Making exercise your clinic’s medicine.
By Carl DeRosa, PT, PhD, FAPTA
Private practice physical therapy has historically centered on orthopedic conditions with referrals for musculoskeletal care targeted toward orthopedic and family practice physicians. Expansion of physical therapy practice is often viewed in the context of ancillary services; that is, massage, Pilates, yoga classes, orthotics fabrication, etc. While these and other ancillaries increase the menu of services and generate revenue, they typically do not contribute to building new or strengthening current referral relationships. Such ancillary ventures rarely contribute to gaining a foothold into larger referral network enterprises. This is especially important in an era of population health and increasing attention to wellness.
The purpose of this article is to provide an overview of a Cardiac Conditioning and Wellness approach to practice expansion. This is a model developed to enhance referral and collaborative business relationships with cardiology, internal medicine, and family practice physicians, as well as other provider specialties. More important, however, we view it as an opportunity to better position the practice to meet the triple aim of health care, and thus be recognized as a potential vital cog in the larger local community’s health enterprise. One of the triple aims is improving the health of the population. This is strongly coupled to the emerging Population Health mandate—the focus on not just minimizing the total cost of care, but also on enhancing the overall health status of a population by supporting wellness at the earliest practical point in the care continuum. Providers of the future will clearly need to develop strategic alliances to position themselves to go above and beyond simply providing individualized care; instead we need to focus on defining their contribution to the overall health of the patient.
We coined the program we developed, “Cardiac Conditioning.” That title was purposeful in order to uncouple it from cardiac rehabilitation. In many ways, it is parallel to the surgical or nonsurgical model of managing musculoskeletal conditions. Quite simply, we developed a focus on nonsurgical management of cardiovascular, pulmonary, and metabolic conditions. This approach is in perfect synchrony with the trend toward lifestyle medicine–the evidence-based practice. This consists of assisting individuals to adopt behaviors such as regular exercise, stress management, and social connection. It also includes sound nutrition, adequate sleep, and an understanding of their family history. In turn, this improves their health and quality of life. Said another way, while health is the current state of equilibrium with the environment and the potential to maintain that balance, wellness and prevention essentially try to expand human function by building reserves to avoid adverse health. Regular exercise, sound nutritional behaviors, and good sleep habits all contribute to this concept of building reserves.
Our program was developed around the following 4 drivers:
- Family history (this is perhaps where the physical therapist will utilize genomics information as part of practice in the future)
- Lifestyle, including physical activity and monitoring of health behaviors such as smoking
- Mind/body interactions which focus on emotional health, stress management, and the importance of social connections
Before one assumes that such an approach is not reasonable for their orthopedic practice, let me suggest that today’s patient profile is much different than 10 or 20 years ago. Historically, we looked at our orthopedic patient in the biomechanical, pain science, and/or movement paradigm. All valuable. However, today’s “orthopedic” patients more often present with coronary artery disease, obesity trending, metabolic syndrome, pre-diabetes or diabetes, pulmonary deficiencies, and frequently have a “buffet of medications” they are taking for a host of health conditions. The emerging practice paradigm suggests that the silos of ortho, neuro, and cardio are no longer valid. Health and lifestyle overwhelmingly influence the condition. Failure to pay attention to that concept significantly decreases the opportunity for physical therapist private practice to access the triple aim of health care.
Our particular expertise in exercise is a key to the success of a cardiac conditioning program. The patient population typically dealing with the comorbidities noted above has a host of orthopedic and neurological conditions. These include stenosis, hip pain, abnormality in balance, and falls or gait instability, which require expert analysis. The premise we marketed was that unless one has expertise in designing and implementing exercise programs for patients with such associated conditions, the chance of adherence to any program is minimal. For example, a cardiac patient who has spinal stenosis usually will not tolerate treadmill walking unless modifications are made to posture or substitution of a recumbent bike are offered. Physical therapists understand and are trained to make these modifications. Cardiac techs are not. This is a critically important concept because dosing exercise is necessary to influence the biochemical, neurological, and anatomical changes required to improve health. These include improving stroke volume, lowering blood pressure, improving glucose tolerance, influencing obesity, improving lipid profile, and increasing muscular capillarization—the ultimate keys to improving the physiological manifestations of the comorbidities. Three sets of ten with rubber tubing or spinal stabilization exercises are good places to start some exercise programs. However, if we want to influence the factors of health, the physiological systems have to be appropriately challenged. The usual orthopedic exercise regimen is simply not adequate. The physical therapist is clearly the best health care provider to work around the orthopedic and neurological constraints these patients have. As exercise ranges from moderate prolonged training to intense interval training to strength training, proper dosing, modifications, or alternatives are required. This is perhaps one of the most important values of a physical therapist–directed wellness program.
Finally, a brief word regarding communicating to potential referral sources. We suggest avoiding the usual “academic lecture” to referral sources regarding the benefits of exercise. Unless providers have been living in a cave, they have already heard such information. Instead, focus on providing “indicators” so the physician has objective information for triggering a referral. Also offer risk stratification so that the provider understands the parameters for exercise intensity, and relay how this program assists him or her in meeting the demands associated with the population health mandate.
While the intervention model of care will certainly always have an important role, the maturation of the profession suggests we are also becoming a people skill- and knowledge-based industry. This wide range of knowledge is why we are optimally positioned to contribute to wellness initiatives and population health mandates through programs such as cardiac conditioning.
Carl DeRosa, PT, PhD, FAPTA, is a PPS member and owner of DeRosa Physical Therapy in Flagstaff, Arizona. He can be reached at firstname.lastname@example.org.