Tell me how you see the future of physical therapy...

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dptstudent2018!

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The healthcare world is ever changing, and I want some of your opinions on what the future of this profession will be. I'm a second year DPT student, and personally I see a universal ability to order imaging to be an enormous hurdle to our profession. If we can do this, I see the profession really expanding. I'd love to hear your thoughts not necessarily on this but just our future in general.

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You will soon have a class that shows that imaging is overrated and overused. As for the future of the profession, just search the threads, as it has been discussed ad nauseam.
 
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Like the TPTA president said at the conference last year, "an MRI is just a really expensive selfie."
 
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A pretty cool selfie to have when you need to know how bad a fracture is before you start stretching or range of motion


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A pretty cool selfie to have when you need to know how bad a fracture is before you start stretching or range of motion


Sent from my iPhone using SDN mobile app

The problem is MRI's are used to justify unnecessary treatment. Asymptomatic people have positive MRI findings and vice versa. I could find 100 people on the street, give them an MRI, and find 40-50 herniated disks.
 
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In regards to imaging I see myself in the near future getting proficient with performing diagnostic MSK ultrasound, buying a machine, and start to do it at the clinic.
 
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It'd be nice to be able to order it as indicated but it's likely there would be lots of bonehead PT's out there there overordering it and overweighting it in terms of importance like physicians constantly do. I could also see quackery sprout around similar to how chiropractors claim/think they are some kind of radiologist. Patients do not need more/easier access to imaging in my view. There's lots of easy ways to get it already with little to no pushback. If you disagree, go ask your doctor for an x ray (likely to succeed) to see what's "going on in there", but be careful as it might be "negative" meaning there's "nothing wrong" or positive (supposedly always meaningful and "the cause").
 
In regards to imaging I see myself in the near future getting proficient with performing diagnostic MSK ultrasound, buying a machine, and start to do it at the clinic.
How do you see the role of diagnostic US within your practice?
 
How do you see the role of diagnostic US within your practice?
1. Diagnostic US would play a huge role in our direct to pt. marketing. Maybe pay per use, ca$h based, "cheaper than MRI".
2. Will most likely use it at end of evaluations to confirm findings. I think it will give patients reassurance for certain conditions (tendonitis, etc) when they get to actually see it and improve pt compliance, retention.
 
You will soon have a class that shows that imaging is overrated and overused. As for the future of the profession, just search the threads, as it has been discussed ad nauseam.

As a former PT and current radiologist I would agree that imaging is over-used but not overrated...ordering clinician needs to be clear on what is the clinical question and how will this affect management
 
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The problem is MRI's are used to justify unnecessary treatment. Asymptomatic people have positive MRI findings and vice versa. I could find 100 people on the street, give them an MRI, and find 40-50 herniated disks.

I get your point but most asymptomatic individuals do not undergo imaging and what do you constitute as unnecessary treatment?...treatment for herniated discs is typically conservative (such as PT)...I've read many MRs where there were disc protrusions/extrusions impinging on nerve roots and treatment was conservative...maybe its regional but not many undergo spinal fusion/laminectomy at the hospital where I practice
 
I get your point but most asymptomatic individuals do not undergo imaging and what do you constitute as unnecessary treatment?...treatment for herniated discs is typically conservative (such as PT)...I've read many MRs where there were disc protrusions/extrusions impinging on nerve roots and treatment was conservative...maybe its regional but not many undergo spinal fusion/laminectomy at the hospital where I practice

There's a lot of false positives and negatives in MRI. The position of the patient or even the time of day can affect the results of the image. Even a true positive can exacerbate symptoms because now the patient is catastrophizing (thinking the problem is worse). I classify unnecessary treatment as any treatment that does no better than natural recovery. Tissues heal with or without treatment.
 
There's a lot of false positives and negatives in MRI. The position of the patient or even the time of day can affect the results of the image. Even a true positive can exacerbate symptoms because now the patient is catastrophizing (thinking the problem is worse). I classify unnecessary treatment as any treatment that does no better than natural recovery. Tissues heal with or without treatment.

Honestly timing of imaging has never been brought up as issue to me during 5 years of residency and 2 years of fellowship (one of which was a MRI fellowship). If you know of a published paper/study that says otherwise I would be interested in reading it....Positioning is an issue if its sub-optimal and limits the exam (usually with shoulder MR)....I'm assuming you are referring to disc hydration when you say time of day but I am unsure how that would create/mask a protrusion. Also to my knowledge rotator cuff/labral/meniscal tear won't change regardless of time of imaging...finally when I was in PT school/practicing as a PT (97-2003) I was taught that most LBP (90%?) would resolve with/without treatment in 6-8 weeks, PT was effective in preventing/minimizing a recurrence, has anything changed?
 
The healthcare world is ever changing, and I want some of your opinions on what the future of this profession will be. I'm a second year DPT student, and personally I see a universal ability to order imaging to be an enormous hurdle to our profession. If we can do this, I see the profession really expanding. I'd love to hear your thoughts not necessarily on this but just our future in general.

2 things determine the health of one's field. 1). Supply and demand (new graduates/openings). 2). How valuable CMS deems your services to be (largely out of ones control but somewhat influenced by ones lobby)
 
Honestly timing of imaging has never been brought up as issue to me during 5 years of residency and 2 years of fellowship (one of which was a MRI fellowship). If you know of a published paper/study that says otherwise I would be interested in reading it....Positioning is an issue if its sub-optimal and limits the exam (usually with shoulder MR)....I'm assuming you are referring to disc hydration when you say time of day but I am unsure how that would create/mask a protrusion. Also to my knowledge rotator cuff/labral/meniscal tear won't change regardless of time of imaging...finally when I was in PT school/practicing as a PT (97-2003) I was taught that most LBP (90%?) would resolve with/without treatment in 6-8 weeks, PT was effective in preventing/minimizing a recurrence, has anything changed?

By time of day, I was referring to the imbibition of fluid by the disks. Also, MRI is only a static position, not a dynamic position, and cannot show movement pathology. I was not referring to RTC tears, only the spine. Perhaps time of day and position aren't that important, but my point is that MRI results have little correlation with pain.

As for most LBP resolving itself, the answer is still yes. The point is, tissues heal, yet you still have people complaining of chronic pain. In those cases I suspect psychosocial factors (fear avoidance, pain catastrophizing, etc.) I'm not saying the pain is in the patient's head, but in the brain. Is "PT" effective? PT is so broad so it's hard to say. What I will say is that exercise, especially aerobic exercise, is effective for preventing back pain, as well as a healthy lifestyle and relaxation. Nothing has changed.

I see you were a PT and now an attending physician. What made you transition? Have you had enough school?

Reference: Savage R, Whitehouse GH, Roberts N. The relationship between MRI appearance of the lumbar spine and LBP, age, and occupation of males. European Spine Journal. 1997; 6: 106-114.
 
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By time of day, I was referring to the imbibition of fluid by the disks. Also, MRI is only a static position, not a dynamic position, and cannot show movement pathology. I was not referring to RTC tears, only the spine. Perhaps time of day and position aren't that important, but my point is that MRI results have little correlation with pain.

As for most LBP resolving itself, the answer is still yes. The point is, tissues heal, yet you still have people complaining of chronic pain. In those cases I suspect psychosocial factors (fear avoidance, pain catastrophizing, etc.) I'm not saying the pain is in the patient's head, but in the brain. Is "PT" effective? PT is so broad so it's hard to say. What I will say is that exercise, especially aerobic exercise, is effective for preventing back pain, as well as a healthy lifestyle and relaxation. Nothing has changed.

I see you were a PT and now an attending physician. What made you transition? Have you had enough school?

Reference: Savage R, Whitehouse GH, Roberts N. The relationship between MRI appearance of the lumbar spine and LBP, age, and occupation of males. European Spine Journal. 1997; 6: 106-114.

Gotcha, I've read many follow-up L/S MRs on non-surgical elderly patients who's initial MR a few years earlier was already a train-wreck, not sure what they are expecting-immaculate regeneration?...maybe patients demand this type of imaging or they have changed clinicians but it is over-utilized...

Yes I have had my fill of school! (2 years community college, 2 years initial BA, 2 years of PT as a BS, then 4 years of med school), then 7 years of residency/fellowship (though I had income with more work/life balance at this point)...Why the transition? Entered PT in 97, fierce competition to get in, hardcore intense coursework (as you know), then graduated in 99 to a miserable job market, had a few jobs where I saw little professional upward mobility (including economic), also wanted an occupation/career that was more intellectual and less physical (see myself working well into my 60s, possibly beyond given current state of economic affairs), finally while stressful and challenging, I do enjoy structure of school/training...these were some of the factors
 
1. Diagnostic US would play a huge role in our direct to pt. marketing. Maybe pay per use, ca$h based, "cheaper than MRI".
2. Will most likely use it at end of evaluations to confirm findings. I think it will give patients reassurance for certain conditions (tendonitis, etc) when they get to actually see it and improve pt compliance, retention.
Seems like an expensive piece of equipment that will play a relatively minor role in patient care. It could take a while to pay for itself. You may have already done this, but you'll want to look at your state practice act and whether or not you are able to legally diagnose pathology - use of US to confirm a diagnosis of patellar tendonitis when the patient comes to you from a physician with the diagnosis of "knee pain" may fall outside of your scope of practice.
 
As a former PT and current radiologist I would agree that imaging is over-used but not overrated...ordering clinician needs to be clear on what is the clinical question and how will this affect management
I think the last part of your statement is what is often missing when imaging is over-utilized. In cases of LBP with or without radiculopathy, early imaging does not likely impact how a physician would choose to treat a patient, nor am I familiar with any literature which indicates that it positively effects the patient's outcome.
 
Seems like an expensive piece of equipment that will play a relatively minor role in patient care. It could take a while to pay for itself. You may have already done this, but you'll want to look at your state practice act and whether or not you are able to legally diagnose pathology - use of US to confirm a diagnosis of patellar tendonitis when the patient comes to you from a physician with the diagnosis of "knee pain" may fall outside of your scope of practice.
I did the math. It will take about 6 months to get money back if I do 2 visits per week. In regards to diagnosing, I usually will have a more specific PT diagnosis on top of the MD diagnosis if appropriate.
Seems like an expensive piece of equipment that will play a relatively minor role in patient care. It could take a while to pay for itself. You may have already done this, but you'll want to look at your state practice act and whether or not you are able to legally diagnose pathology - use of US to confirm a diagnosis of patellar tendonitis when the patient comes to you from a physician with the diagnosis of "knee pain" may fall outside of your scope of practice.
I did the math and it take me 6mkntha to get money back if I do 2 visits/week cash based.
In regards to diagnosing, state act says PT can use ultrasound to assess and treat. I usually will put a more specific PT diagnosis on evals if the MD diagnosis is general like "knee pain".
 
1. Diagnostic US would play a huge role in our direct to pt. marketing. Maybe pay per use, ca$h based, "cheaper than MRI".
2. Will most likely use it at end of evaluations to confirm findings. I think it will give patients reassurance for certain conditions (tendonitis, etc) when they get to actually see it and improve pt compliance, retention.

Gotcha, I've read many follow-up L/S MRs on non-surgical elderly patients who's initial MR a few years earlier was already a train-wreck, not sure what they are expecting-immaculate regeneration?...maybe patients demand this type of imaging or they have changed clinicians but it is over-utilized...

Yes I have had my fill of school! (2 years community college, 2 years initial BA, 2 years of PT as a BS, then 4 years of med school), then 7 years of residency/fellowship (though I had income with more work/life balance at this point)...Why the transition? Entered PT in 97, fierce competition to get in, hardcore intense coursework (as you know), then graduated in 99 to a miserable job market, had a few jobs where I saw little professional upward mobility (including economic), also wanted an occupation/career that was more intellectual and less physical (see myself working well into my 60s, possibly beyond given current state of economic affairs), finally while stressful and challenging, I do enjoy structure of school/training...these were some of the factors

It's very interesting that you went from such a face to face touch based field to going through imaging in the hospital in much more seclusion. I shadowed radiology in undergrad when looking at pre health fields. The guys and residents here are really cool people but man....they are running on coffee and dictation down there. Ha!

I did the math. It will take about 6 months to get money back if I do 2 visits per week. In regards to diagnosing, I usually will have a more specific PT diagnosis on top of the MD diagnosis if appropriate.

I did the math and it take me 6mkntha to get money back if I do 2 visits/week cash based.
In regards to diagnosing, state act says PT can use ultrasound to assess and treat. I usually will put a more specific PT diagnosis on evals if the MD diagnosis is general like "knee pain".

.....Honestly, has anyone ever done the cost savings for patients to see what would happen if they directly had a therapist diagnose and start a conservative treatment plan for strains, sprains, tendinitis, etc. instead of having different contact points in which the result was a diagnosis of
"(insert anatomical region here) pain" within a five minute meeting?

I'm well aware that the pain could be indicative of red flag pathology which is absolutely necessary to rule out......but ruling out is across the board, taught in curriculums currently...........
 
Seems like an expensive piece of equipment that will play a relatively minor role in patient care. It could take a while to pay for itself. You may have already done this, but you'll want to look at your state practice act and whether or not you are able to legally diagnose pathology - use of US to confirm a diagnosis of patellar tendonitis when the patient comes to you from a physician with the diagnosis of "knee pain" may fall outside of your scope of practice.

Isn't this just absolutely pathetic in your opinion? Especially if the referral is anyone outside of Physiatry or orthopaedic?
I.e. pediatrics, internal medicine, family medicine? All of whom have patients come to them since they think they are the correct servicer who will treat their problem?........and they arent
 
It's very interesting that you went from such a face to face touch based field to going through imaging in the hospital in much more seclusion. I shadowed radiology in undergrad when looking at pre health fields. The guys and residents here are really cool people but man....they are running on coffee and dictation down there. Ha!

Seclusion is a drawback to the field...I do miss the positive patient interactions I had as a PT but on the other hand I def do not miss the negative interactions!
 
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