Prospective Chronic Disease Management

An unprecedented opportunity to transform society.

By Nicole L. Stout, DPT, CLT-LANA, FAPTA

I believe that our professional potential far exceeds the current capabilities that we bring to bear in practice. I believe that we have bound ourselves to traditional models of care that perpetuate a comfortable status quo rather than seeking impactful change. Our Association’s efforts to explore nontraditional models of care, a multiyear expenditure, yielded several reports but little action. We talk of “practicing at the top of our license,” and yet we are beholden to post-injury care models. I believe that we are missing the greatest opportunity for our profession, and more importantly, the greatest need in society: secondary prevention care in chronic disease.

We languish here with excuses about the barriers: “We can’t get payers to cover this service”; “Patients won’t come in for another visit”; or “This really isn’t applicable to us because these people don’t have problems [ICD-10 codified problems] to rehabilitate.” Excuses are tools of incompetence. If we are naively content to be reassured that the passage of an American Physical Therapy Association (APTA) House of Delegates motion for the Annual Physical Therapy (PT) Exam is the answer, we will be bound to languish and condemned to mediocrity with progressively diminishing value.

If we are to be a profession that transforms society, we must truly understand their needs, in their homes, in their communities, and in their workplaces. Are we willing to practice in a way that is aligned with meeting those needs, or are we seeking to wedge society into our clinic to our two or three hours a week care bubble? Do we really understand the needs of society? Currently in the United States, more than 90 million people over 65 have heart disease, nearly 20 million have a history of cancer treatment, 20 million have diabetes, and more than 1 in 5 people over 65 have more than 4 comorbidities.¹ Their health literacy is poor, and their adherence to historical approaches to “preventive care,” via nursing-based education programs, is poor. Their struggle to function, however, is real but perhaps not overtly, visibly, disabling . . . yet. And that is why they need us now.

Every one of them has a significant risk for functional compromise. All of them can be screened using a functional performance measure with the results stratified as to the severity of the condition’s impact on their function. All of them can be followed prospectively by a physical therapist to receive interventions, likely intermittently, that can prevent or mitigate the risk for functional decline associated with their condition. I believe that our profession must move beyond episodes of postinjury and postoperative care and deploy prospective care models that emphasize secondary prevention and supportive care for those with chronic illnesses.

I recently saw an older, obese woman with “well-controlled diabetes” and postbilateral knee arthroscopy for “long-standing joint pain.” She had observable, bilateral, Charcot joint malformation that was visibly apparent with her clothes and shoes on. According to her history, no one had ever really looked at her feet other than to check her skin and to talk to her about watching for sores. No one ever assessed her gait; no one ever suggested a foot orthotic or any kind of specific exercises. No one looked at the mechanics of her feet. What she needed was for you, a physical therapist, to look at them. She needed you to see those feet, years ago, to proactively see an abnormal gait pattern and prevent the malformation.

The falls risk in individuals with diabetic neuropathies who have a clinically significant Semmes-Weinstein monofilament test score is up to 60 percent greater than their peers without neuropathy.² Individuals with diabetes and also a history of receiving neurotoxic chemotherapy regimens fall seven times more frequently. Early balance screening and proprioceptive and strengthening interventions in individuals with peripheral neuropathies over a two-year period have been found to reduce their risk for falls.³

In individuals treated with an anthracycline chemotherapeutic agent, one of the most common drugs used in the last several decades in cancer care, left ventricular ejection fraction reduction is common and often continues to progressively worsen after the completion of treatment, leading to heart failure in approximately 20 percent of individuals. Exercise at 50 to 75 percent heart rate max, over a course of 12 to 14 weeks improves ejection fraction, even in individuals undergoing treatment with an anthracycline.⁴ The effect of exercise is protective when prescribed proactively, and left ventricle ejection fraction reductions can be nearly cut in half.

What these individuals need is repeated interval screening by an expert in function. They need education and intervention in a proactive manner for a rehabilitative exercise prescription. These individuals need you to screen them, identify early impairment, provide an abbreviated intervention in the presence of early, less severe impairment and triage them when they need rehabilitative care for more severe impairments. Risk-based screening, assessment, and triage is a different model of care for physical therapy practice.

The Comprehensive Geriatric Assessment (CGA) is a functional assessment tool that includes functional, cognitive, and activity screening.⁵ While we have been debating about what elements we think should be a part of the annual PT exam, an international consensus has been discussing the components of the CGA as a functional screening tool for older adults.⁶ We would be wise to explore this as a foundational element in support of our prospective model of care.

I believe that the episode of care that we need to focus on is the lifespan. I believe that we need to abolish the idea of discharging individuals with chronic diseases for which there are known late effects that occur in an aggregate burden,—precipitating risk for significant functional decline—not only for diabetes, obesity, chemotherapy-induced peripheral neuropathy, and chemotherapy-related cardiotoxicities but for many others.

I believe that this is far simpler than what we fret about. It’s evidence based^4,7,8 and it is happening right now, in clinics around the country and around the world; it’s not just a sound bite or a model that looks good on paper. We already have every skill that we need to enact this change, aside from the desire to overcome the status quo. Maintaining mediocrity is easy; doing something different is hard. I believe that we will fail to transform society until we can leave the excuses at the door and move forward with a prospective model of care.

References:

¹ Bluethmann SM, Mariotto AB, Rowland JH. Anticipating the “silver tsunami”: prevalence trajectories and comorbidity burden among older cancer survivors in the United States. Cancer Epidemiol Biomarkers Prev. 2016;25(7):1029-1036.

² Wilson SJ, Garner JC, Loprinzi PD. The influence of multiple sensory impairments on functional balance and difficulty with falls among US adults. Prev Med. 2016;87:41-46.

³ Winters-Stone KM, Horak F, Jacobs PG, et al. Falls, functioning, and disability among women with persistent symptoms of chemotherapy-induced peripheral neuropathy. J Clin Oncol. 2017;35(23):2604-2612.

⁴ Scott JM, Nilsen TS, Gupta D, Jones LW. Exercise therapy and cardiovascular toxicity in cancer. Circulation. 2018;137(11):1176-1191.

⁵ Jolly TA, Deal AM, Nyrop KA, et al. Geriatric assessment-identified deficits in older cancer patients with normal performance status. Oncologist. 2015;20(4):379-385.

⁶ Decoster L, Van Puyvelde K, Mohile S, et al. Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations. Ann Oncol. 2015;26(2):288-300.

⁷ Gu Y, Dennis SM. Are falls prevention programs effective at reducing the risk factors for falls in people with type-2 diabetes mellitus and peripheral neuropathy: a systematic review with narrative synthesis. J Diabetes Complications. 2017;31(2):504-516

⁸ Dalzell MA, Smirnow N, Sateren W, et al. Rehabilitation and exercise oncology program: translating research into a model of care. Curr Oncol. 2017;24(3):e191-e198.

Nicole L. Stout, DPT, CLT-LANA, FAPTA, is a PPS member and chief executive officer of 3e Services, an information technology consulting firm where she serves as a medical affairs consultant for biotech and health care wearable firms. She can be contacted at nlstout90@gmail.com.