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REP 6 - Into the prevention sphere

Christina Nowak MScPT, CSCS, PhD (student)

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:
 

  1. How do you think we as physiotherapists can be involved in the health promotion or the disease management sphere? 
  2. What is our role?
  3. How can we advocate as a profession for our role in this space? 
  4. Where are the boundary lines? 

 

By Christina Nowak MScPT, CSCS, PhD (student)

 

 

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Comments

 

What a great initiative! I agree that being a Physiotherapist gives us tremendous potential, yet also comes with limitations related to scope of practice and other profession-related restrictions. I have been working in chronic disease prevention and management for the past decade, as Regional Coordinator and sole mentor in a case-managed home program called FrancoForme (francoforme.ca). As part of the cardiac rehabilitation team, I see rehab patients, but I also accept primary prevention referrals from the community. My role is to assess a person's cardiovascular risk factors and guide them in adopting lifestyle changes to reduce their overall cardiovascular risk. Within this role is exercise prescription, nutritional counseling, stress management, diabetes education and smoking cessation counseling. Although I hold many additional credentials (ACSM Certified Clinical Exercise Physiologist, Certified Diabetes Educator, TEACH certified in Smoking Cessation), I am always mindful of the College guidelines related to scope of practice (and have checked in with them whenever I obtained a new credential). We often want to do more for our patients and take the necessary steps to do just that. Hopefully, one day, we will have the autonomy to break out of the traditional silos of Physiotherapy sub-specialties and get more creative with what we call "Physiotherapy"! In the meantime, keep up the good work!

I would love to visit you at Stave Off, just to see you in action. I am about to start a similar program locally. Please keep my contact info and include me in your symposium list!

Of course! You can send me an email at info@staveoff.ca and we can discuss it more. - Christina 

Thank you so much for your comment and what a wonderful role you play in the community! I believe you are right in that we are only scratching the surface on the role the physiotherapist's can do for their clients. Checking in with the College is always the safest bet. I will have to check out your website. I appreciate you taking the time to read my rep and have a wonderful day! 

 MeThankyou  very much for your work, as a PT working clinically for 30+ years your issues are dear to my heart . My understanding of our licensure is that we need to be providing treatment that is making positive change with  outcome measurement results. Yet many of us struggle with the cases where we feel we are slowing decline and helping manage disease.  In NS Medavie BCross has a plan to encourage clients to seek their advice on chronic disease management . The acceptance of this as an important service/resource will need to include research/ payers and license bodies.

   Individually we need to lobby /discuss this important work. Thankyou!

I 100% agree with you. PTs need to advocate for our role. With the WHO and UN initiatives calling for healthcare reform that is preventative and proactive in nature, this is our time to show our value and role in the prevention sphere. Thank you for reading my rep - these are where the conversations get started! - Christina 

As a physiotherapist with 45 years of experience and a primary focus on manual therapy, of course it is easy for me to understand the difficulty of "double blinding" research in the area of manual therapy, but how "evidence-based" biomechanical, exercise-focussed therapy can be "substantiated" more easily.  As you become a physiotherapy professor, please impress on your students the vital role our professional scope offers to those of us who use physiological and neurophysiological principles with manual therapy skills to monitor and manage physical conditions with highly sensitive anatomically-based perception and feed-back gained from palpation skills! Otherwise other professions will infringe and erode our professional scope of practice!

Yeah!!  I have been practicing 24 years and have had challenges in billing and promoting preventative exercise and treatment. I agree , as physiotherapists, we have the unique knowledge base and skills to be a leader and provider of preventative care. I salute your continued effort in this. It will not just benefit patients but the profession as well!

You have no idea how excited I am to see this!!!

It's like a mirror image of my expereince through Uni and the practice I opened 15 months ago in Australia www.pride.physio

It's a big challenge pushing prevention over 'fix' and the traditional, dare I say outdated, passive interventions our profession is more widely known for. 

Keep up the great work Christina; I will be following your work with interest. 

Neil, DPT
 

Well done Christina!

Relatively speaking of the recent times in my 31+ years career, I seemed to encounter a bit of a conundrum; the College had seemed to "remove" the idea of prevention and management/ maintenance out of our physiotherapist skills/goals at some point but yet I didn't know when or why and I was diligent about annual review of the guidelines. In my undergraduate training (Manitoba) this role of physiotherapy was stressed as a key element and we were told that we were"uniquely" positioned and trained for this very thing, yet the implications as time passed is that it wasn't appropriate to bill as physiotherapy in private and the public sector (in small community hospitals anyway) ceased many of these services.

I had many post physiotherapy care incidences of transferring/referring these prevention/ maintenance people to fitness trainers at regular gyms where they have not thrived, or they abandoned it for obvious and not so obvious reasons, or in one instance had actually declined and a year later ended back in my care in worse condition than they had been discharged because the areas I recommended focus were completely ignored and the individual was not able to empower herself and vocalize her needs. So in 2004, when I co-owned a private clinic with another physiotherapist we did just what you have described and labelled it, we included a "physio-gym" within our facility. We tried a few classes but majority was one to one fitness for those that needed that supervision after the "prgressive" care goals were acheived and billed it private pay as you have. We did not have the extensive success of attendance as it sounds like you have but situations and times were different; small town, the public not yet adjusted to concepts of "private physiotherapy" as just a few short years before our hospital did all the community care as out-patients and of course that was free.

It is exciting times, you younger physiotherapy professionals have the skills and drive at the front end of your careers currently, to prove through the reseach what we, in all those distance years past, only knew through our creative experience. The trick is to bring the "paying" world up to speed, what the public sector had been doing before health care cuts decided "we weren't primary care" and so much more dispensible. There are so many other skills and knowledge base that I had acquired in my training and used in the first 13 years of my career, that like this aspect, was thrown to the wayside and are waiting for someone to re-discover; equally as valuable as this aspect you are so passionate about.  

Again well done!

I appreciate your comments - thank you so much. I agree with you, I think we are in exciting times and we have so much that we can offer to our clients with our expertise. I always saw a bit of that disconnect as well - truly resonating with the community health and prevention pieces of our curriculum and then feeling road blocks and barriers for implementation. For me, these conversations become so pivotal to the change we wish to see. Thank you for taking the time to read through my rep - it truly means a lot to me. - Christina 

Great article Christina.  As you know, I'm a big fan of your work.

After reading your article my biggest concern is that you're not billing your services as physiotherapy based on feedback from your college and our national association.  Is that correct? 

Or is it that private insurance companies won't cover your services as physiotherapy? 

Is it concern based on concern that because your services are provided in a group format that there will be issues with coverage and scope of practice?

 

Exercise-based, group programming for the management of many chronic health conditions are routinley (well maybe not routinely, but certainly not uncommonly) provided by physiotherapists in the public sector.  In those instances I have never heard of any issues about scope of practice. 

You are using your professional trainnig to screen, assess, establish patient-centred goals and training programs, then re-assess individuals' progress with standardized outcome tools.

The services you are providing absolutely fit the description of physiotherapy practice in our Canadian essential competencies profile.

If what you describe is not physiotherapy, then what is?

The mind boggles.

Keep up the great work!

 

 

Christina, I share in the excitement of the other commentators over the innovative and important work you are carrying out. I too have struggled with the question of "what's next" for my clients who have met their progressive rehab goals, but who have complex medical needs and would benefit from an ongoing, supervised exercise program. Your model is exciting and innovative. I also question what the best funding model is for this type of approach. PTs have the training and expertise to carry out these types of interventions, yet our services are expensive (in comparison to PTAs or personal trainers) and are only covered publicly/by insurance in certain circumstances. I think the model of many cardiac rehab programs (i.e. PTs complete the assessment and the kinesiologists supervise the gym program) offers one solution, and I look forward to an expansion of this model in the years to come.

@dkjacks

 

 

I'm very happy to see that our profession is starting to ask these very important questions. My only concern, as stated by a prior comment was why you feel that peventative exercise is not billiable as physiotherapy?

In my opinion, many modalities such as heat and electrotherapy should not be billable as the evidence is questionable and the effects are short-lasting.

One-on-one movement/exercise therapy and education are by far the most effective approach for the majority of our patients and the population in general. It is the dosage that needs to be controlled, and that's where our patients, gyms and personal trainers many times fail.

We should be leaders in the field of exercise and injury prevention. 

I look forward to following your work!

Thanks to Christina for sharing her story and writing this excellent blog post!  @CPA_Melissa

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