treatment for this problem”?
• We measure…and then we re-measure. Many times a few treatment sessions starts to uncover an underlying problem that wasn’t evident during the initial treatment. It’s important to frequently re-assess to make sure that we are making the best use of our treatment and that patients are responding to this treatment.
• We take your needs into consideration. When we are establishing our treatment programs, we are incorporating YOUR goals, not just ours. Our goals may be to improve your range of motion, increase your strength, maximize your flexibility…but these are just benchmarks. Ultimately the most important goal is to help you get back to what you want to do and we have to use the latest in research and techniques to accomplish this.
• We measure ourselves so we can keep improving. Not all physical therapy offices utilize outcome studies…we do. We do initiate outcome studies on 100% of our patients and we measure and track improved function, symptom relief and patient satisfaction. We subscribe to a national data base that not only allows us to track how we are doing, but compare ourselves to other physical therapy practices from around the country…and we do well.
At Blue Hills Sports & Spine we are proud to be a group of offices that all subscribe to the philosophy of Evidence Based Practice…it’s why you can be seen by any of our therapists, at any of our locations and get the same, quality treatment. Without evidence, you are just guessing!
Michael Vacon, PT
Proud to be Evidence Based
I was reading an online article from CNNMoney that discussed the trend of physicians in private practice selling to hospital groups. The article reports that this is happening at a much higher rate and the expectation is that it will continue. The main reasons being cited are just general frustration in dealing with insurance company rules and regulations as well as the overall decline in reimbursement. For many having a private practice just isn’t a viable option anymore and they are selling to hospitals and becoming employees again.
It made me think about all the reasons I have decided to have a private practice and whether or not I would be willing to trade those for the “stability” of being an employee again. When I started a private practice it wasn’t to “get rich”. I am a physical therapist so “getting rich” isn’t part of the job anyway…if you run a clean practice that is. I opened a private practice for autonomy. To do things my way. To offer a level of care that is better that what can be provided at the majority of hospital locations that I compete with. I have achieved that and continue to strive for new ways to improve our services and expand to be able to allow more patients to experience the level of care that can be expected in a private practice.
Unfortunately, being “the best” and offering “premium service” doesn’t come with better reimbursement…although being part of a large hospital that has more clout with the insurance companies sure does. It is no secret that services received in a hospital setting are both charged and reimbursed at a higher rate. It has been well publicized in the news and the Attorney General in Massachusetts has many tasks forces looking in to it…but it still happens.
Locally we have Partners Health Care poised to acquire South Shore Hospital “for the good of patient care”. That couldn’t be further from the truth…what Partners Health Care is interested in is expanding their foot print to enroll more patients in preparation for the continued development of ACO’s and for more clout with the insurance companies which will allow them to have more leverage in negotiations for reimbursement.
As a small private practice I have to compete with much larger groups with deeper pockets for advertising…groups that “own” their doctors and dictate where the patient can go, regardless if it is the best place for them to provide care.
I wish I could see the future, but reading this article made me think that the trends are not in my favor. It’s not that all hospitals and large institutions give bad care…it’s just sometimes you are just another number and not someone that they develop a relationship with. The small, local private practice that works hard to earn your business and even harder to keep it should be able to survive.
I know what has happened with the “Walmartization” of retail and how it has affected the “mom and pop” stores…the same is happening in healthcare. Big groups are forming that push the little guy out…join us or compete against us. You would think with superior service, cutting edge technology and top notch staff you could do it, but the odds are not in favor and the regulations are becoming more and more cumbersome everyday…so for those groups that are selling, I get it…maybe it will let you get back to just patient care again?
Keep in mind that as a patient you do have a choice…when you can, choose local private practices that really do have your best interests are heart…before they are all gone.
Michael Vacon, PT
Proud private practioner (for as long as it lasts)