Time to Heal or a Quick-Fix
In our modern world, we often take a quick fix for granted. When something breaks down – like our car or our computer – we can repair or replace it fairly quickly. All too often we find that it is cheaper and better in the long-run to just replace a broken appliance than to repair it.
We often apply this same line of thought to our healthcare, and in many cases there is a ‘quick fix’ that can help us overcome injury or illness quickly – whether it is medicine, surgery, or some other treatment. We want to get better and get back to life as quickly as possible! For some problems, this is the best approach. However, as a Physical Therapist, there really is no ‘quick fix’ solution for many of the injuries I see, although our desire for that ensures that there is no shortage of market for treatments and gadgets promising just that! In fact, I was quoted in an article reviewing such a gadget, a continuous passive motion (CPM) machine for the low back – it promises the moon but in reality may offer very little!
These options usually do not offer long-term success because they are not addressing the underlying cause of the injury. So a cycle develops where a patient might have short-term relief from a treatment, but once the treatment stops, the pain returns, and the patient is back to square one. The patient may seek out the treatment that gave relief before, and may repeat this cycle many times – even coming to accept it as their ‘new normal’. Potentially this can cost a lot of time and money, not to mention the pain and lifestyle limitations of continually struggling with injury and pain. But the frustrating thing to me is that I know in most cases long-term healing is possible! The approach that leads to long-term healing will probably not have measurable results overnight, and it does take a sustained effort from the patient over a longer period – but the result is ultimately freedom from the cycle of pain and ongoing treatment!
Ultrasound: An Example Of a Short-Term Fix:
Within the category of short-term relief, let us consider ultrasound treatment, which is typically offered by Physical Therapists and Chiropractors. Patients may claim that it fixed their problems, and therapists may also claim that they have seen it make their patients feel better. However, this does not mean that it is making any real difference! Most of the research points to ultrasound being a placebo, which begs the question: Even with temporary perceived relief, if it is not making any underlying changes is it worth your time and money?
Ultrasound is typically done as part of a PT visit, and it might not seem to cost much time or money. But here in the US, it will be charged as a 15min unit of therapy time. If you go 3x/week for four weeks, that is 180min of time and 12 units that you and/or your insurance have been charged for. Again, do you want to spend your time/money this way when there could be something that could give longer term (real) relief?
You might argue that we should give the consumer what they want, and in some ways, from the point-of-view of a free society, I agree. However, I believe that what most patients really want is relief from their symptoms and ultimately complete recovery. If a patient has had perceived relief in the past, or been told that a certain treatment will help them, it is natural that they will request that treatment specifically –what they are really asking for is help getting better, but they may not be aware of other treatment options that are more likely to bring true, long-term, relief.
Why Does Ultrasound Persist as a Treatment Option?
If research shows that ultrasound isn’t truly effective, why is it still used so often?
- Providers were/are taught about ultrasound in school, and if they have not kept up with the latest research, they may be unaware that it has been shown to be ineffective.
- Patients and providers may feel like it is helping, without realizing that the relief is actually coming from other parts of the PT treatment, or natural recovery.
- Patients like and/or request it. Ultrasound has been in use for a long time, and many people feel they have benefitted from it, or have heard positive things about it. Once a patient has perceived a benefit from it, it is very hard to convince them otherwise.
- Insurance will reimburse for it – this goes back to it being an established, accepted treatment, even though recent research doesn’t support its use. In an environment of falling insurance reimbursements, it is hard for a provider to turn down the opportunity to bill a treatment unit, especially if it is one the patient is positive about.
- In some clinics, ultrasound may be done by non-skilled staff, freeing up the therapist to see another patient.
In summary, ultrasound treatment persists because it is simple, easy, and accepted without question by patients and insurance companies; treatment protocols and insurance company expectations simply haven’t caught up with the latest research yet. Once a patient has had the treatment again and again, many clinicians will choose not to rock the boat, which reinforces the perceived benefit. I say that as someone who has ethically refused to do ultrasound on a patient who was determined that it was the only thing that would fix her.
What Does Treatment Look Like That Can Provide Long Lasting Relief?
Let’s say a patient comes in with an 8-week history of Achilles pain and is diagnosed with Achilles tendinopathy. The gold standard evidence-based treatment for tendinopathy is to 1) relatively reduce loading, 2) educate, and 3) load the tendon appropriately. The main point is that treatment should be individually designed and exercise based, which will take time. There is no quick fix; the time it will take to get better is proportional to how long you have had the problem and the state of the tendon tissue. There are certainly some adjuncts that may be helpful such as manual therapy, heel wedges, and orthotics, to provide short-term relief (true relief, not placebo), but they do not yield long-term results like exercise has shown to do. A therapist that understands the latest state of the evidence may use these adjunct treatments at the beginning to make the longer-term treatment more palatable and successful. However, they will gradually reduce the use of these in favor of self-managed treatment, which gives the patient power, not needing to see the therapist as often and perhaps never having to see them again! The therapist will educate vigorously against those treatments that are not helpful such as ultrasound, and will try to reduce patient dependency on the clinician. In my clinic, I do not even have an ultrasound machine, and I aim as much as possible to provide treatment that the client can repeat at home and have control of their progress!
Why is Pursuing Short-term Relief Not Helpful?
The long-term exercise-based approach I describe above really doesn’t fit with the typical 2-3 x a week for 4 weeks therapy that we are used to in the US. Four weeks of treatment just isn’t going to cut it with a tendinopathy that has been a problem for eight weeks (and has likely been developing for even longer)! Today’s treatment model is focused on those quick-fix approaches – intense/frequent therapy sessions for a relatively short period of time, with many passive treatments (like ultrasound) applied along with exercise, and little- to-no time for patient education. It may feel good psychologically to be ‘doing something’ to help the patient get better quickly, but recent research is showing that all too often these traditional approaches are ineffective. At the end of the treatment, our tendinopathy patient will not be fully recovered, possibly without understanding why or having realistic expectations about how long it will take to get better. They may believe that it was the short-term treatments like ultrasound that were helping, when really what they need is time to heal and appropriate exercise to alter their tendon. Their pain is likely to return, only to begin the short-term treatment cycle again.
Surgery is another frequently-chosen alternative that patients hope will provide a quick fix. Unfortunately, this is often not the case, and I can point to several people I have met over the years who have found this out the hard way! Don’t underestimate the recovery and risk of complications that come along with surgery to correct a problem like Achilles tendinopathy.
In my practice, I typically evaluate a patient such as this, see them back one week later, and then taper out appointments as indicated (for example, return in two weeks, then three weeks, then four weeks). I typically see my patients less regularly, but over a longer period of time (in this example, likely 3+ months). I use treatments that a patient can themselves do at home (e.g. self manual therapy) as it empowers them and, as in the case of specific exercise, is often the gold standard approach.
Does Insurance Cover This?
The long-term exercise approach does not really fit in with insurance-based rehabilitation as it is currently set up. With reimbursement rates falling, in-network clinics need to have a high volume of patients coming through the clinic, and the typical (2-3 x a week) scheduling fits well. I am not suggesting that anyone is purposely working unethically; it’s just that today’s model of care has evolved over 20+ years to work with our system of insurance reimbursement, and what was believed to be the best practice when the standards were set are sometimes being shown to be wrong by the latest research. The system isn’t changing quickly enough to keep up with the latest evidence-based approaches. For example:
- Many insurances need a referral or insurance authorization every 4-weeks, which is a large burden for a clinic if the patient only comes once in that period.
- Insurance also only covers you getting back to basic activities of daily living (ADL) such as walking, and stairs, but does not cover return to sports, or even guarantee return to normal work duties. This discourages the longer-term approach, and increases the odds of the problem returning.
- Insurance, very reasonably, does not want you doing the same exercise (that you should learn in 1-2 visits) six-visits in a row. This typically leads to patients ending up with multiple exercises, which soon lead to overload. I have actually seen multiple patients who have had a list of 20+ exercises given over a four-week period and by that point they had no idea which ones they should be doing and see no benefit of exercise.
PhysioWorks is Out Of Network To Free Us Up To Provide Best Care:
I have chosen to take my practice out of network to allow me to base my care purely on clinical need, with a relationship between the client and myself, and without insurance as an interfering middle man. There may be a higher initial cost to see me (or not with high deductible plans we now see!), but in the long term, with fewer overall visits, the care I provide is often less expensive – especially if you take advantage of any out-of-network benefits you may have! This approach also reduces the likelihood of the problem recurring, or developing other issues, because rehab continues beyond the basic ADLs, helping you to safely return to all activities – potentially saving you even more time and money down the road. But most importantly, I believe the long-term approach is the best way to get my patients better and back to enjoying life, without ongoing pain or recurring injury!