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Toni Talks about PT Today

Caring for the Severely Impaired Patient

Published May 8, 2012 4:54 PM by Toni Patt

There is new evidence in the physical therapy world that creates a paradox. The patients who benefit the most are the patients who receive the least therapy. Everything I read demonstrated that the more impaired patients made the greatest improvement when provided with the most intense therapy. This was true in the acute, subacute and chronic stage. Higher-functioning patients tended to have similar results regardless of intervention, intensity or duration. Lower-level patients improved by leaps and bounds.

Severely impaired patients often require two people. It takes them twice as much effort to do less than half the work. They fatigue quickly. Cognitive problems interfere with participation. They are usually the first ones skipped when caseloads get heavy. Therapy durations may be longer but actual time in therapy is less. I walk away exhausted when I have a few of these on my caseload.

Traditional teaching says these patients have poor rehab potential. The evidence is saying something else. The AVERT (A Very Early Rehabilitation Trial) found up to a fourfold increase in good outcomes when these patients received early mobilization. Body-weight support is being found to be most effective for stroke patients who are non-ambulatory at the start of therapy.

Brains are the most plastic immediately after injury. Later plasticity is dependent on what happens in those early months. It seems we're doing these patients a disservice when we regularly skip them or substitute ROM exercises for more functional activities. Getting them moving can be exhausting work for the therapist.

Even chronic patients were benefiting. It seems dense hemiplegics and lower-level brain injuries benefit just as much from intense therapy even later in the game. Sometimes it takes the brain a longer time to heal and get to a place where it can process the input from therapy. I wonder if some of these patients are being discharged for lack of progress just as they finally begin to be able to participate.


I like Caren's response to this topic. I'm guessing with the MBA after her name that she has most likely moved on from PTA work into some sort of management role. That is GREAT! I worked for a managed care plan in NYC and I was the only PT giving advice to the case managers. Most case/claim managers are nurses by profession. This type of work may not be why we became PTs to start with, but we need more PTs in these and higher management roles in order to have more of a voice in decisions about care and payment.

Me? I'm nearly finished with my Masters in Public Health and will be moving on to a new role at some point soon. I will always be a PT at heart (even if its called physio in my new home) and I can use that experience to make a difference on a whole new level now. We need more people to move on and take the reins at levels that will make a difference for patients and those PTs practicing on the clinical level.

Just my 2 pence.


Dean Metz May 10, 2012 1:40 PM

Toni and Jason each identify the real frustrations of providing PT care to the patients that need it most. So, what can we do to change this? Toni mentions evidence based practice measures and Jason mentions limitations imposed by payers. The first concept that comes to mind is education. Therapists should be educated about these points so that we can in turn educate insurers, case managers, patients, and families as well as ancillary staff in settings such as acute and inpatient rehab. It seems that there should be some type of categorization system that we could use to separate  patient populations in terms of the level of care that they need instead of or in addition to their "potential to meet goals in a given time frame."  Frequently, these patients are deemed to have low potential when acually they need a higher intensity of therapy over a longer period of time. Unfortunately, the time frame is often set based on finances instead of need.

So, how do we educate the insurers to allow these patients more time or comensurate reimbursement to intensity? And if we cannot do this, how do we provide appropriate level of patient care and get paid for it?  During my 21 years as a PTA this has always been an issue and a frustration.

I believe that one way to address the problem is to educate the public to reclaim personal responsibility for their healthcare, and not accept the situation of payers making healthcare decisions through reimbursement rules. And for healthcare providers to advocate more strongly for our patients so that we can truly provide the level of care and positive outcomes that they require.

Caren Brooks, PTA, MBA

Caren Brooks, PTA May 10, 2012 8:31 AM
Atlanta GA

A typical scenario is if a patient has not "progressed appropriately" in a 2-4 week time frame, discharge them.  Heavily involved patients will generally not progress the way insurance wants them to, and if the person cannot walk they will be d/c'd.

Those facilities without proper equipment will not be able to adequately progress these types of patients and yet it will be the therapists who receive the brunt of family dissatisfaction.

Jason Marketti May 8, 2012 8:16 PM

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