In this episode, host Dr. Nick Rainey is joined by Dr. Bremen Abuhl and Dr. Dallas Ehrmantraut to discuss their 2025 Physical Therapy Journal article, “First Contact Physical Therapy Compared to Usual Primary Care for Musculoskeletal Disorders: A Systematic Review and Meta-Analysis of RCTs.”
The conversation explores whether physical therapists should serve as the first point of contact for patients with musculoskeletal disorders and how first contact PT compares with usual primary care.
Dr. Abuhl and Dr. Ehrmantraut discuss their findings, including reduced imaging utilization, reduced prescription medication utilization, and similar clinical outcomes for pain, disability, and health-related quality of life. They also unpack the terminology around direct access, first contact PT, and primary care PT, and explain why direct triage models may offer a more efficient pathway for patients.
The episode also addresses real-world implementation barriers, including reimbursement models, state scope-of-practice variation, imaging privileges, medication prescribing, stakeholder buy-in, and the need for PTs to step confidently into first contact roles.
Key Takeaways- First contact PT is not the same as direct access.
- Direct access means patients can choose PT without referral. First contact PT means the PT is the first provider evaluating the patient for that episode of care.
- The study found lower healthcare utilization.
- First contact PT was associated with 45% less imaging and 71% less prescription medication utilization compared with usual primary care.
- Clinical outcomes were similar.
- Pain, disability, and health-related quality of life outcomes were statistically similar between first contact PT and usual primary care.
- Less imaging is not automatically the goal.
- The more important question is appropriate utilization: avoiding both overuse and underuse.
- Implementation is a system problem.
- Scope of practice, reimbursement, stakeholder buy-in, state law, and health system workflows all influence whether first contact PT can work.
- Direct triage may be the stronger model.
- Compared with warm handoffs, direct triage allows patients with appropriate MSK presentations to start with PT as the first provider.
- PTs need to be ready for real-world first contact care.
- That includes identifying red flags, determining urgency, ordering or recommending imaging when appropriate, and referring to the right provider when needed.
Chapters:
00:00 — Welcome and guest introductions
01:17 — Dr. Bremen Abuhl’s path into first contact PT research
03:13 — Dr. Dallas Ehrmantraut’s clinical spark for the topic
06:16 — Overview of the PTJ systematic review and meta-analysis
09:52 — Direct access vs first contact PT vs primary care PT
13:15 — Global evidence and limited U.S.-based RCTs
16:24 — Imaging findings and appropriate utilization
20:37 — Medication utilization findings
23:27 — Clinical outcomes: pain, disability, and quality of life
25:20 — Study limitations and downstream utilization
27:13 — Why longer-term outcomes matter
31:15 — Risk of bias and crossover between groups
33:36 — U.S. system barriers to first contact PT
36:37 — Reimbursement, payer models, and stakeholder concerns
40:45 — Direct triage vs warm handoff models
44:15 — Scope of practice and state-level barriers
46:08 — Real-world safety, red flags, and PT decision-making
48:01 — Call to action for physical therapists
50:06 — Closing thoughts
00:00:05 --> 00:00:06 All right.
00:00:06 --> 00:00:08 Welcome to the AOMS Hands-On,
00:00:08 --> 00:00:10 Hands-Off podcast.
00:00:11 --> 00:00:12 I am Dr. Nick Rainey.
00:00:12 --> 00:00:14 I'm part of the research committee.
00:00:15 --> 00:00:19 So my job is to interview researchers.
00:00:19 --> 00:00:21 And so that's why we have Dr.
00:00:21 --> 00:00:25 Bremen Abel and Dr. Dallas Ehrmantraut.
00:00:25 --> 00:00:27 Did I get both of those names correctly?
00:00:27 --> 00:00:28 You got it.
00:00:28 --> 00:00:29 Okay.
00:00:29 --> 00:00:30 Very good.
00:00:32 --> 00:00:32 They...
00:00:33 --> 00:00:35 I've done some interesting research,
00:00:35 --> 00:00:37 at least what I find interesting.
00:00:37 --> 00:00:39 So hopefully our listeners do as well.
00:00:42 --> 00:00:43 A little bit about them.
00:00:43 --> 00:00:44 I'll give a little bit of intro and
00:00:44 --> 00:00:45 they can fill us in.
00:00:46 --> 00:00:49 They both practice together and teach
00:00:49 --> 00:00:51 together in North Dakota.
00:00:51 --> 00:00:53 They're at University of Jamestown's DPT
00:00:53 --> 00:00:54 program.
00:00:55 --> 00:00:59 And they're both PhDs and they're also in
00:01:00 --> 00:01:00 orthopedics.
00:01:01 --> 00:01:01 Dr.
00:01:02 --> 00:01:03 Abel is actually waiting for his results
00:01:03 --> 00:01:06 to see after he's completed residency,
00:01:06 --> 00:01:07 waiting for his results.
00:01:07 --> 00:01:11 Fingers crossed for his OCS.
00:01:11 --> 00:01:11 Dr.
00:01:11 --> 00:01:15 Ehrmantraut already has his OCS as well.
00:01:15 --> 00:01:16 Dr. Abel,
00:01:16 --> 00:01:18 is there anything that you would like to
00:01:18 --> 00:01:19 add to that background,
00:01:19 --> 00:01:22 particularly in light of what has made you
00:01:22 --> 00:01:24 interested in first contact physical
00:01:24 --> 00:01:25 therapy?
00:01:26 --> 00:01:28 Yeah, it's a really good question.
00:01:28 --> 00:01:31 I think it came about throughout DPT
00:01:31 --> 00:01:31 school.
00:01:31 --> 00:01:33 So I actually went here where I teach
00:01:33 --> 00:01:34 to the University of Jamestown.
00:01:36 --> 00:01:39 And the program is set up to try
00:01:39 --> 00:01:40 to push the profession forward.
00:01:40 --> 00:01:43 So there's always conversations about how
00:01:43 --> 00:01:46 can we practice at the top of our
00:01:46 --> 00:01:48 license and how can we provide the best
00:01:48 --> 00:01:48 patient care.
00:01:50 --> 00:01:51 As I went through school,
00:01:51 --> 00:01:53 there were developing conversations just
00:01:53 --> 00:01:58 among faculty and I started my PhD halfway
00:01:58 --> 00:01:59 through my DPT.
00:01:59 --> 00:02:02 So it was kind of this converging of
00:02:02 --> 00:02:04 what I'm learning in class and then trying
00:02:04 --> 00:02:07 to expand upon that and study some of
00:02:07 --> 00:02:09 the questions I had about kind of,
00:02:10 --> 00:02:12 PTs acting as primary assessors,
00:02:12 --> 00:02:13 first contact role.
00:02:14 --> 00:02:15 So that's kind of where the interest came
00:02:15 --> 00:02:16 about,
00:02:16 --> 00:02:18 was probably from conversations with
00:02:18 --> 00:02:20 faculty and collaborations with some of
00:02:20 --> 00:02:20 them.
00:02:21 --> 00:02:23 And then as I went into developing my
00:02:23 --> 00:02:25 PhD research questions,
00:02:25 --> 00:02:27 it kind of flowed directly into that.
00:02:27 --> 00:02:28 And thankfully, at the same time,
00:02:28 --> 00:02:29 Dallas and I were,
00:02:30 --> 00:02:31 he was my professor at the time,
00:02:31 --> 00:02:34 but we were working closely in class,
00:02:34 --> 00:02:35 of course, and then in the clinic,
00:02:35 --> 00:02:36 in the pro bono clinic.
00:02:37 --> 00:02:38 So we kind of started having some
00:02:38 --> 00:02:40 interesting conversations there.
00:02:44 --> 00:02:44 Wow,
00:02:45 --> 00:02:46 that is a very interesting background,
00:02:46 --> 00:02:49 starting a PhD while you're still working
00:02:49 --> 00:02:51 under DPT and then going on into
00:02:51 --> 00:02:52 residency.
00:02:52 --> 00:02:54 And that's a lot all at once.
00:02:55 --> 00:02:56 I don't need to tell you that.
00:02:56 --> 00:02:57 You realize that?
00:03:00 --> 00:03:02 I was going to say,
00:03:02 --> 00:03:04 throw a kid in the middle of it
00:03:04 --> 00:03:05 for Bremen.
00:03:06 --> 00:03:07 Oh, good, good.
00:03:07 --> 00:03:08 We didn't want to make it any easier.
00:03:08 --> 00:03:10 Yeah, exactly.
00:03:12 --> 00:03:13 Dr. Amantra,
00:03:13 --> 00:03:15 what is your background that I didn't
00:03:15 --> 00:03:15 share,
00:03:16 --> 00:03:17 particularly what makes you interested in
00:03:17 --> 00:03:18 first contact physical therapy?
00:03:19 --> 00:03:19 Yeah,
00:03:20 --> 00:03:23 it's obviously an area of both practice
00:03:23 --> 00:03:24 and research that Bremen and I and
00:03:24 --> 00:03:25 yourself are interested in.
00:03:26 --> 00:03:27 And honestly,
00:03:27 --> 00:03:28 it kind of started during my residency.
00:03:29 --> 00:03:30 There was an orthopedic residency in a
00:03:30 --> 00:03:33 large health system in Fargo,
00:03:33 --> 00:03:34 North Dakota.
00:03:34 --> 00:03:35 And during that residency,
00:03:36 --> 00:03:38 you have various opportunities to shadow
00:03:38 --> 00:03:39 different disciplines.
00:03:40 --> 00:03:42 And one of the places that I shadowed
00:03:42 --> 00:03:44 was just in a family practice.
00:03:44 --> 00:03:46 and throughout the morning we're seeing
00:03:46 --> 00:03:48 things that are definitely not within my
00:03:48 --> 00:03:50 scope of practice but then one of the
00:03:50 --> 00:03:52 patients that was upcoming was coming in
00:03:52 --> 00:03:55 with i believe it was shoulder pain and
00:03:55 --> 00:03:58 i was excited to see how this np
00:03:58 --> 00:04:00 would practice in that situation but she
00:04:00 --> 00:04:02 on the other hand had a different
00:04:02 --> 00:04:04 perspective she she looked at me and she
00:04:04 --> 00:04:06 said oh no now you're going to realize
00:04:06 --> 00:04:07 that i don't know what i'm doing with
00:04:07 --> 00:04:08 musculoskeletal pain
00:04:09 --> 00:04:12 And so that is what really sparked my
00:04:12 --> 00:04:13 interest in this.
00:04:14 --> 00:04:16 And she was humble enough to recognize
00:04:16 --> 00:04:16 like,
00:04:17 --> 00:04:19 i'm not as interested in musculoskeletal
00:04:19 --> 00:04:21 stuff that's not where i've put my
00:04:22 --> 00:04:24 dedicated efforts towards learning and i
00:04:25 --> 00:04:27 i'm not an expert anymore i would rather
00:04:27 --> 00:04:29 do these other things so that's what got
00:04:29 --> 00:04:32 me interested in thinking about what what
00:04:32 --> 00:04:35 should our role be in these health systems
00:04:35 --> 00:04:36 what should our role be in private
00:04:36 --> 00:04:38 practice what should physical therapist
00:04:38 --> 00:04:40 role be and then that's when i started
00:04:40 --> 00:04:40 doing some
00:04:41 --> 00:04:42 literature review,
00:04:42 --> 00:04:44 doing additional observational
00:04:44 --> 00:04:45 experiences.
00:04:45 --> 00:04:47 Early on in my research inquiry during the
00:04:47 --> 00:04:48 PhD,
00:04:48 --> 00:04:50 I shadowed an orthopedic PA and I asked
00:04:50 --> 00:04:51 them,
00:04:52 --> 00:04:53 when did you get all this training to
00:04:53 --> 00:04:58 do all of these injections and surgical
00:04:58 --> 00:04:59 assistance?
00:04:59 --> 00:05:01 And the response was, Dallas,
00:05:01 --> 00:05:03 it was literally all on the job training,
00:05:03 --> 00:05:03 which
00:05:04 --> 00:05:06 sparked a lot of interest for me,
00:05:06 --> 00:05:08 but also a lot of fear in me
00:05:09 --> 00:05:12 as far as the patient care that is
00:05:12 --> 00:05:13 being provided right now.
00:05:13 --> 00:05:16 And it's not to say that that's their
00:05:16 --> 00:05:18 fault by any means.
00:05:18 --> 00:05:19 It's just the system that's been
00:05:19 --> 00:05:19 developed.
00:05:19 --> 00:05:21 And I think the main thing that I
00:05:21 --> 00:05:24 took away from it is DPT education is
00:05:25 --> 00:05:27 really impressive when it comes to
00:05:27 --> 00:05:29 preparing clinicians to care for
00:05:29 --> 00:05:31 musculoskeletal conditions.
00:05:31 --> 00:05:32 And if that's the case,
00:05:32 --> 00:05:35 and these other disciplines don't have as
00:05:35 --> 00:05:35 rigorous training
00:05:36 --> 00:05:37 education in those areas,
00:05:37 --> 00:05:41 then how can we manipulate or change the
00:05:41 --> 00:05:41 system,
00:05:41 --> 00:05:44 the structure that's in place to improve
00:05:44 --> 00:05:46 patient care, improve patient outcomes,
00:05:46 --> 00:05:48 improve the efficiency of healthcare
00:05:49 --> 00:05:49 systems,
00:05:49 --> 00:05:52 and honestly offload the overburdened
00:05:52 --> 00:05:55 providers that are caring for these
00:05:55 --> 00:05:56 patients already.
00:05:56 --> 00:05:58 So I think those were,
00:05:58 --> 00:06:01 that's a brief summary of what sparked my
00:06:01 --> 00:06:03 interest.
00:06:03 --> 00:06:04 I like stories like that.
00:06:04 --> 00:06:05 Thank you.
00:06:06 --> 00:06:10 That's a great lead-in to the paper that
00:06:10 --> 00:06:11 they authored.
00:06:12 --> 00:06:16 This came out in twenty-five in Physical
00:06:16 --> 00:06:17 Therapy Journal.
00:06:19 --> 00:06:20 It is titled,
00:06:20 --> 00:06:22 First Contact Physical Therapy Compared to
00:06:22 --> 00:06:25 Usual Primary Care for Musculoskeletal
00:06:25 --> 00:06:26 Disorders,
00:06:27 --> 00:06:29 A Systematic Review and Meta-Analysis of
00:06:29 --> 00:06:31 RCTs.
00:06:33 --> 00:06:35 Would one of you mind giving us
00:06:36 --> 00:06:40 elevator-style summary pitch of a high
00:06:40 --> 00:06:41 level of what this article was about,
00:06:42 --> 00:06:43 and then we can dive into some more
00:06:43 --> 00:06:44 questions.
00:06:45 --> 00:06:45 Yeah, for sure.
00:06:46 --> 00:06:48 So as Dallas mentioned,
00:06:49 --> 00:06:51 he and I both became really interested in
00:06:52 --> 00:06:54 what type of provider manages patients
00:06:54 --> 00:06:57 with musculoskeletal conditions and what
00:06:57 --> 00:06:59 kind of provider is best suited for that
00:06:59 --> 00:06:59 role.
00:07:00 --> 00:07:02 And so throughout literature review and
00:07:02 --> 00:07:03 personal experiences,
00:07:03 --> 00:07:06 we recognize just how overburdened the
00:07:06 --> 00:07:08 healthcare system is in general.
00:07:08 --> 00:07:10 And when you look at some of the
00:07:10 --> 00:07:12 numbers, it varies by country,
00:07:12 --> 00:07:14 but musculoskeletal disorders are one of
00:07:14 --> 00:07:16 the primary reasons for years lived with
00:07:16 --> 00:07:18 disability and for pain and healthcare
00:07:18 --> 00:07:19 spending.
00:07:19 --> 00:07:22 And so we were really interested in how
00:07:22 --> 00:07:24 can we improve the value of care and
00:07:25 --> 00:07:27 the type of care for patients with
00:07:27 --> 00:07:29 musculoskeletal disorders while also
00:07:29 --> 00:07:31 supporting our healthcare systems and
00:07:31 --> 00:07:34 teams and offloading providers to allow
00:07:34 --> 00:07:36 them the capacity to better manage other
00:07:36 --> 00:07:38 conditions, like Dallas mentioned,
00:07:38 --> 00:07:40 that maybe they're more interested in or
00:07:40 --> 00:07:42 more prepared to do so.
00:07:42 --> 00:07:44 And so by investigating that,
00:07:44 --> 00:07:48 we wanted to look at how do outcomes
00:07:48 --> 00:07:50 for patients, including clinical outcomes,
00:07:50 --> 00:07:53 so things like pain and disability and
00:07:53 --> 00:07:54 health-related quality of life,
00:07:55 --> 00:07:57 and also the societal side of things,
00:07:57 --> 00:07:59 so healthcare utilization like clinical
00:07:59 --> 00:08:02 imaging or prescription medications and
00:08:02 --> 00:08:03 the cost to the patients,
00:08:03 --> 00:08:06 How do those differ when a patient is
00:08:06 --> 00:08:10 first evaluated by a physical therapist in
00:08:10 --> 00:08:14 the first contact role versus a usual care
00:08:14 --> 00:08:17 provider, physician, nurse practitioner,
00:08:17 --> 00:08:18 or physician assistant?
00:08:19 --> 00:08:21 So at a baseline,
00:08:22 --> 00:08:23 we wanted to assess the differences.
00:08:23 --> 00:08:24 Now, this has been done before.
00:08:25 --> 00:08:26 Multiple systematic reviews have looked at
00:08:26 --> 00:08:27 the same thing.
00:08:28 --> 00:08:29 None of the studies had looked at just
00:08:30 --> 00:08:31 randomized controlled trials,
00:08:31 --> 00:08:33 and then some of our outcomes hadn't been
00:08:33 --> 00:08:34 studied either.
00:08:34 --> 00:08:36 So healthcare utilization hadn't been
00:08:36 --> 00:08:37 studied with a meta-analysis,
00:08:37 --> 00:08:39 and neither had a health-related quality
00:08:39 --> 00:08:39 of life.
00:08:40 --> 00:08:41 So we wanted to get a good,
00:08:42 --> 00:08:44 broad picture of when we're in these
00:08:44 --> 00:08:46 roles, what are the patient outcomes?
00:08:47 --> 00:08:49 Is there a difference between this usual
00:08:49 --> 00:08:50 primary care and the first contact
00:08:51 --> 00:08:51 physical therapist?
00:08:52 --> 00:08:55 So when we dive into some of the
00:08:55 --> 00:08:57 methods and results a little bit later,
00:08:57 --> 00:08:59 we can talk about those specifically.
00:08:59 --> 00:09:01 But ultimately, we wanted to know,
00:09:02 --> 00:09:03 At baseline,
00:09:03 --> 00:09:05 are we at least as good as what
00:09:05 --> 00:09:07 we're already doing in the medical system
00:09:07 --> 00:09:09 in managing patients with musculoskeletal
00:09:09 --> 00:09:09 disorder?
00:09:09 --> 00:09:12 Because that should be the minimum, right?
00:09:12 --> 00:09:13 At minimum,
00:09:13 --> 00:09:15 can we do this as effectively and achieve
00:09:15 --> 00:09:16 the same patient outcomes?
00:09:16 --> 00:09:19 Not necessarily having to prove something.
00:09:19 --> 00:09:20 We just wanted to know how we compare.
00:09:21 --> 00:09:24 So the findings were interesting in two of
00:09:24 --> 00:09:27 the outcomes that hadn't been studied
00:09:27 --> 00:09:28 before with a meta-analysis,
00:09:28 --> 00:09:29 clinical imaging and prescription
00:09:29 --> 00:09:30 medications.
00:09:30 --> 00:09:32 We found significant less healthcare
00:09:32 --> 00:09:34 utilization with the physical therapists
00:09:35 --> 00:09:37 as the first contact provider compared to
00:09:37 --> 00:09:38 usual primary care.
00:09:38 --> 00:09:40 And then all of the outcomes were
00:09:40 --> 00:09:43 statistically similar to usual primary
00:09:43 --> 00:09:48 care compared to physical therapy.
00:09:48 --> 00:09:49 That's a great overview.
00:09:49 --> 00:09:50 Thank you.
00:09:52 --> 00:09:53 I want to back up a little bit
00:09:53 --> 00:09:55 with terminology.
00:09:55 --> 00:09:57 You know, as I've, you know,
00:09:57 --> 00:09:58 when I was a student long ago,
00:09:58 --> 00:09:58 you know,
00:09:58 --> 00:10:00 we talked about direct access and how many
00:10:00 --> 00:10:01 states have direct access.
00:10:02 --> 00:10:04 Some of the literature now is showing
00:10:04 --> 00:10:06 first contact physical therapy.
00:10:06 --> 00:10:07 I know in Utah,
00:10:07 --> 00:10:09 they recently passed a bill that
00:10:09 --> 00:10:11 classifies physical therapists as primary
00:10:11 --> 00:10:14 care providers and other states have been
00:10:14 --> 00:10:15 pushing for that as well.
00:10:16 --> 00:10:17 Is there a difference between the terms?
00:10:18 --> 00:10:20 Why would you choose first contact
00:10:20 --> 00:10:22 physical therapy versus direct access or
00:10:22 --> 00:10:23 primary care physical therapy?
00:10:26 --> 00:10:27 We went back and forth on this a
00:10:27 --> 00:10:28 lot, actually.
00:10:29 --> 00:10:30 And part of it was just due to
00:10:30 --> 00:10:32 the literature review and seeing the
00:10:32 --> 00:10:33 variability.
00:10:33 --> 00:10:36 But if you look at definitions of primary
00:10:36 --> 00:10:37 care or first contact,
00:10:37 --> 00:10:39 you'll see variability throughout the
00:10:39 --> 00:10:40 research.
00:10:40 --> 00:10:42 I mean, it all started with direct access,
00:10:42 --> 00:10:42 right?
00:10:43 --> 00:10:44 We want our patients to be able to
00:10:44 --> 00:10:46 choose to go see a physical therapist
00:10:46 --> 00:10:47 without having to have
00:10:47 --> 00:10:48 a physician referral.
00:10:48 --> 00:10:49 So that's kind of where it started back
00:10:49 --> 00:10:51 with like Vision Twenty Twenty and even
00:10:51 --> 00:10:52 before that,
00:10:52 --> 00:10:54 trying to get direct access for patients
00:10:54 --> 00:10:56 to physical therapy services.
00:10:57 --> 00:10:59 Then as we continue to look at integration
00:10:59 --> 00:11:01 of PTs into health care systems,
00:11:01 --> 00:11:03 I think there's there's multiple different
00:11:03 --> 00:11:05 ways that PTs have been and can be
00:11:05 --> 00:11:06 implemented.
00:11:06 --> 00:11:08 And so we went back and forth on
00:11:08 --> 00:11:10 the primary care versus first contact
00:11:10 --> 00:11:10 definition.
00:11:11 --> 00:11:13 But the first contact definition is
00:11:14 --> 00:11:16 primarily you're the first provider that
00:11:16 --> 00:11:18 this person sees for their plan of care.
00:11:18 --> 00:11:19 So that could be,
00:11:20 --> 00:11:22 it could be in a primary care clinic
00:11:22 --> 00:11:24 or it could be in an orthopedic walk-in
00:11:24 --> 00:11:27 or in a sports environment or in the
00:11:27 --> 00:11:29 emergency department or there's a vast
00:11:30 --> 00:11:31 range that it could be.
00:11:32 --> 00:11:33 Versus when you think of primary care,
00:11:33 --> 00:11:34 that's typically,
00:11:34 --> 00:11:36 at least in the health care system that
00:11:36 --> 00:11:37 we work in,
00:11:37 --> 00:11:40 we talk about family medicine and internal
00:11:40 --> 00:11:42 medicine as kind of that primary care.
00:11:43 --> 00:11:44 But I think that physical therapists have
00:11:44 --> 00:11:46 been integrated and can be integrated in a
00:11:46 --> 00:11:47 wider range than that,
00:11:48 --> 00:11:50 rather than just that overarching,
00:11:50 --> 00:11:50 you know,
00:11:52 --> 00:11:54 overarching big scope you know you can
00:11:54 --> 00:11:56 manage a lot of different conditions
00:11:56 --> 00:11:58 whereas we're focusing on musculoskeletal
00:11:58 --> 00:12:01 disorders rather than rather than you know
00:12:01 --> 00:12:04 vestibular and oncology and pelvic floor
00:12:04 --> 00:12:07 and whatever else it is so we wanted
00:12:07 --> 00:12:09 to focus primarily on the musculoskeletal
00:12:09 --> 00:12:11 disorder so that's why we chose the the
00:12:11 --> 00:12:12 first contact term
00:12:13 --> 00:12:14 Anything to add to that, Dallas?
00:12:16 --> 00:12:17 Not necessarily.
00:12:17 --> 00:12:19 I guess just to reiterate,
00:12:20 --> 00:12:22 the primary care definition was recently
00:12:22 --> 00:12:24 released for physical therapy.
00:12:25 --> 00:12:28 And it's very comprehensive and went
00:12:28 --> 00:12:29 through multiple iterations.
00:12:29 --> 00:12:32 And it does a great job describing what
00:12:32 --> 00:12:33 primary care physical therapy is.
00:12:34 --> 00:12:37 And we felt in our study,
00:12:37 --> 00:12:38 because we're isolating musculoskeletal
00:12:38 --> 00:12:39 conditions,
00:12:40 --> 00:12:41 that it wouldn't do the primary care
00:12:42 --> 00:12:43 definition justice necessarily.
00:12:44 --> 00:12:45 And so that's why we went with the
00:12:45 --> 00:12:48 first contact provider is we're focused on
00:12:48 --> 00:12:49 musculoskeletal disorders.
00:12:49 --> 00:12:51 And like Bremen said,
00:12:51 --> 00:12:54 we want to make sure that we're isolating
00:12:54 --> 00:12:56 studies that had physical therapists as
00:12:56 --> 00:12:58 that first point of contact before they
00:12:58 --> 00:13:02 saw anybody else.
00:13:02 --> 00:13:03 That was a fabulous answer.
00:13:03 --> 00:13:03 I figured that
00:13:04 --> 00:13:05 When you've spent a lot of time here,
00:13:06 --> 00:13:08 you know the nuanced differences of words.
00:13:08 --> 00:13:11 And so I figured you'd have a great,
00:13:11 --> 00:13:11 insightful answer.
00:13:11 --> 00:13:12 So I appreciate that.
00:13:13 --> 00:13:15 Let's go on to some of the studies
00:13:15 --> 00:13:17 that you were looking at in there.
00:13:18 --> 00:13:19 Both of your experience has been in
00:13:19 --> 00:13:22 American healthcare in the United States.
00:13:24 --> 00:13:25 Looking at the studies,
00:13:25 --> 00:13:25 if I remember right,
00:13:25 --> 00:13:27 there's only one that was based,
00:13:27 --> 00:13:28 one of the RCTs was based in the
00:13:28 --> 00:13:29 U.S.
00:13:29 --> 00:13:31 Fiber in Sweden and the rest were
00:13:31 --> 00:13:32 scattered.
00:13:33 --> 00:13:35 Tell me a little bit about how does
00:13:35 --> 00:13:37 that affect the results?
00:13:37 --> 00:13:39 What was interesting to you based on
00:13:39 --> 00:13:40 geography?
00:13:41 --> 00:13:41 Yeah,
00:13:41 --> 00:13:43 we weren't totally sure what we were going
00:13:43 --> 00:13:47 to get as we began our literature review
00:13:47 --> 00:13:49 and trying to go figure out our search
00:13:49 --> 00:13:51 terms and determine which studies we're
00:13:51 --> 00:13:52 going to include.
00:13:52 --> 00:13:53 But we knew that we wanted to go
00:13:53 --> 00:13:54 global because we
00:13:54 --> 00:13:56 We weren't sure if there had been enough
00:13:56 --> 00:13:58 done in the United States as far as
00:13:58 --> 00:13:59 randomized control trials that would be
00:13:59 --> 00:14:02 able to suffice for a meta-analysis.
00:14:02 --> 00:14:04 And lo and behold, we were right.
00:14:05 --> 00:14:05 As you said,
00:14:05 --> 00:14:08 there was only one RCT that we included
00:14:08 --> 00:14:10 from the United States, five from Sweden,
00:14:10 --> 00:14:13 and then a scattered mix from there.
00:14:13 --> 00:14:14 So yeah,
00:14:15 --> 00:14:16 half of our articles were from Sweden.
00:14:17 --> 00:14:18 And from there,
00:14:19 --> 00:14:21 I think it kind of just shows that
00:14:21 --> 00:14:22 this has been studied outside of the
00:14:22 --> 00:14:24 United States more than it has within the
00:14:24 --> 00:14:26 United States from a randomized control
00:14:26 --> 00:14:27 trial perspective.
00:14:28 --> 00:14:29 And because of that,
00:14:29 --> 00:14:31 there are limitations as far as the direct
00:14:31 --> 00:14:33 applicability within the United States.
00:14:33 --> 00:14:34 However,
00:14:34 --> 00:14:36 what I will say is this idea of
00:14:36 --> 00:14:37 primary care,
00:14:37 --> 00:14:40 first contact physical therapy is not new
00:14:40 --> 00:14:42 to the United States.
00:14:42 --> 00:14:43 Right.
00:14:43 --> 00:14:45 The United States military has had first
00:14:45 --> 00:14:46 contact physical therapists practicing in
00:14:46 --> 00:14:48 those roles for over fifty years.
00:14:48 --> 00:14:50 When you look at the civilian sector,
00:14:51 --> 00:14:53 Kaiser Permanente has been having physical
00:14:53 --> 00:14:55 therapists in primary care first contact
00:14:55 --> 00:14:57 roles for about thirty years now.
00:14:57 --> 00:14:59 When we began our literature review,
00:14:59 --> 00:15:01 we came across an APTA perspective that
00:15:02 --> 00:15:04 did a great job breaking down country by
00:15:04 --> 00:15:06 country and what physical therapists are
00:15:06 --> 00:15:08 practicing, how they're practicing,
00:15:08 --> 00:15:10 what their privileges are as far as scope
00:15:10 --> 00:15:11 of practice is concerned in these
00:15:11 --> 00:15:12 different countries.
00:15:13 --> 00:15:15 And another thing that stood out to us
00:15:16 --> 00:15:19 that we took from Erin Kyle's study a
00:15:19 --> 00:15:22 little while ago was at that time,
00:15:22 --> 00:15:24 the United States was the only entry-level
00:15:24 --> 00:15:26 doctorate degree when you look at it
00:15:26 --> 00:15:28 across the globe as far as physiotherapy
00:15:28 --> 00:15:29 training.
00:15:29 --> 00:15:31 Everywhere else was either bachelor or
00:15:31 --> 00:15:32 master's,
00:15:32 --> 00:15:32 but yet
00:15:33 --> 00:15:35 they had more expansive scopes of practice
00:15:35 --> 00:15:37 than we did in the United States,
00:15:37 --> 00:15:39 which is something that we thought was
00:15:39 --> 00:15:41 interesting and it led to better
00:15:41 --> 00:15:44 discussion as far as what we're doing here
00:15:44 --> 00:15:47 in the United States and what other
00:15:47 --> 00:15:49 countries are doing as far as their
00:15:49 --> 00:15:51 advanced physiotherapy practice or
00:15:51 --> 00:15:52 standard physiotherapy practice.
00:15:54 --> 00:15:56 to note the differences,
00:15:56 --> 00:15:58 learn from the differences and try to
00:15:58 --> 00:16:00 apply those and make sure we're closing
00:16:00 --> 00:16:02 the gap as far as the quality of
00:16:02 --> 00:16:10 care being provided in the United States.
00:16:10 --> 00:16:11 I'm glad you opened it up to the
00:16:12 --> 00:16:14 more than just the United States when
00:16:14 --> 00:16:15 you're setting forth what you want to do,
00:16:15 --> 00:16:17 because obviously, like you said,
00:16:17 --> 00:16:19 only one showed up in the United States,
00:16:19 --> 00:16:20 even though it's been done.
00:16:20 --> 00:16:20 Like you said,
00:16:20 --> 00:16:21 it's not a brand new concept.
00:16:23 --> 00:16:26 Let's go, let's move towards imaging.
00:16:26 --> 00:16:28 One of your findings related to imaging,
00:16:28 --> 00:16:30 and that's where there's been a pretty big
00:16:30 --> 00:16:31 movement throughout the United States for
00:16:32 --> 00:16:34 physical therapists to have increased
00:16:34 --> 00:16:36 imaging privileges.
00:16:36 --> 00:16:36 First,
00:16:36 --> 00:16:39 what was the finding in your paper and
00:16:39 --> 00:16:41 any other thoughts you have on physical
00:16:41 --> 00:16:42 therapists ordering imaging?
00:16:43 --> 00:16:44 Yeah,
00:16:44 --> 00:16:46 it's one of our key interest areas and
00:16:46 --> 00:16:48 something that we hope to continue
00:16:49 --> 00:16:50 studying outside of the scope of this
00:16:50 --> 00:16:51 paper.
00:16:51 --> 00:16:54 But the main finding from our study was
00:16:54 --> 00:16:57 significantly less imaging utilization
00:16:58 --> 00:16:59 from the physical therapy group.
00:17:00 --> 00:17:02 And so when we look at just overall
00:17:02 --> 00:17:05 health care utilization in the United
00:17:05 --> 00:17:05 States, at least,
00:17:05 --> 00:17:09 is we see a lot of unnecessary images
00:17:09 --> 00:17:09 being ordered.
00:17:09 --> 00:17:11 We see that in our own personal practice,
00:17:11 --> 00:17:14 but also in some of the research that
00:17:14 --> 00:17:16 we read in our literature review is we're
00:17:16 --> 00:17:20 seeing this expansive overutilization or
00:17:20 --> 00:17:21 we might change the term to kind of
00:17:22 --> 00:17:25 a misutilization where we're relying on it
00:17:25 --> 00:17:27 too heavily to influence our clinical
00:17:27 --> 00:17:28 decision making.
00:17:29 --> 00:17:31 And when we look at the findings,
00:17:31 --> 00:17:33 we see significantly less healthcare
00:17:33 --> 00:17:34 utilization in general,
00:17:35 --> 00:17:36 less imaging being ordered.
00:17:37 --> 00:17:39 We don't necessarily need to show that
00:17:39 --> 00:17:41 we're using less imaging,
00:17:41 --> 00:17:43 but rather we would hope in the future
00:17:43 --> 00:17:45 to be able to identify that we're more
00:17:45 --> 00:17:47 appropriately using imaging for patients
00:17:47 --> 00:17:48 with musculoskeletal disorders.
00:17:49 --> 00:17:51 When you look at some of the research
00:17:51 --> 00:17:53 on when we should use imaging for
00:17:53 --> 00:17:55 musculoskeletal disorders,
00:17:55 --> 00:17:57 a lot of the conversation is if it's
00:17:57 --> 00:17:59 going to change your management plan.
00:18:00 --> 00:18:02 That's one of the key features of ordering
00:18:03 --> 00:18:04 imaging is if it's going to change your
00:18:04 --> 00:18:06 management or not.
00:18:06 --> 00:18:06 If it's not,
00:18:06 --> 00:18:09 then you might rethink your utilization of
00:18:09 --> 00:18:09 it.
00:18:09 --> 00:18:12 So the imaging conversation is a really
00:18:12 --> 00:18:15 comprehensive and challenging one to have
00:18:16 --> 00:18:17 because I think it challenges a lot of
00:18:17 --> 00:18:20 biases with imaging findings in
00:18:20 --> 00:18:22 asymptomatic control groups.
00:18:22 --> 00:18:26 And the safety conversation plays into it
00:18:27 --> 00:18:28 too of, well,
00:18:28 --> 00:18:30 are you just ordering an image to protect
00:18:30 --> 00:18:32 yourself in the event that something does
00:18:32 --> 00:18:33 happen?
00:18:33 --> 00:18:34 Or are you actually using clinical
00:18:34 --> 00:18:36 reasoning and decision making to come to
00:18:36 --> 00:18:37 that decision of ordering an image?
00:18:39 --> 00:18:42 So certainly as the scope of practice
00:18:42 --> 00:18:43 expands,
00:18:43 --> 00:18:45 we are interested to continue studying it
00:18:45 --> 00:18:48 to see as PTs gain access to this,
00:18:48 --> 00:18:50 are we going to go the other way
00:18:50 --> 00:18:51 on the pendulum where now because we have
00:18:51 --> 00:18:52 the access,
00:18:52 --> 00:18:54 we're just ordering it as much as any
00:18:54 --> 00:18:55 provider is?
00:18:55 --> 00:18:58 Or do we at a baseline have more
00:18:58 --> 00:19:00 tools in the toolbox to make those
00:19:00 --> 00:19:02 decisions than just using an image to
00:19:02 --> 00:19:03 guide the plan of care?
00:19:07 --> 00:19:09 So it sounds like the finding in the
00:19:09 --> 00:19:11 study was that it's ordered less when
00:19:11 --> 00:19:13 physical therapists are first contact
00:19:13 --> 00:19:14 providers.
00:19:15 --> 00:19:16 Well, the hope is,
00:19:16 --> 00:19:18 it didn't elucidate this in the study,
00:19:19 --> 00:19:22 is that decreased ordering is
00:19:22 --> 00:19:24 appropriately decreased ordering.
00:19:24 --> 00:19:26 Obviously we know that there's a lot of
00:19:27 --> 00:19:27 excessive ordering,
00:19:28 --> 00:19:30 but what we may not know is,
00:19:31 --> 00:19:32 are we under utilizing imaging?
00:19:33 --> 00:19:35 And if more privileges we get,
00:19:35 --> 00:19:37 are we going to overutilize it like maybe
00:19:37 --> 00:19:38 other professionals have?
00:19:40 --> 00:19:41 Exactly.
00:19:41 --> 00:19:43 Any other thoughts on that, Dr.
00:19:44 --> 00:19:44 Ehrmanthrop?
00:19:44 --> 00:19:45 No.
00:19:46 --> 00:19:47 No, not necessarily.
00:19:47 --> 00:19:49 I think Bremen did a good job summarizing
00:19:49 --> 00:19:50 the results.
00:19:50 --> 00:19:51 Forty five percent less imaging being
00:19:52 --> 00:19:54 utilized in our study.
00:19:54 --> 00:19:55 And yeah,
00:19:56 --> 00:19:57 it's the it's the misutilization that
00:19:57 --> 00:19:58 we're concerned about.
00:19:58 --> 00:19:59 We don't want to underutilize it.
00:19:59 --> 00:20:00 We don't want to overutilize it.
00:20:00 --> 00:20:02 It seems as though the consensus in the
00:20:02 --> 00:20:03 literature right now is that it's
00:20:03 --> 00:20:04 overutilized.
00:20:04 --> 00:20:06 The only metric that we've seen in our
00:20:06 --> 00:20:07 literature review as far as
00:20:08 --> 00:20:10 Are we utilizing it appropriately?
00:20:10 --> 00:20:14 Are there adverse events in the cases
00:20:14 --> 00:20:16 where an image wasn't referred for?
00:20:17 --> 00:20:18 And we haven't seen that in any of
00:20:18 --> 00:20:19 the literature.
00:20:19 --> 00:20:19 So that's a win.
00:20:20 --> 00:20:21 But also, as Bremen talked about,
00:20:22 --> 00:20:23 it may end up changing your plan of
00:20:23 --> 00:20:25 care if you get an image in some
00:20:25 --> 00:20:26 circumstances.
00:20:26 --> 00:20:28 And so we haven't picked up any additional
00:20:28 --> 00:20:31 information on those things.
00:20:31 --> 00:20:32 Cool.
00:20:32 --> 00:20:32 Thank you.
00:20:35 --> 00:20:36 Let's move on to medications now.
00:20:36 --> 00:20:39 There's also findings with relation to how
00:20:39 --> 00:20:42 much medication patients were using when
00:20:42 --> 00:20:44 physical therapists were first contact
00:20:44 --> 00:20:44 providers.
00:20:45 --> 00:20:48 What were the findings and what
00:20:48 --> 00:20:49 implications do you think that has for
00:20:50 --> 00:20:50 practice?
00:20:51 --> 00:20:54 yeah similar to imaging for medications
00:20:54 --> 00:20:57 the utilization was seventy one percent
00:20:57 --> 00:20:58 less so for imaging it was forty five
00:20:58 --> 00:21:00 percent less in the pt group for imaging
00:21:00 --> 00:21:02 it was seventy one percent less in the
00:21:02 --> 00:21:05 pt group which is a significant difference
00:21:05 --> 00:21:06 between groups
00:21:07 --> 00:21:08 I would think that's a win,
00:21:08 --> 00:21:10 especially since we're seeing patients are
00:21:10 --> 00:21:12 getting similar, if not superior outcomes.
00:21:12 --> 00:21:14 And so of course we would want that.
00:21:14 --> 00:21:15 If you don't have to be taking a
00:21:15 --> 00:21:16 medication,
00:21:17 --> 00:21:19 let's not take that medication as long as
00:21:19 --> 00:21:23 your health won't be negatively impacted.
00:21:24 --> 00:21:25 The one thing that I will say with
00:21:25 --> 00:21:27 the medication part is it did have
00:21:27 --> 00:21:29 considerable heterogeneity and it was
00:21:29 --> 00:21:31 based on low certainty of evidence.
00:21:32 --> 00:21:33 So we have to take that with a
00:21:33 --> 00:21:35 grain of salt to some degree.
00:21:35 --> 00:21:37 The language that we would use for
00:21:37 --> 00:21:39 prescription medication in our study is
00:21:39 --> 00:21:42 that it may reduce the utilization of
00:21:42 --> 00:21:43 prescription medication.
00:21:44 --> 00:21:47 There was only one study that explicitly
00:21:47 --> 00:21:49 listed the types of meds that the PTs
00:21:49 --> 00:21:50 were able to prescribe.
00:21:51 --> 00:21:51 And in that,
00:21:51 --> 00:21:54 it ranged everything from a simple NSAID,
00:21:54 --> 00:21:56 ibuprofen, all the way up to opioids,
00:21:56 --> 00:21:58 which we were kind of surprised by
00:21:58 --> 00:21:59 considering
00:22:00 --> 00:22:01 Most of the time,
00:22:01 --> 00:22:02 from our research at least,
00:22:02 --> 00:22:04 in these countries or in different
00:22:04 --> 00:22:05 military settings,
00:22:05 --> 00:22:07 if PTs do have a scope of practice
00:22:07 --> 00:22:10 that allows for prescriptive authority,
00:22:10 --> 00:22:12 it's usually somewhat limited in what they
00:22:12 --> 00:22:13 can prescribe.
00:22:13 --> 00:22:15 So I thought that was pretty interesting
00:22:16 --> 00:22:16 too.
00:22:17 --> 00:22:19 As far as the practical implications of
00:22:19 --> 00:22:21 this, I think it's quite timely.
00:22:22 --> 00:22:23 Over the last few years,
00:22:23 --> 00:22:25 there was an APTA task force that was
00:22:25 --> 00:22:27 developed to look at feasibility of
00:22:27 --> 00:22:29 prescribing medications and ordering lab
00:22:29 --> 00:22:31 testing in the United States.
00:22:32 --> 00:22:34 And they put together a really well
00:22:34 --> 00:22:36 written document that describes the
00:22:36 --> 00:22:37 feasibility of that.
00:22:37 --> 00:22:39 And then within the last year,
00:22:39 --> 00:22:41 the APTA put out position statements
00:22:41 --> 00:22:44 talking about how prescriptive authority
00:22:45 --> 00:22:47 is something that they stand by.
00:22:47 --> 00:22:49 And so I wouldn't be surprised if over
00:22:50 --> 00:22:52 the years similar to imaging right now
00:22:53 --> 00:22:54 where we're seeing more and more states
00:22:55 --> 00:22:56 giving imaging privileges to physical
00:22:56 --> 00:22:59 therapists we see the same thing with some
00:22:59 --> 00:23:05 level of prescriptive authority very
00:23:05 --> 00:23:07 timely that's why it's in ptj so thank
00:23:07 --> 00:23:10 you uh you mentioned a little bit about
00:23:10 --> 00:23:12 clinical outcomes and that they seem to be
00:23:12 --> 00:23:13 at least as good
00:23:14 --> 00:23:16 Can you also expound on what were the
00:23:16 --> 00:23:19 findings in the paper and what your
00:23:19 --> 00:23:21 opinions on those findings are?
00:23:22 --> 00:23:22 Yeah.
00:23:22 --> 00:23:24 So when we look at the clinical outcomes,
00:23:24 --> 00:23:26 so pain, disability,
00:23:26 --> 00:23:27 and health-related quality of life,
00:23:29 --> 00:23:30 there weren't any statistically
00:23:30 --> 00:23:32 significant differences between the first
00:23:32 --> 00:23:33 contact physical therapy group and the
00:23:33 --> 00:23:35 usual primary care group.
00:23:35 --> 00:23:36 That gets back to kind of that
00:23:36 --> 00:23:40 conversation of we want to see if we're
00:23:40 --> 00:23:43 at least as good as the standard of
00:23:43 --> 00:23:46 care in improving pain and disability and
00:23:47 --> 00:23:48 then improving health-related quality of
00:23:48 --> 00:23:48 life.
00:23:49 --> 00:23:50 I think
00:23:50 --> 00:23:52 With a study,
00:23:52 --> 00:23:54 with a statistical analysis like a
00:23:54 --> 00:23:54 meta-analysis,
00:23:55 --> 00:23:59 you can get broad changes in pain or
00:23:59 --> 00:23:59 disability.
00:23:59 --> 00:24:02 You definitely can't capture the nuance of
00:24:02 --> 00:24:03 clinical scenarios.
00:24:03 --> 00:24:05 And as we continue to learn about the
00:24:05 --> 00:24:06 complexity of pain,
00:24:06 --> 00:24:08 I don't think it's too surprising to me
00:24:08 --> 00:24:10 that there wasn't a massive difference
00:24:10 --> 00:24:11 either way.
00:24:12 --> 00:24:13 But when you look at the two groups,
00:24:13 --> 00:24:15 we did see improvements in both groups.
00:24:15 --> 00:24:17 So from baseline,
00:24:17 --> 00:24:18 the physical therapy group
00:24:19 --> 00:24:21 had improvements in pain and disability
00:24:21 --> 00:24:22 and health related quality of life and so
00:24:22 --> 00:24:25 did the usual primary care group.
00:24:25 --> 00:24:29 So I think that that's another just sign
00:24:29 --> 00:24:32 that this is a feasible integration of
00:24:32 --> 00:24:34 first contact physical therapy into
00:24:34 --> 00:24:35 healthcare managing patients
00:24:36 --> 00:24:37 with musculoskeletal disorders.
00:24:38 --> 00:24:41 Clearly, it's not as nuanced as specific,
00:24:42 --> 00:24:44 maybe patient-specific findings as far as
00:24:45 --> 00:24:48 returning to meaningful activities for the
00:24:48 --> 00:24:51 patient or an improvement in ways to
00:24:51 --> 00:24:53 manage their pain in the future.
00:24:53 --> 00:24:55 It doesn't capture the complexities of
00:24:55 --> 00:24:55 that,
00:24:55 --> 00:24:56 so future studies would have to
00:24:56 --> 00:24:58 investigate that.
00:24:58 --> 00:24:58 So, yeah.
00:25:03 --> 00:25:04 In summary,
00:25:04 --> 00:25:07 it sounds like the main findings that we
00:25:07 --> 00:25:09 have pretty similar outcomes with less
00:25:09 --> 00:25:10 imaging and less medication.
00:25:11 --> 00:25:13 Is there anything you wanna add to those
00:25:14 --> 00:25:16 results of that summary results?
00:25:16 --> 00:25:18 I think one of the limitations of studying
00:25:19 --> 00:25:20 clinical imaging and prescription
00:25:20 --> 00:25:23 medications in PTs is the scope of
00:25:23 --> 00:25:24 practice definitely limits the
00:25:24 --> 00:25:25 interpretation of that.
00:25:25 --> 00:25:27 Where in all the studies,
00:25:28 --> 00:25:31 PTs were able to either directly order
00:25:31 --> 00:25:34 imaging and prescription medications or
00:25:34 --> 00:25:36 indirectly where they were given...
00:25:37 --> 00:25:40 a pathway where if they determined that an
00:25:40 --> 00:25:41 image was appropriate,
00:25:41 --> 00:25:43 but they didn't have the scope of practice
00:25:43 --> 00:25:45 in their area to physically order it,
00:25:45 --> 00:25:47 they could indirectly order it by
00:25:47 --> 00:25:49 communicating with another provider to get
00:25:49 --> 00:25:51 that image or that prescription
00:25:51 --> 00:25:51 medication.
00:25:52 --> 00:25:55 which inherently will probably limit the
00:25:55 --> 00:25:56 utilization of it,
00:25:56 --> 00:25:59 which needs to be understood in the
00:25:59 --> 00:26:01 interpretation of the results.
00:26:01 --> 00:26:04 Additionally, in a couple of the papers,
00:26:04 --> 00:26:08 there wasn't data on which provider
00:26:08 --> 00:26:09 ordered the image or the prescription
00:26:09 --> 00:26:10 medication,
00:26:10 --> 00:26:12 so we looked at downstream results.
00:26:12 --> 00:26:16 So three months or six months out from
00:26:16 --> 00:26:17 the intervention,
00:26:17 --> 00:26:20 did this person receive imaging at all?
00:26:20 --> 00:26:22 And we don't necessarily know if the PT
00:26:22 --> 00:26:24 initiated that or if the patient went
00:26:24 --> 00:26:25 elsewhere for it.
00:26:25 --> 00:26:27 But I think that still,
00:26:28 --> 00:26:29 it still demonstrates that there was less
00:26:29 --> 00:26:31 imaging and prescription medications
00:26:31 --> 00:26:32 utilized,
00:26:32 --> 00:26:35 whether the provider ordered it on day one
00:26:35 --> 00:26:37 or if it came, you know,
00:26:37 --> 00:26:41 in the months preceding.
00:26:42 --> 00:26:43 As you talked about the timeframe there,
00:26:44 --> 00:26:45 it looked like when I was,
00:26:45 --> 00:26:46 you obviously know the
00:26:47 --> 00:26:48 all the numbers in there better than I
00:26:48 --> 00:26:48 do,
00:26:49 --> 00:26:50 that a lot of the outcomes were looking
00:26:50 --> 00:26:52 at about three months.
00:26:53 --> 00:26:54 You know, I'm very curious.
00:26:54 --> 00:26:56 I think physical therapists have had
00:26:56 --> 00:26:58 really an opportunity to decrease
00:26:58 --> 00:27:01 downstream costs even further,
00:27:01 --> 00:27:02 the twelve and even twenty four month
00:27:02 --> 00:27:03 mark.
00:27:04 --> 00:27:06 Is the three months accurate?
00:27:06 --> 00:27:07 Am I remembering that correctly?
00:27:07 --> 00:27:08 And if so,
00:27:09 --> 00:27:10 how does what do you think would happen
00:27:10 --> 00:27:12 if we had studies looking at the twelve
00:27:12 --> 00:27:13 and twenty four month marks?
00:27:15 --> 00:27:16 Yeah, you are remembering it correctly.
00:27:17 --> 00:27:19 We focused on kind of the medium-term,
00:27:19 --> 00:27:21 three-month timeframe as far as our
00:27:21 --> 00:27:23 meta-analyses are concerned.
00:27:24 --> 00:27:25 And the reason that we didn't do longer
00:27:25 --> 00:27:27 duration is because we just don't have
00:27:27 --> 00:27:29 enough randomized control trials out there
00:27:29 --> 00:27:31 to be able to run a meta-analysis that
00:27:31 --> 00:27:33 would give us enough valuable insights to
00:27:34 --> 00:27:34 make any claims.
00:27:35 --> 00:27:36 So yeah,
00:27:36 --> 00:27:37 definitely another thing that we're
00:27:37 --> 00:27:39 interested in continuing to investigate
00:27:39 --> 00:27:41 because there's a desperate need for it.
00:27:42 --> 00:27:42 Right now,
00:27:43 --> 00:27:45 as far as what speculating on what we
00:27:45 --> 00:27:46 might see,
00:27:46 --> 00:27:48 I would like to think that the PT
00:27:48 --> 00:27:51 groups would continue to see less
00:27:51 --> 00:27:53 utilization, appropriate utilization,
00:27:54 --> 00:27:56 and at the same time, similar,
00:27:56 --> 00:27:59 if not superior clinical outcomes as well.
00:28:00 --> 00:28:02 It's hard for me to say for sure.
00:28:02 --> 00:28:03 I think one thing we might run into
00:28:03 --> 00:28:05 as far as issues with a long term
00:28:06 --> 00:28:08 randomized control trial like that is
00:28:08 --> 00:28:09 crossover between groups.
00:28:10 --> 00:28:12 If you see a physical therapist for the
00:28:12 --> 00:28:15 initial session and then three months go
00:28:15 --> 00:28:15 by,
00:28:15 --> 00:28:17 the patient maybe isn't seeing enough
00:28:17 --> 00:28:18 improvement,
00:28:18 --> 00:28:19 now all of a sudden they want to
00:28:19 --> 00:28:21 cross over to the usual primary care
00:28:21 --> 00:28:24 provider because they didn't get the image
00:28:24 --> 00:28:26 they wanted with the physical therapist.
00:28:27 --> 00:28:28 Something along those lines.
00:28:28 --> 00:28:30 So that's one.
00:28:31 --> 00:28:33 One data point that I'd be interested to
00:28:33 --> 00:28:35 check in on is what is that crossover
00:28:35 --> 00:28:38 rate and how does that impact the results?
00:28:39 --> 00:28:40 But then the other thing is,
00:28:41 --> 00:28:43 I think if we look at musculoskeletal
00:28:44 --> 00:28:47 health in general and the short-term
00:28:47 --> 00:28:49 versus medium-term versus long-term
00:28:49 --> 00:28:49 outcomes,
00:28:50 --> 00:28:52 Improving long-term outcomes,
00:28:52 --> 00:28:56 comparing methods or provider types or
00:28:57 --> 00:28:59 specific interventions seems to be a bit
00:28:59 --> 00:29:01 more challenging than the short-term ones.
00:29:02 --> 00:29:04 It seems like there's always inevitably
00:29:04 --> 00:29:07 some sort of regression to the mean.
00:29:08 --> 00:29:10 An example that comes to my mind when
00:29:10 --> 00:29:13 I was during my residency year,
00:29:13 --> 00:29:15 there was a new orthopedic surgeon that
00:29:15 --> 00:29:18 came in and he stopped sending his total
00:29:18 --> 00:29:20 knees over to the physical therapist
00:29:20 --> 00:29:23 because a study was published and it
00:29:23 --> 00:29:25 showed no significant differences at the
00:29:25 --> 00:29:27 two-year mark whether they did post-op
00:29:27 --> 00:29:29 physical therapy or not.
00:29:31 --> 00:29:35 it caused a lot of havoc in our
00:29:35 --> 00:29:36 department and the health system in
00:29:37 --> 00:29:37 general.
00:29:38 --> 00:29:41 It was news to us that that was
00:29:41 --> 00:29:41 the case.
00:29:41 --> 00:29:42 But really,
00:29:42 --> 00:29:44 we did put ourselves in a bad position
00:29:44 --> 00:29:46 by seeing everybody two times a week for
00:29:46 --> 00:29:47 twelve weeks when it maybe wasn't
00:29:47 --> 00:29:47 necessary.
00:29:47 --> 00:29:49 So I can see where he was coming
00:29:49 --> 00:29:49 from.
00:29:49 --> 00:29:51 And from a research standpoint,
00:29:51 --> 00:29:51 he was right.
00:29:51 --> 00:29:53 The study showed there were no significant
00:29:53 --> 00:29:54 differences two years down the road.
00:29:55 --> 00:29:55 But
00:29:56 --> 00:29:57 One of my mentors, Scott Brown,
00:29:58 --> 00:30:00 always talked about that's important
00:30:00 --> 00:30:01 information.
00:30:02 --> 00:30:03 What if we could help them get better
00:30:03 --> 00:30:03 faster?
00:30:03 --> 00:30:05 What if we could care for them
00:30:05 --> 00:30:07 appropriately early on to help them
00:30:07 --> 00:30:09 achieve better outcomes early on?
00:30:09 --> 00:30:11 And in this case,
00:30:11 --> 00:30:12 even though it's a different type of a
00:30:12 --> 00:30:13 study,
00:30:13 --> 00:30:16 I wouldn't be surprised if two years down
00:30:16 --> 00:30:16 the road,
00:30:16 --> 00:30:18 we end up seeing some sort of regression
00:30:18 --> 00:30:19 to the mean,
00:30:19 --> 00:30:20 because we're dealing with complex
00:30:20 --> 00:30:22 musculoskeletal conditions with complex
00:30:22 --> 00:30:23 health systems.
00:30:23 --> 00:30:24 But at the same time,
00:30:25 --> 00:30:27 the hope as a physical therapist would be
00:30:28 --> 00:30:32 to see still significant differences in
00:30:32 --> 00:30:33 imaging utilization,
00:30:34 --> 00:30:35 prescription medication utilization,
00:30:35 --> 00:30:37 and similar to superior clinical outcomes.
00:30:41 --> 00:30:42 That is a great overview.
00:30:42 --> 00:30:44 I know a lot of your data that
00:30:44 --> 00:30:46 I've looked at is episode-based care a lot
00:30:46 --> 00:30:49 of times in that a ninety-day window.
00:30:50 --> 00:30:51 Same as your mentor.
00:30:51 --> 00:30:52 You know, we've all seen that.
00:30:53 --> 00:30:54 If I could get back,
00:30:54 --> 00:30:55 if I had a total knee and I
00:30:55 --> 00:30:57 could walk, you know, a mile in,
00:30:57 --> 00:30:57 you know,
00:30:57 --> 00:30:59 a month or two versus eight months or
00:30:59 --> 00:31:00 a year,
00:31:01 --> 00:31:02 I'd be willing to pay a lot of
00:31:02 --> 00:31:03 money to get back, you know,
00:31:03 --> 00:31:04 walking a lot quicker.
00:31:04 --> 00:31:11 Yep.
00:31:11 --> 00:31:15 As far as one of the,
00:31:15 --> 00:31:17 one thing I was interested in the,
00:31:17 --> 00:31:17 in your article is,
00:31:18 --> 00:31:21 One of the risk of biases was deviation
00:31:21 --> 00:31:23 from intended interventions.
00:31:24 --> 00:31:26 Could you expand a little bit on that,
00:31:26 --> 00:31:26 please?
00:31:27 --> 00:31:28 Absolutely.
00:31:28 --> 00:31:29 Yeah.
00:31:29 --> 00:31:32 So the tool that we used to assess
00:31:32 --> 00:31:34 risk of bias is the Cochrane Risk of
00:31:34 --> 00:31:35 Bias.
00:31:35 --> 00:31:37 It's their second version of the tool.
00:31:37 --> 00:31:40 And so there's a list of questions that
00:31:40 --> 00:31:42 they ask on a bunch of different domains.
00:31:43 --> 00:31:45 And one of the domains is deviation from
00:31:46 --> 00:31:47 intended interventions.
00:31:47 --> 00:31:48 And so some of the things that they
00:31:49 --> 00:31:50 ask in that domain is,
00:31:51 --> 00:31:54 Was there blinding of the patients?
00:31:54 --> 00:31:57 Was there blinding of the carers or the
00:31:57 --> 00:31:59 providers caring for the patients?
00:32:00 --> 00:32:03 Was there crossover from the allocation
00:32:03 --> 00:32:04 groups?
00:32:04 --> 00:32:06 And so when you add,
00:32:06 --> 00:32:08 when you have different responses to those
00:32:09 --> 00:32:10 factors, such as like,
00:32:11 --> 00:32:11 Yeah,
00:32:11 --> 00:32:13 it's impossible to blind the person who's
00:32:13 --> 00:32:14 caring for someone,
00:32:14 --> 00:32:16 whether they're providing physical therapy
00:32:16 --> 00:32:18 or whether they're providing usual primary
00:32:19 --> 00:32:19 care.
00:32:19 --> 00:32:21 There's an inherent risk of bias with this
00:32:21 --> 00:32:24 type of analysis that's impossible to
00:32:24 --> 00:32:25 avoid.
00:32:25 --> 00:32:26 In some of the studies,
00:32:26 --> 00:32:28 that was the case where it had a
00:32:28 --> 00:32:30 lower risk of bias because that's just
00:32:30 --> 00:32:32 inherent to the study design.
00:32:33 --> 00:32:34 But then in some of the studies,
00:32:34 --> 00:32:37 there was reported some evidence of
00:32:37 --> 00:32:37 crossover.
00:32:37 --> 00:32:40 So if the patient went through the
00:32:40 --> 00:32:45 allocation and decided that they wanted a
00:32:45 --> 00:32:47 evaluation from the primary care group or
00:32:48 --> 00:32:48 vice versa,
00:32:49 --> 00:32:51 that was considered a deviation from
00:32:51 --> 00:32:52 intended intervention where they ended up
00:32:53 --> 00:32:55 receiving both usual primary care and
00:32:55 --> 00:32:57 first contact physical therapy.
00:32:57 --> 00:33:00 So in the event that there was deviation
00:33:00 --> 00:33:01 and no blinding,
00:33:02 --> 00:33:04 that would be a higher risk of bias
00:33:04 --> 00:33:05 for that domain.
00:33:07 --> 00:33:09 Real life makes research messy,
00:33:09 --> 00:33:09 doesn't it?
00:33:15 --> 00:33:17 So let's talk about our big picture,
00:33:18 --> 00:33:19 United States health care.
00:33:21 --> 00:33:22 All three of us are on the same
00:33:22 --> 00:33:24 page that we would love to be able
00:33:24 --> 00:33:25 to see physical therapists be first
00:33:25 --> 00:33:26 contact
00:33:26 --> 00:33:27 you know,
00:33:27 --> 00:33:29 providers in a number of settings and much
00:33:29 --> 00:33:31 more ubiquitous than what it is.
00:33:31 --> 00:33:33 All states have some form of direct access
00:33:33 --> 00:33:34 now.
00:33:35 --> 00:33:38 It's far from being the norm that patients
00:33:38 --> 00:33:39 are coming to see us direct access.
00:33:40 --> 00:33:45 What system-related challenges do you see
00:33:45 --> 00:33:48 for making this the norm and more
00:33:48 --> 00:33:49 prevalent so we have more studies that we
00:33:49 --> 00:33:52 could have a United States meta-analysis?
00:33:53 --> 00:33:54 What do you see as the challenges of
00:33:55 --> 00:33:56 making this the norm?
00:33:58 --> 00:33:59 A variety of things.
00:34:01 --> 00:34:02 Of course,
00:34:02 --> 00:34:04 with research and especially even beyond
00:34:04 --> 00:34:06 research and looking at just clinical
00:34:06 --> 00:34:07 practice in general,
00:34:07 --> 00:34:08 when we're working with complex health
00:34:08 --> 00:34:10 systems and legislation,
00:34:10 --> 00:34:12 there's going to be various factors from
00:34:12 --> 00:34:16 multiple angles that play a role in making
00:34:16 --> 00:34:17 something actually happen.
00:34:18 --> 00:34:21 From my personal experience working in a
00:34:21 --> 00:34:22 large health system,
00:34:23 --> 00:34:25 it really started with one department
00:34:25 --> 00:34:27 who was all on the same page,
00:34:27 --> 00:34:29 getting stakeholders from different
00:34:29 --> 00:34:32 disciplines, getting managerial support,
00:34:32 --> 00:34:36 and coming together to develop this
00:34:36 --> 00:34:38 structure and implement it.
00:34:38 --> 00:34:40 Track how it goes for a little while,
00:34:41 --> 00:34:42 and then expand and then expand and then
00:34:42 --> 00:34:43 expand.
00:34:43 --> 00:34:44 Then all of a sudden we might have
00:34:44 --> 00:34:47 system wide changes and we can report that
00:34:47 --> 00:34:49 out to the rest of the states,
00:34:49 --> 00:34:50 rest of the United States,
00:34:50 --> 00:34:52 whatever it might be to learn by example
00:34:52 --> 00:34:54 and try to implement what's already been
00:34:54 --> 00:34:54 in.
00:34:55 --> 00:34:56 And there's been study after study kind of
00:34:56 --> 00:34:59 talking about how PTs can be integrated
00:34:59 --> 00:35:02 into these different roles.
00:35:02 --> 00:35:04 When we look at United States in general,
00:35:06 --> 00:35:09 and you compare it to the other countries
00:35:09 --> 00:35:11 that we investigated and how they're
00:35:11 --> 00:35:16 seemingly more easily integrating PTs into
00:35:16 --> 00:35:16 these roles,
00:35:17 --> 00:35:19 one thing stands out pretty clearly that
00:35:20 --> 00:35:21 the payer model
00:35:22 --> 00:35:25 drives a lot of what happens in health
00:35:25 --> 00:35:25 care.
00:35:26 --> 00:35:28 And so until we can make sure that
00:35:28 --> 00:35:29 these health systems are getting
00:35:30 --> 00:35:32 reimbursement from us being in these roles
00:35:32 --> 00:35:35 and until we can make sure that there's
00:35:36 --> 00:35:39 appropriate care being provided to justify
00:35:39 --> 00:35:40 all of that,
00:35:40 --> 00:35:42 it'll be challenging to see this
00:35:42 --> 00:35:45 integrated regularly across the United
00:35:45 --> 00:35:45 States.
00:35:45 --> 00:35:47 And then you get into the
00:35:49 --> 00:35:51 different types of insurance and the
00:35:51 --> 00:35:52 different restrictions across each.
00:35:53 --> 00:35:55 There's a variety of things just in that
00:35:55 --> 00:35:58 entity by itself that makes it challenging
00:35:58 --> 00:35:59 and adds a lot of barriers.
00:36:00 --> 00:36:01 Beyond that,
00:36:02 --> 00:36:05 one other area of research in my agenda
00:36:05 --> 00:36:07 for the PhD was looking at stakeholders
00:36:07 --> 00:36:09 and their beliefs and getting PTs into
00:36:09 --> 00:36:12 these roles and basically asking them what
00:36:12 --> 00:36:14 their opinions were of PTs compared to
00:36:14 --> 00:36:16 these other allied health professions and
00:36:18 --> 00:36:19 getting results on that so we can make
00:36:19 --> 00:36:22 sure that we're not just making an
00:36:22 --> 00:36:23 informed decision based on the research
00:36:23 --> 00:36:25 that we've conducted and consumed,
00:36:25 --> 00:36:27 but also what are the perspectives and
00:36:27 --> 00:36:30 beliefs of relevant stakeholders who can
00:36:30 --> 00:36:36 help move the needle in these directions?
00:36:36 --> 00:36:37 Very insightful.
00:36:37 --> 00:36:39 Dr. Abel, what thoughts do you have?
00:36:41 --> 00:36:41 It's really good.
00:36:42 --> 00:36:45 I think Dallas hit one of the main
00:36:46 --> 00:36:48 limitations that we keep coming across.
00:36:49 --> 00:36:51 We've presented this research a couple of
00:36:51 --> 00:36:53 times now and every time there's always
00:36:53 --> 00:36:56 really good discussion afterwards of
00:36:56 --> 00:36:59 opinions both in support of and both which
00:36:59 --> 00:37:00 have
00:37:01 --> 00:37:04 questions that need to be answered before
00:37:04 --> 00:37:06 this becomes more widespread.
00:37:06 --> 00:37:07 But across the board,
00:37:08 --> 00:37:11 it seems that patients are satisfied when
00:37:11 --> 00:37:13 a PT is the first point of contact,
00:37:14 --> 00:37:16 providers value our opinions,
00:37:17 --> 00:37:19 and stakeholders seem to view physical
00:37:19 --> 00:37:20 therapy highly.
00:37:21 --> 00:37:23 But I think it keeps coming back to
00:37:23 --> 00:37:25 the fee-for-service model and the payer
00:37:25 --> 00:37:26 model that we have,
00:37:26 --> 00:37:28 where healthcare systems care
00:37:29 --> 00:37:30 about patient outcomes.
00:37:30 --> 00:37:32 They care about patient access,
00:37:32 --> 00:37:34 but they also care about the bottom line
00:37:34 --> 00:37:35 at the end of the day.
00:37:35 --> 00:37:37 And so in our discussions with some of
00:37:37 --> 00:37:39 the leaders in health care systems in this
00:37:39 --> 00:37:39 area,
00:37:40 --> 00:37:41 one of the biggest questions that they
00:37:41 --> 00:37:42 have is, well,
00:37:42 --> 00:37:45 if a physician gets reimbursed X amount of
00:37:45 --> 00:37:48 money for seeing a patient with back pain
00:37:48 --> 00:37:50 and a physical therapist gets reimbursed a
00:37:50 --> 00:37:52 third of that or half of that or
00:37:52 --> 00:37:53 whatever the number is,
00:37:54 --> 00:37:56 How can they justify pushing for that if
00:37:57 --> 00:38:00 at face value it seems like it will
00:38:00 --> 00:38:02 decrease revenue for the health care
00:38:02 --> 00:38:02 system?
00:38:03 --> 00:38:04 And so I think there's a lot of
00:38:04 --> 00:38:05 conversations to be had around that.
00:38:06 --> 00:38:06 And ultimately,
00:38:07 --> 00:38:08 I don't know if we'll know until we
00:38:08 --> 00:38:09 try it.
00:38:09 --> 00:38:12 But some of the conversations that we've
00:38:12 --> 00:38:14 had is there's no shortage of patients
00:38:14 --> 00:38:15 with back pain.
00:38:15 --> 00:38:17 There's no shortage of patients with
00:38:17 --> 00:38:18 musculoskeletal disorders.
00:38:18 --> 00:38:18 In fact,
00:38:18 --> 00:38:20 there's a surplus and there's a shortage
00:38:20 --> 00:38:21 of providers.
00:38:22 --> 00:38:24 So when it comes to patient care and
00:38:25 --> 00:38:25 safety,
00:38:26 --> 00:38:29 the patients who have those concerning
00:38:29 --> 00:38:32 disorders or things that need urgent or
00:38:32 --> 00:38:35 emergent medical care quickly are having
00:38:35 --> 00:38:37 to wait because the patients with
00:38:37 --> 00:38:38 musculoskeletal disorders and other
00:38:39 --> 00:38:42 conditions that are lower urgency are
00:38:42 --> 00:38:44 occupying such a large proportion of the
00:38:44 --> 00:38:44 space.
00:38:45 --> 00:38:47 So one of the questions that we have,
00:38:47 --> 00:38:48 we don't have an answer to it,
00:38:48 --> 00:38:49 but one of the questions that we have
00:38:50 --> 00:38:52 is if physical therapists can reduce that
00:38:52 --> 00:38:55 burden on usual primary care providers,
00:38:55 --> 00:38:58 take away a large chunk of the patients
00:38:58 --> 00:38:59 with musculoskeletal disorders,
00:38:59 --> 00:39:02 does that free up the providers to see
00:39:02 --> 00:39:06 patients with more complex conditions,
00:39:07 --> 00:39:09 cardiovascular disease, diabetes, cancer,
00:39:09 --> 00:39:10 all these things?
00:39:11 --> 00:39:13 and does that improve patient access
00:39:13 --> 00:39:15 decreasing wait times improve patient
00:39:15 --> 00:39:18 satisfaction does it improve attrition
00:39:18 --> 00:39:21 rates all of these conversations can be
00:39:21 --> 00:39:22 had and and ultimately i don't know if
00:39:22 --> 00:39:25 we'll know until we try it but but
00:39:25 --> 00:39:27 i would argue that with the with the
00:39:27 --> 00:39:29 amount of of patients that we have and
00:39:29 --> 00:39:32 the the shortage of providers integrating
00:39:32 --> 00:39:34 physical therapists even if it's reducing
00:39:34 --> 00:39:36 the reimbursement for that individual plan
00:39:37 --> 00:39:37 of care
00:39:37 --> 00:39:40 overall might actually help the health
00:39:40 --> 00:39:43 system rather than hurting it so i think
00:39:43 --> 00:39:45 that there's there's a definitely some
00:39:46 --> 00:39:48 reform that needs to happen with the payer
00:39:48 --> 00:39:50 model but integrating physical therapists
00:39:51 --> 00:39:53 in this role is likely to support our
00:39:53 --> 00:39:55 health teams and empower the the other
00:39:55 --> 00:39:57 providers to to do what they do best
00:39:57 --> 00:40:03 as well that's a lot of good insight
00:40:03 --> 00:40:05 there you know i've always ever since
00:40:06 --> 00:40:06 I was a student, you know,
00:40:06 --> 00:40:08 my whole time in this profession,
00:40:08 --> 00:40:10 we see research showing the,
00:40:10 --> 00:40:12 the savings that physical therapists can
00:40:12 --> 00:40:12 provide.
00:40:13 --> 00:40:15 And then I've realized that savings in a
00:40:15 --> 00:40:18 fee for service system means that somebody
00:40:18 --> 00:40:20 is making less money, you know,
00:40:21 --> 00:40:22 and it sounds good in research,
00:40:23 --> 00:40:24 but then you get into meetings with
00:40:24 --> 00:40:27 stakeholders and in a fee for service
00:40:27 --> 00:40:27 system,
00:40:28 --> 00:40:30 less money means that somebody is making
00:40:30 --> 00:40:31 less money and value-based.
00:40:31 --> 00:40:32 It can be different.
00:40:32 --> 00:40:33 There's ways that even in a fee for
00:40:33 --> 00:40:34 service that,
00:40:35 --> 00:40:36 Maybe then they can go treat other things,
00:40:37 --> 00:40:38 but that's conjecture.
00:40:38 --> 00:40:38 If they're wrong,
00:40:40 --> 00:40:41 there could be people that are upset in
00:40:41 --> 00:40:45 those systems.
00:40:45 --> 00:40:45 For sure.
00:40:45 --> 00:40:47 So part of the research you had was
00:40:47 --> 00:40:48 on triage.
00:40:50 --> 00:40:52 If you had your druthers and you could
00:40:52 --> 00:40:54 design a system, you know,
00:40:54 --> 00:40:55 you said we're going to embed physical
00:40:55 --> 00:40:59 therapists to provide the maximal benefit
00:40:59 --> 00:40:59 possible.
00:41:00 --> 00:41:02 What would it look like for physical
00:41:02 --> 00:41:02 therapists to,
00:41:03 --> 00:41:06 in primary care settings, triage,
00:41:06 --> 00:41:08 so that way patients could get the help
00:41:08 --> 00:41:11 they need the quickest from the right
00:41:11 --> 00:41:12 provider.
00:41:15 --> 00:41:18 Direct triage model is my quick response,
00:41:18 --> 00:41:18 I would say.
00:41:19 --> 00:41:21 Seth Peterson and Katie O'Bright,
00:41:21 --> 00:41:22 they published a perspective a couple of
00:41:23 --> 00:41:24 years ago, maybe three years ago now,
00:41:25 --> 00:41:28 that looked at the different models within
00:41:28 --> 00:41:29 the United States as far as primary care
00:41:30 --> 00:41:30 physical therapy is concerned.
00:41:31 --> 00:41:32 And they highlighted two primary models,
00:41:32 --> 00:41:34 the warm handoff model and the direct
00:41:34 --> 00:41:35 triage model.
00:41:36 --> 00:41:38 The warm handoff model being they go in
00:41:38 --> 00:41:39 to see their,
00:41:39 --> 00:41:42 let's say it's an NP for a general
00:41:42 --> 00:41:42 inquiry.
00:41:43 --> 00:41:44 They talk about their shoulder pain.
00:41:44 --> 00:41:47 The NP calls the PT in the moment
00:41:47 --> 00:41:48 and sees if they're available.
00:41:48 --> 00:41:48 If they are available,
00:41:48 --> 00:41:51 the PT comes in and they provide an
00:41:51 --> 00:41:53 evaluation to that patient on the spot.
00:41:53 --> 00:41:55 It does a good job of making sure
00:41:55 --> 00:41:58 the PT sees them early and hopefully can
00:41:58 --> 00:41:59 recognize if PT is necessary.
00:41:59 --> 00:42:00 And if so,
00:42:00 --> 00:42:02 hopefully there isn't as much attrition
00:42:02 --> 00:42:04 from that first appointment to their
00:42:04 --> 00:42:05 follow-up PT appointment.
00:42:06 --> 00:42:07 When it comes to first contact physical
00:42:07 --> 00:42:08 therapy, though,
00:42:09 --> 00:42:12 I don't know if that's necessarily first
00:42:12 --> 00:42:13 contact physical therapy.
00:42:14 --> 00:42:16 They've already been somewhat evaluated by
00:42:16 --> 00:42:18 the other provider in that situation.
00:42:18 --> 00:42:20 So that's why Rem and I are advocates
00:42:20 --> 00:42:21 for the direct triage model.
00:42:22 --> 00:42:25 The problem is it might have more
00:42:25 --> 00:42:27 challenges logistically to try and figure
00:42:28 --> 00:42:30 out right away and make sure everybody is
00:42:30 --> 00:42:31 on board with that as far as other
00:42:31 --> 00:42:33 personnel and other stakeholders.
00:42:34 --> 00:42:37 So the ideal model in my mind is
00:42:37 --> 00:42:39 kind of similar to that
00:42:40 --> 00:42:43 that really valuable study done in the
00:42:43 --> 00:42:45 military a few years back that basically
00:42:46 --> 00:42:49 allowed for a call to action across the
00:42:49 --> 00:42:50 United States military saying,
00:42:50 --> 00:42:53 we should be practicing in these first
00:42:53 --> 00:42:55 contact roles where they had a series of
00:42:55 --> 00:42:56 questions.
00:42:56 --> 00:42:58 If they answered this to this question,
00:42:58 --> 00:43:00 they would be put in the PT group.
00:43:00 --> 00:43:01 If they answered this to this question,
00:43:01 --> 00:43:04 they'd go into the usual primary care
00:43:04 --> 00:43:04 group.
00:43:04 --> 00:43:05 And if at the end of the series
00:43:06 --> 00:43:06 of questions,
00:43:07 --> 00:43:08 they're still in the PT group,
00:43:09 --> 00:43:10 they would be directly triaged to the
00:43:10 --> 00:43:11 physical therapist.
00:43:11 --> 00:43:13 Physical therapist would be the first
00:43:13 --> 00:43:15 provider that provides care for that
00:43:15 --> 00:43:15 patient.
00:43:16 --> 00:43:18 The person doing the triage, ideally,
00:43:18 --> 00:43:21 it could just be a patient thing where
00:43:21 --> 00:43:23 they fill out a form online and then
00:43:23 --> 00:43:25 they get set up with the appointment right
00:43:25 --> 00:43:25 away.
00:43:25 --> 00:43:28 Or maybe they call in to a patient
00:43:28 --> 00:43:30 access representative and the patient
00:43:30 --> 00:43:31 access representative brings them through
00:43:31 --> 00:43:31 that.
00:43:32 --> 00:43:33 I know there's challenges to it.
00:43:33 --> 00:43:34 It sounds easy.
00:43:34 --> 00:43:35 I know it's not.
00:43:35 --> 00:43:38 But from my perspective and the patient
00:43:38 --> 00:43:40 experience perspective and patient outcome
00:43:40 --> 00:43:43 perspective, I think it would be valuable.
00:43:44 --> 00:43:45 And that's going to look different, too,
00:43:45 --> 00:43:47 depending on the setting that you're in.
00:43:47 --> 00:43:50 If this health system has certain policies
00:43:50 --> 00:43:52 and procedures and this one has different
00:43:52 --> 00:43:53 policies and procedures,
00:43:53 --> 00:43:55 that triage system might look a little bit
00:43:55 --> 00:43:56 different.
00:43:56 --> 00:43:57 They might ask slightly different
00:43:57 --> 00:43:58 questions.
00:43:58 --> 00:43:59 But at the end of the day,
00:43:59 --> 00:44:01 can there be some sort of a questionnaire,
00:44:01 --> 00:44:01 simple enough,
00:44:02 --> 00:44:04 to have a nurse or a patient access
00:44:04 --> 00:44:07 representative or the patient itself to
00:44:07 --> 00:44:09 complete it and then directly be triaged
00:44:09 --> 00:44:12 to a first contact physical therapist
00:44:13 --> 00:44:14 bremen do you have anything to add to
00:44:14 --> 00:44:14 that
00:44:15 --> 00:44:15 Yeah,
00:44:15 --> 00:44:18 it's definitely based on healthcare
00:44:18 --> 00:44:19 system,
00:44:19 --> 00:44:22 but also state and scope of practice too,
00:44:22 --> 00:44:25 where if you have access to ordering
00:44:25 --> 00:44:27 imaging and laboratory studies and
00:44:28 --> 00:44:31 specialty referral and all of these
00:44:32 --> 00:44:35 healthcare necessities are given access to
00:44:35 --> 00:44:36 the PT,
00:44:36 --> 00:44:37 it makes a lot of sense to do
00:44:37 --> 00:44:38 the direct triage model,
00:44:38 --> 00:44:40 but we're seeing a ton of limitations
00:44:40 --> 00:44:42 across the states still in
00:44:42 --> 00:44:45 whether it's even still limitations in
00:44:45 --> 00:44:45 direct access.
00:44:46 --> 00:44:46 In Minnesota,
00:44:46 --> 00:44:48 after ninety days of seeing someone,
00:44:48 --> 00:44:50 you still have to get a physician
00:44:50 --> 00:44:50 referral.
00:44:51 --> 00:44:52 In multiple different states,
00:44:52 --> 00:44:54 there's limitations where they can't do
00:44:54 --> 00:44:55 certain functions like ordering imaging.
00:44:56 --> 00:44:59 So the direct triage model is something
00:44:59 --> 00:45:00 that is the ideal situation,
00:45:01 --> 00:45:03 but there's multiple steps we need to hit
00:45:03 --> 00:45:04 before getting to that point.
00:45:05 --> 00:45:05 Yeah,
00:45:05 --> 00:45:06 the way that Bremen and I have talked
00:45:06 --> 00:45:09 about it is kind of like four different
00:45:09 --> 00:45:10 levels within the United States.
00:45:10 --> 00:45:11 First, what's the sector?
00:45:11 --> 00:45:13 Is it civilian or is it military?
00:45:13 --> 00:45:15 Then we have state legislation and what
00:45:15 --> 00:45:16 are the requirements there?
00:45:16 --> 00:45:18 And then it's health system to health
00:45:18 --> 00:45:21 system and what are the policies and
00:45:21 --> 00:45:22 procedures within those?
00:45:22 --> 00:45:24 And then even below that is department to
00:45:24 --> 00:45:25 department.
00:45:25 --> 00:45:27 How does each department operate within
00:45:27 --> 00:45:27 itself?
00:45:32 --> 00:45:34 I think there's a lot of wisdom to
00:45:34 --> 00:45:34 that model.
00:45:36 --> 00:45:37 If we're hoping that we can educate every
00:45:37 --> 00:45:39 patient on where they should be going
00:45:39 --> 00:45:40 first, that's going to be a challenge.
00:45:41 --> 00:45:42 If we just have a system,
00:45:42 --> 00:45:45 everybody gets triaged quickly with low
00:45:45 --> 00:45:50 contact, there's a lot of benefit.
00:45:50 --> 00:45:51 Well,
00:45:52 --> 00:45:55 that's the end of my questions that I
00:45:55 --> 00:45:56 had planned for us.
00:45:58 --> 00:46:00 What else were you hoping that you could
00:46:00 --> 00:46:01 share about
00:46:01 --> 00:46:03 first contact physical therapy that you
00:46:03 --> 00:46:05 haven't had an opportunity to share so
00:46:05 --> 00:46:07 far?
00:46:07 --> 00:46:08 One thing that just came to mind as
00:46:08 --> 00:46:10 we're talking about triage model is when
00:46:10 --> 00:46:12 you look at a lot of the research
00:46:12 --> 00:46:15 as far as their inclusion and exclusion
00:46:15 --> 00:46:15 criteria,
00:46:16 --> 00:46:17 even in these first contact studies,
00:46:18 --> 00:46:20 some of them will specify the patient
00:46:20 --> 00:46:23 can't have had any recent trauma or the
00:46:23 --> 00:46:24 patient can't have
00:46:25 --> 00:46:27 any signs or symptoms of concerning
00:46:27 --> 00:46:28 pathology or anything like that.
00:46:28 --> 00:46:31 And I think that limits the applicability
00:46:31 --> 00:46:33 because we talk about not having any
00:46:34 --> 00:46:34 adverse events,
00:46:35 --> 00:46:37 but in a true first contact scenario,
00:46:38 --> 00:46:40 the PT should be tasked to identify those
00:46:40 --> 00:46:42 things and refer when necessary,
00:46:42 --> 00:46:44 demonstrating their clinical reasoning and
00:46:44 --> 00:46:44 decision making
00:46:45 --> 00:46:47 where you can't always specify that the
00:46:47 --> 00:46:50 patient is not going to have a red
00:46:50 --> 00:46:53 flag or sign of something more concerning.
00:46:53 --> 00:46:57 So I think that we need to stop
00:46:57 --> 00:47:00 putting barriers up to what the PT can
00:47:00 --> 00:47:01 or can't evaluate,
00:47:01 --> 00:47:03 where if I'm in a first contact setting
00:47:04 --> 00:47:06 and the patient has neck pain after a
00:47:07 --> 00:47:08 motor vehicle accident,
00:47:08 --> 00:47:08 I
00:47:09 --> 00:47:10 I should be able to identify,
00:47:11 --> 00:47:12 does this person need imaging?
00:47:12 --> 00:47:14 Do I think something serious is going on?
00:47:15 --> 00:47:16 And if I do think something serious is
00:47:16 --> 00:47:16 going on,
00:47:17 --> 00:47:19 at what level of urgency am I going
00:47:19 --> 00:47:20 to refer this patient?
00:47:20 --> 00:47:23 Do they need to get an x-ray today,
00:47:23 --> 00:47:24 right now?
00:47:24 --> 00:47:26 Do they need to go to the emergency
00:47:26 --> 00:47:28 room immediately due to either
00:47:29 --> 00:47:32 cardiovascular concerns or spinal cord
00:47:32 --> 00:47:33 injury potential?
00:47:34 --> 00:47:35 That's the conversation we need to be
00:47:35 --> 00:47:35 having.
00:47:36 --> 00:47:40 And if we limit that and put these
00:47:40 --> 00:47:44 barriers up to what we as a profession
00:47:44 --> 00:47:46 or what the medical system thinks we can
00:47:46 --> 00:47:47 handle as physical therapists,
00:47:48 --> 00:47:49 I think it's going to limit our
00:47:49 --> 00:47:52 interpretation of how safe PTs can be in
00:47:52 --> 00:47:53 this role.
00:47:56 --> 00:48:00 Yeah, the, the, I like it.
00:48:00 --> 00:48:00 What do you think?
00:48:01 --> 00:48:01 Yeah.
00:48:02 --> 00:48:03 The only other thing that I would add
00:48:03 --> 00:48:05 is kind of like a call to action,
00:48:05 --> 00:48:06 to be honest.
00:48:08 --> 00:48:10 Working in the health system that we were
00:48:10 --> 00:48:10 in,
00:48:11 --> 00:48:13 it was challenging to get physical
00:48:13 --> 00:48:16 therapists to want to step into these
00:48:16 --> 00:48:19 roles out of discomfort.
00:48:19 --> 00:48:21 Like they might be a bit of uncomfortable
00:48:21 --> 00:48:24 stepping out into these new roles or extra
00:48:24 --> 00:48:27 workload or scope of practice concerns,
00:48:27 --> 00:48:28 whatever it might be.
00:48:30 --> 00:48:32 So a call to action to physical therapists
00:48:32 --> 00:48:33 to step into these roles.
00:48:33 --> 00:48:37 Like we have very good musculoskeletal
00:48:37 --> 00:48:39 education through our DPT education.
00:48:40 --> 00:48:42 And even before that, people claim, well,
00:48:42 --> 00:48:44 it hasn't always been a DPT.
00:48:44 --> 00:48:45 That's true,
00:48:45 --> 00:48:47 but we have had military providers for the
00:48:47 --> 00:48:49 last fifty years who have accomplished
00:48:49 --> 00:48:50 similar things.
00:48:51 --> 00:48:53 And so we should trust our education and
00:48:53 --> 00:48:54 our training,
00:48:54 --> 00:48:56 clinical experience to be able to provide
00:48:56 --> 00:48:58 this care and recognize that we,
00:48:58 --> 00:48:59 in some cases,
00:48:59 --> 00:49:00 should be the provider of choice for
00:49:00 --> 00:49:02 musculoskeletal conditions.
00:49:03 --> 00:49:07 So one thing as a professor and seeing
00:49:08 --> 00:49:11 each new cohort leaving in the positions
00:49:11 --> 00:49:12 that they take,
00:49:12 --> 00:49:13 it does seem
00:49:14 --> 00:49:15 to me at least in our region,
00:49:15 --> 00:49:18 that it's the younger clinicians who are
00:49:18 --> 00:49:21 motivated to maximize their DPT education
00:49:21 --> 00:49:23 and step into these roles.
00:49:23 --> 00:49:26 And I would continue to encourage them and
00:49:26 --> 00:49:28 tell them to stay motivated and continue
00:49:28 --> 00:49:32 to push forward and try to change the
00:49:32 --> 00:49:34 health care system to improve the quality
00:49:34 --> 00:49:37 of care being provided to these patients
00:49:37 --> 00:49:38 who are dealing with musculoskeletal
00:49:38 --> 00:49:40 conditions to improve the burden
00:49:41 --> 00:49:43 of current primary care providers and them
00:49:43 --> 00:49:46 being overworked and not having enough of
00:49:47 --> 00:49:49 the primary care physicians and increased
00:49:49 --> 00:49:52 volume of patients and try to help out
00:49:52 --> 00:49:55 the health systems by stepping in to these
00:49:55 --> 00:49:57 roles as uncomfortable as it might be
00:49:57 --> 00:50:00 right away to improve patient care and
00:50:00 --> 00:50:06 improve the provider burden.
00:50:06 --> 00:50:09 Let's be real doctors.
00:50:09 --> 00:50:10 That's right.
00:50:11 --> 00:50:12 Thank you, Dr. Avill.
00:50:12 --> 00:50:13 Thank you, Dr. Ehrmantraut.
00:50:14 --> 00:50:15 I appreciate you being on here today and
00:50:15 --> 00:50:18 for your hard work on this research.
00:50:18 --> 00:50:20 Thank you very much.
00:50:20 --> 00:50:20 Thanks, Dr. Rainey.