It was the early 1980s. The words still ring loudly in my mind. I had experienced some knee problems during my growth spurt as an adolescent. I had my share of knee surgeries – and probably your share as well. I had a well-respected orthopedist who told me I should never run, but that it would be alright to swim or bike. How could I ever doubt “the expert”?

Not long after that, I became a physiotherapist. I focused my career on orthopedics and sports injuries. Countless patients over the years have been told the same things that I was told. They have put their faith in conventional thinking, in traditional medicine, much as we have been taught to do over the years. Many haven’t asked enough questions. All have come to me feeling frustrated and hopeless. I understand the feeling well, having been there myself.

But today, I stand here having just completed my 10th consecutive Capitol 10K in Austin. That’s 100K of running in one event alone over the past decade - not bad for a guy that shouldn’t be running at all, according to the experts. So how did this happen?

Health care is a service industry. It is incumbent upon the provider of the service to aim to give you the best possible experience – just like any other service industry. But as consumers, we’ve lost our way. First of all, there is a growing chasm between “accepted standards” – and “evidence-based standards”. This drives our expectations - one of the primary issues surrounding health care consumerism. If you have been told by the health care marketplace, the media, and countless other lay articles, that time and countless visits is the standard, then your expectations will reflect this. However, accepted community standards of care are not the same as evidence-based standards of care. Our bottom line, our expectations, need to rise to reflect the standards found within the science of medicine.

So let’s start with a few “reality checks” and basic elements of consumerism when it comes to health care.

We could call this new independent nation Backpainia (for lack of a better name). Maybe it could start as the 51st state of the US, and then seek its independence from the tyranny of, oh, lobbyist-driven health care.

But take heed, resolute citizens of Backpainia. Revolution is taking place throughout the world. Be it Egypt, Libya, or any of a plethora of nations, change is upon us. Something is also amiss in Backpainia – perhaps it is the next nation in need of a revolution?

The research data and socioeconomics of this nation explain everything.

Sadly, many of the assessment and treatment approaches found in the current market place are exactly that – palpation-based and passive in nature.

What is truly at stake in all of this is far more elemental. It is the issue of perception – of the role of the clinician in the care of the patient. Is it as a health guru … fixer and healer? – or as a health mentor … problem solver, investigator, teacher, coach,  and educator? The future of effective and optimal health care requires a reality check. The solutions lie in the perceptions of the clinicians, the educators, and the consumers themselves.

To briefly summarize the results, it was found that most physical therapy programs worldwide place a very heavy emphasis on teaching palpation skills and palpation-based assessment and treatment models. These would include massage, manual mobilization, active release therapies, trigger points, and the like. Not much has changed from my own PT education in the ‘80s all the way to current 2011 educational programs. The same focus on palpation skills holds true for the educational programs of chiropractors, massage therapists, and many other alternative therapies.

But there are some major reasons to debate and reject palpation-based assessment and treatment approaches. The scientific literature on palpation has been very well-documented over the years – and the results will probably surprise you.

Note: This post is an adaptation of an article that I wrote for the February 2011 issue of the Austin Runner’s Club Newsletter.

When training for or competing in any event, be it your first 5K or your 10^th marathon, there are always going to be some nagging aches and pains. It is a reality of training. As you place demands on your body, it has to then recover from the training sessions and adapt to the imposed demands. During this cycle of training and recovery, your muscles, bones, and tissues undergo transformation. There may be times when the rate of recovery and adaptation is diminished relative to the actual training demands. It is at this time that an “over-use” or “under-recovery” injury may occur.

But how do I know that what I am experiencing is an injury? I have little aches and pains all the time. I need to know which aches and pains should be considered an injury that would benefit from the advice of a health care provider – and those which don't require that level of attention. And I definitely don't want whatever this is to limit my training. How do I know that this is something that I need to have assessed?

According to the American Physical Therapy Association (APTA), 46 states currently have what they call “some form of direct access”. I am not sure what, exactly, “some form” means. If you look at the states that have “unfettered direct access” – which is also a misnomer unto itself – you are looking at about 16 at last count.

Texas is considered a “direct access” state. I can tell you right now – it simply is not, in any way, shape, or form. But the APTA continues to put Texas (and many other states) in this nebulous category of “some form of direct access”. Sure, you can do an evaluation of a patient without a referral – but what good is that if you can’t then treat the patient without someone else’s consent or approval?

Telling the media, legislators, lobbyists, and worst of all, patients – that patients have “direct access” to physical therapy – is simply not telling the truth. When we go back to legislators and tell them we only have “some form of direct access, but we need to expand it”, should we really expect them to do so? “Well, you already have it according to your own professional association”, I can hear them saying. One would have to wonder if this in fact impairs our position in the health care world instead of enhancing it.

You either have direct access to a physical therapist – or you don’t. There’s no in-between. You can either access a physical therapist, by patient choice, without limitations and referral requirements and other silliness – or you can’t. You can either make full use of their skills and training within their scope of practice – or you can’t.

It’s that simple.

This would require a patient having access to health care first and foremost, something that in the state of Texas is a significant problem. Texas ranks dead last in access to health care. The primary care physician supply ratio ranks 47th in the nation.

Two groups of practitioners – physical therapists and advanced practice nurse practitioners – have proposed valid solutions to this growing dilemma. If a patient has direct access to appropriate care within these providers’ current scope of practice and education, more patients will have access to necessary care and patients will have choices regarding their care.

In Texas, the 82nd Legislative session is upon us. Health care will almost certainly be an important issue. Once again, direct access to physical therapy will be a topic of discussion amongst legislators. But there is another debate being waged on similar battle grounds - with a common foe.

Sadly, this is no longer the case.

In the current insurance-based payment model, your insurance company will "approve" payment for a certain number of physical therapy visits for your current episode of care (and oftentimes over a calendar year). This is typically anywhere from 8 to 12 physical therapy visits. This is what CAN be utilized, not what MUST be utilized.

Physical therapists that are part of these insurance networks are usually reimbursed at a very low rate per patient or per treatment activity. In order to compensate for this, it is then in the best financial interest of the physical therapist to either a) utilize ALL available treatments that have been approved by the insurance company, or b) increase the overall cost to the insurance company in the hope of attaining a greater income based on the percentage paid by the insurance company. The average cost per visit billed by a physical therapist, based on a number of references, is in the range of $100 to $200 per visit

The patient is typically billed a copay, and many insurance companies are also implementing a specific deductible for physical therapy or allied health services, or a percentage of the bill to be paid by the patient. Patients are now typically facing $40 copays and up to 20% of the cost of care along with their copay.

More treatment visits do not mean greater improvements in function. Though the national average for back pain is along the lines of 12 visits per episode of care, most practitioners are utilizing non-evidence-based assessment and treatment strategies, and are not focusing on elements of competent self care in conjunction with clinical care provided in order to optimize the patient outcome.

With this in mind, SSI is proud to note that over the past 7 years, the average number of visits per patient episode of care is less than 6 visits. This is less than half the national average. This amounts to an improved functional outcome at a lower cost.

Don't forget that each treatment visit costs the patient time away from home or work, which is oftentimes forgotten in the process. How much is your time worth to you?

SSI provides a number of models for care that break these traditional approaches in order to provide cost-effective and optimized solutions for care, with a focus on competent self care strategies combined with evidence-based clinical strategies. Let's examine the actual patient costs, and then make a judgment based on consumer values of quality and value.

Taking another step forward on this line of thought - in order to solve the problem, you need to be able to think, to reason, to “connect the dots” of your thinking, and to do so logically and based on good, sound data. I don’t think that’s much of a quantum leap in thinking either.

Sadly, this is not the clinical reality that patients experience – with physicians, with chiropractors, with massage therapists, with physical therapists, or with countless other clinicians.

That’s a strong statement that may require some explanation.