Many healthcare consumers are unaware of the fact that they are free to access the services of a physical therapist without a physician referral. Every state allows for evaluation and some form of treatment without a physician referral. This has been the case in the state of New Jersey for almost 15 years, yet most of the patients that we work with in our Barnegat and Manahawkin physical therapy clinics are unaware of this. Most continue to believe that they must first visit another health care provider before seeking the services of a physical therapist. When we educate people about direct access we are greeted with a bit of surprise and many questions. Below are a few of the common questions we receive about Direct Access.
What are some of the advantages of accessing the services of a physical therapist first?
Directly accessing the services of a physical therapist saves time and money. Consumers are able to avoid wait times to see physicians and avoid delays in treatment while further testing might be pursued. Often these tests are not necessary and can potentially slow or negatively impact recovery (MRI for Low Back Pain>). A 2014 systematic review concluded that direct access controls health care costs and promotes high quality healthcare1. Compared to accessing physical therapy through a physician referral, those who directly accessed services were more satisfied with care, were prescribed fewer medications, underwent fewer diagnostic tests, and achieved better overall outcomes in fewer physical therapy treatment sessions. We have observed similar findings at both our Barnegat and Manahawkin physical therapy clinics. Patients who access our care directly achieve better overall outcomes in 20% fewer treatment sessions.
Are physical therapists qualified to deliver direct access services independent of physician referral?
Yes. Physical therapists are licensed healthcare professional who hold doctoral degrees. Physical therapists undergo extensive training in differential diagnosis and medical screening. This entails distinguishing non-serious musculoskeletal problems (low back pain, rotator cuff problems, meniscus tears, arthritis, etc) from more sinister potentially life threatening conditions (cardiac disorders, cancer, etc). Physical therapists at BSR Physical Therapy have also undergone more extensive residency, fellowship, and board certification training which focus further on these diagnostic skills. Physical therapists are not trained to make or confirm serious diagnoses but we are able to recognize when patients do not belong in our clinics and need an appropriate medical referral. We routinely refer patients to other medical specialists based on our physical exam or when the patient is not progressing towards their goals. Physical therapist’s clinical examination skills are on par with or better than most other healthcare professionals (Evidence here). How many other healthcare providers are going to spend one full hour actively listening to their patients in order to elicit all their concerns and then perform a comprehensive physical examination?
Will insurance companies cover direct access physical therapy services provided without a physician referral?
More and more health insurance companies are now covering physical therapy services without a physician referral. This is because of emerging research evidence showing cost savings with this approach2. At our clinics our front office professionals verify all health insurance benefits before starting treatment. In the majority of instances (>75% of cases) we are finding that a physician referral is not necessary to access and cover physical therapy care.
Approximately 10% to 20% of our patients access physical therapy care directly and this number is on the rise. Healthcare consumers are saving time, money, and achieving superior outcomes with greater convenience when directly accessing physical therapy. Health insurance companies are now recognizing these advantages as well. As health care reform continues to evolve, the health care consumer is becoming a more active participant in their own care. Direct access to physical therapy is here to stay and growing.
Ojha H a, Snyder RS, Davenport TE. Direct access compared with referred physical therapy episodes of care: a systematic review. Phys Ther. 2014;94(1):14-30.
Pendergast J, Kliethermes S a, Freburger JK, Duffy P a. A Comparison of Health Care Use for Physician-Referred and Self-Referred Episodes of Outpatient Physical Therapy. Health Serv Res. September 2011:1-22.
Retraining neutral sitting posture is an important factor in the recovery from of an episode of neck pain and also for preventing future episodes of neck pain. Sitting postural correction becomes especially important for those of us who spend a great deal of our time working at a computer or seated at a workstation of any kind. Most present day occupations and many leisure activities (involving the internet or a mobile device) place the neck and upper back in vulnerable positions stressing many anatomical structures of the cervical spine.
Frequent correction of neutral sitting posture serves two primary functions. First, it allows for regular reduction of adverse loads placed on the joints of the spine due to poor neck and upper back posture. Second it provides a training effect to the deep cervical stabilizing muscles during their functional postural supporting role. The aim of postural correction strategies is to change postural habits, not to strengthen weak muscles. Ultimately this should result in a comfortable low effort strategy which is easily assumed and maintained during prolonged sitting activities. Rigid high-effort correction of sitting posture should always be discouraged as this often results in increased muscle activity and pain.
Key Aspects of the Seating Surface
The feet should be flat on the floor
The thighs should be slightly inclined downward from horizontal (hips slightly higher than knees)
The buttocks should be completely supported by the seating surface
Gently roll the pelvis back and forth until sitting on the bony prominences deep within the buttock (ischial tuberosity). This will restore the natural curve (lordosis) in the small of the low back. This first step is the most important.
Without arching or extending the spine, slightly lift the breast bone (sternum). Minimal correction should be needed here.
Finally, slightly lift the back of the head towards the ceiling in order to achieve a neutral position of the eyes relative to the horizon. If steps one and two are performed correctly, minimal to no correction will be needed at the head and neck.
The neutral position should be comfortably maintained for ten seconds and repeated every 10 to 20 minutes during sitting. A timer is recommended to ensure adherence to the schedule. In between repetitions of the postural correction exercise a relaxed non-rigid posture should be assumed. We should not attempt to maintain “the perfect posture” during prolonged sitting. This is not recommended or realistic. Over the course of several days or a few weeks of practice, the neutral sitting posture will be more easily attained without conscious thought. Through self-awareness the body will learn this new strategy just like any other practiced skill ultimately leading to a healthy postural habit requiring little effort or conscious thought.
Now go ahead and try it….then re-read this blog post for reinforcement.
Falla, D., O’Leary, S., Fagan, A., & Jull, G. (2007). Recruitment of the deep cervical flexor muscles during a postural-correction exercise performed in sitting. Manual Therapy, 12(2), 139–43.
Wegner, S., Jull, G., O’Leary, S., & Johnston, V. (2010). The effect of a scapular postural correction strategy on trapezius activity in patients with neck pain. Manual Therapy, 15(6), 562–6.
It’s not often that I am in agreement with health insurance companies but they seem to be getting one thing right as of late. We have noticed an increase in patient’s referred to our clinics for low back pain that have not undergone advanced diagnostic imaging techniques, such as MRI. It appears that large insurance companies are denying authorization for these MRI’s until the patient has undergone a course of physical therapy (more on the topic). Physical therapists are certainly on board with these decisions but some of our patients are often confused or annoyed by their insurance company dictating their care. So, should patients with an acute onset of low back pain undergo routine MRI or undergo a course of physical therapy first? Why not be safe and undergo the MRI first? How can a physical therapist offer treatment without knowing what the problem or diagnosis is?
Physical Therapy or MRI First?
A recent study published in the journal Health Services Research investigated this question. Researchers found that those patients seeking primary care services for low back pain and were referred for an early MRI underwent higher health care utilization at increased costs compared to those receiving early physical therapy. The additional cost of receiving the MRI first was nearly $5000 more than receiving early physical therapy. Earlier research studies show that consulting a physical therapist early results in decreased odds of undergoing diagnostic imaging (here) and decreased odds of undergoing future surgery for low back pain (here). Delaying physical therapy has also been associated with increased prescription opioid (narcotic pain medication) use and most of us are aware of how big of an epidemic this is becoming (more here).
Why Not Play it Safe and Undergo the MRI First?
A 2003 study in the Journal of the American Medical Association compared the use of early MRI vs. early x-ray for patients with a new episode of low back pain. One year later, pain levels and disability were no better in those undergoing the MRI. Of note, the group receiving the early MRI was more likely to undergo back surgery. This is not surprising given the high likelihood of pathological findings in asymptomatic subjects (no low back pain) who undergo advanced diagnostic imaging. A 2015 systematic review reported the prevalence of disc degeneration in asymptomatic individuals ranged from 37% of 20-year olds to 96% of 80-year olds. Similar rates were reported for asymptomatic disc bulges. If so many people without low back pain have these findings on MRI we cannot confidently conclude that these findings are the true cause of symptoms. Making erroneous assumptions based on MRI findings often leads to over treatment. The more testing and treatment a patient undergoes the more likely factors such as fear and anxiety come into play and these are the factors that have been associated with persistent or chronic low back pain.
Physical Therapy Treatment without Imaging
MRI or further medical work up is always indicated in situations where serious pathology is suspected or when response to initial treatment is poor. However, low back pain emanating from serious pathology has been estimated to occur in less than 2 percent of cases. Doctor’s of physical therapy are trained in screening for these signs and when there are any suspicions of non-musculoskeletal problems prompt referral is indicated. In most cases these problems are ruled out based on a detailed interview and medical history. Physical therapists then base their examination and treatment on the individual patient’s signs and symptoms; not based on a diagnosis or MRI scan. Physical therapists are concerned with how movement affects symptoms and how symptoms affect movement.
In most cases of low back pain delaying the MRI is the best approach.