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Patient in Pain? When to Refer for Physical Therapy

Appreciating the value of, and the need for, restorative care and rehabilitation services will serve patients well, particularly when proper expectations are communicated by pain practitioners.
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Physical therapy (PT) is defined by the World Confederation for Physical Therapy (WCPT) as the practice of evaluation and treatment that remediates impairments and promotes mobility, function, and quality of life through examination, diagnosis, and physical intervention (exercise, manual therapies, and modalities).1 It is carried out by physical therapists and PT assistants.

For those astute physicians who might be taken aback at the inclusion of “diagnosis” within the context of PT, it pertains to the identification of musculoskeletal (MSK) impairment, not medical pathology. Physical therapists are trained and educated in differential screening, so they are better able to identify non-MSK problems and symptoms that perhaps originate from visceral disease or adverse effects of medication.

Pain practitioners will serve patients well by referring them to physical therapy for chronic pain management.

People now have direct access to physical therapists in all 50 states, which means they can access PT without medical referral. Although the legal requirement for written referral is lifted in a direct-access environment, the regulatory (insurance) requirement for medical referral continues to be in place in many states, which has direct implications for PT reimbursement.

Growing Field

From 2009 to 2011, 24.8 million Americans (8% of the population) reported an MSK injury.2 Physical therapists are trained as experts in movement dysfunction and functional remediation and restoration. According to the Bureau of Labor Statistics, PT is one of the leading high-demand occupations in all economic categories.3 PT is a blending of pathology, pharmacology, biomechanics, exercise physiology, radiology, and rehabilitative techniques—with emphasis on biomechanics. Many physical therapists continue their training to include postgraduate courses in manipulation, mobilizations, and the myriad of available joint and soft tissue techniques available to practitioners.

An emerging role for physical therapists is that of health and wellness provider, who helps guide patients toward healthier lifestyles and positive behavior change. A physical therapist sees patients 2 to 3 times per week for several weeks to months, providing a valuable opportunity to build long-lasting relationships based on trust and confidence. These extended episodes of care provide invaluable teaching opportunities to promote a healthy lifestyle as part of the ongoing dialogue between patients and their physical therapist.

Why Refer to Physical Therapy

There are many reasons why a person might need PT. The most common patient complaint is pain, and approximately 75% of all patients referred to outpatient PT have pain as their primary symptom.4 The potential causes of pain are similar to those seen in medical and surgical practices, and include pain syndromes, diseases, injury, aging, overuse, stress, and faulty biomechanics.

Along with pain, other reasons for PT referral include weakness, inflammation, atrophy, deconditioning, spasm and tightness, tenderness, active range of motion (AROM) and mobility loss, balance and vestibular deficits, postural faults, and fear and other avoidance behaviors. This latter point is a focus of patient education sessions and a primary factor in de-conditioning, which underlies many pain states associated with centralized pain disorders. In fact, it would not be inconceivable that de-conditioning might be a pre-condition in centralizing pain disorders.5

Physicians should focus less on the methodology used by a therapist and more on the endpoint(s), including patient satisfaction levels. Physical therapists use a myriad of methods while treating patients, and these techniques generally fall into 1 of 3 categories: therapeutic exercise, manual therapy, or a modality (eg, ultrasound, electrotherapy, or traction, etc).

This inherent variation in treatments has been the subject of criticism, but the concerns are largely misplaced. Provider variation is inherent in all medical specialties, especially when making decisions about the need for surgery, drug prescriptions, ordering of tests, lab findings, outside consultations, etc. It is reflective of 3 things:

  • There is nothing more variable, complicated, and unpredictable than human behavior and physiology. What works for one patient does not for another with seemingly similar diagnoses.
  • There are at least 350 known soft tissue methods on record, along with a multitude of different modalities belonging to just as many technology categories. The number of possible combinations and permutations of these interventions, not to mention dosimetry options, makes choosing the best therapy nothing more than a value judgment, or best guess, in many cases. In the absence of comparative effectiveness research, the clinician must choose a therapy based on available evidence, clinical judgment and experience, and patient values—a similar concept to the Evidence Based Medicine paradigm suggested by David Sackett in the early 1990s.6
  • Practice environments (jurisdictions) vary from state to state and sometimes from region to region. In a perfect world, all providers would have access to their local populations. The available population is carved into groups, subsets of the total population, and defined by their insurance plan. Each plan decides, to a large degree, how therapy will be administered (which patient is approved, the stipulations, number of visits, who can treat, reimbursement parameters, reporting format, etc). For example, in our region, there has been a shift from traditional and preferred provider plans (PPOs) to the more affordable but higher deductible and co-pay health maintenance organizations (HMO) plans. These managed care organizations (MCOs) have, in many cases, closed provider panels, limiting new providers in the areas.

Clinical variation is a natural consequence of inherent variation from provider training, experiences, and beliefs; patient characteristics; and reimbursement and regulatory sources. Physical therapists’ practice patterns have been shaped not by evidence-based practice but based on what insurance companies will cover. The entire notion of doing what is best for a patient may get lost in the sea of regulatory requirements mandated by government agencies, the insurance industry, and health policy analysts.

Last updated on: July 12, 2017
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Somatic Symptom Disorder: DSM-5's Removal of Mind-Body Separation
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