Direct Access for PTs & Independence for NPs: HB 4643 & HB313

Historically, Illinois has been one of the most conservative states for all non-physician providers. With antiquated policies coming to an end, NPs and PTs will finally be able to practice to their fullest extent. With the political landscape of Illinois changing, physical therapists (PT) will have direct access and nurse practitioners (NP) will be able to practice independently. While this is a huge celebration for both professions, there are caveats. According to HB4643, a PT may evaluate and treat a patient for 10 visits (or 15 business days, whichever comes first) without a written prescription from a provider. Thereafter, the PT must notify the patient’s healthcare provider within 5 business days of starting treatment. Under HB313, NPs will be able to practice independently after obtaining 4000 hours of clinical experience with a provider and 250 hours of continuing education.

PTs not having direct access in Illinois is pretty archaic, as there are many states that have direct access and it does not compromise patient safety. Massage therapists and personal trainers continue to see patients without a script despite PTs having doctoral level training. Does it make sense that they have full autonomy with their clients but PTs do not? Not really. At last, physicians do not have to waste their time seeing a patient they would normally refer to PT anyway. Patients not appropriate for PT can be screened by the therapist and referred to the physician. This new policy does not undermine the collaborative relationship of the PT and provider: it actually strengthens it.

NPs will be able to provide primary care without collaborative written agreements after ~2 years. Collaboration will continue to exist, but there will be substantially less paperwork for physicians. Why should NPs be restricted by written agreements when other states have proven that independent NPs can provide safe and effective care? An NP will never be able to replace a physician who has completed residency and/or fellowship. However, NPs are vital, as they have shown that they are safe and cost-effective with their care.

I never thought I would see these rules change in my lifetime. With greater power comes greater responsibility; nevertheless, both of these professions are equipped for the challenge. More information can be found at the following websites:

HB313
https://www2.illinois.gov/Pages/news-item.aspx?ReleaseID=14838

HB4643
http://www.ilga.gov/legislation/billstatus.asp?DocNum=4643&GAID=14&GA=100&DocTypeID=HB&LegID=109632&SessionID=91

Finding the right PT for you

I have had an increasing number of colleagues ask me the following questions: (1) “What physical therapy (PT) clinic do you recommend?” and (2) “which PT should I go to?” Considering all the physical therapy clinics that are readily available in the area, it is an important question to ask. Picking the right PT can influence your prognosis and how soon you recover (and save you money in the long run).  Listed below are some important questions to ask yourself when considering where to go:

1. Is this a practical location?

For most patients, 1-3 visits per week is to be expected. If the location is too far or too difficult to get to (ex. area has a lot of traffic, no parking, etc.), chances are likely that you might not go. If you don’t go you won’t get better. It sounds simple, but some patients give up on PT without trying to go to another convenient location. You should have easy access from home or work (or wherever you are on a daily basis).

2. What type of training has the PT received?

Check to see if the therapist is residency-trained, fellowship-trained or board-certified by the American Board of Physical Therapy Specialties (ABPTS). These PTs undergo vigorous training after their doctoral studies, usually 1-1.5 years long. If you see these credentials, chances are they are very good at what they do. PTs can have an alphabet soup after their name, but here are a couple honorable mentions:

-Board-Certified Orthopedic Clinical Specialist (OCS)

-Board-Certified Sports Clinical Specialist (SCS)

-Board-Certified Neurology Clinical Specialist (NCS)

-Fellow of the American Academy of Orthopedic Physical Therapy (FAAOMPT) (I know, that’s a mouthful).

There are great therapists who do not have any of these credentials; however, significant time and effort went into these certifications. The majority of them are well-trained in exercise prescription and manual therapy. There are other credentials that exist, but some of them are not as standardized as the ones above. My recommendation is to call the clinic and ask if any of the providers have the aforementioned certifications. If you are looking for certain types of manual therapy treatments, see if they offer dry needling (DN), active release technique (ART), graston, etc.

3. How much individual attention can the PT provide?

This is probably the most important question to ask. Nowadays, there are so many clinics that receive a high volume of patients. They see TONS of patients blocked in 15-30 minute increments. Some patients are double or triple-booked, meaning you might only see the PT for 15 minutes. I have a problem with this, especially early on in a patient’s care. For a patient who is on the tail end of rehab? Sure. For a patient who is halfway through rehab? Maybe. There are various nuances involved, but the PT should be hands-on and actively engaged in your care. The rehab technicians are great at what they do, but they are not trained to see what PTs see. They will assist with exercises and modalities, but the bulk of your care should not be spent with them: it should be spent with a PT.

Additionally, most of the insurance plans that I see have moderately high/high co-pays. The question you must ask yourself is this: do you want to spend your co-pays (and your deductible) on a therapist who spends little time with you? I wouldn’t. You’re paying for the PT’s time, so spend your money wisely and make your money count. If you go online and look at the yelp reviews, many of the negative reviews revolve around the fact that they received very little attention/poor individualized care. While some of the reviews need to be taken with a grain of salt, you don’t want to be in a place that has consistently bad feedback. The clinics with the best reviews are the ones with PTs who provide stellar one-to-one patient care.

4. Do you feel like you can build a solid rapport with the PT? 

This is one of the most important aspects of rehab along with (3). If you have a solid relationship with your therapist, the experience will be more rewarding. You will enjoy the time spent in the clinic if you trust their expertise and are able to relate in some capacity. PT is hard work, but you should not dread going to the clinic. Even more important, if any musculoskeletal issues arise in the future, look no further! If you found a great PT, stick with that person!

 

 

 

Don’t write a script for physical therapy; refer them to a physical therapist.

You have heard it countless times: “I’m going to refer you to physical therapy (PT)” or “What you need is physical therapy.” While I understand that these statements are said with good intentions, I do have some issues with the phrasing. My physician assistant (PA) colleagues are similarly unsatisfied with the term “physician’s assistant.” It is physician assistant, not physician’s assistant (with an ‘s). The “‘s” implies ownership of some kind: it also implies that they are merely an assistant to the physician. A regular medical assistant is not the same as a PA. Referring someone for physical therapy sounds as silly as referring someone to medicine, dentistry, or law. Have you ever heard someone say “I’m going to refer you to medicine” or “I need to refer you to dentistry”?

Semantics is the study of linguistics and the meaning associated with words. PT is a noun, just like medicine, dentistry, or law. These phrases put more emphasis on PT as a verb and less on the therapist implementing the actions. Just as every orthopedic surgeon is not created equal, neither are physical therapists. There are really bad physical therapists, just as there are bad apples in other professions. It is pertinent for providers to refer patients to a physical therapist that they trust, someone who is up to date on evidence based practice and consistently has solid patient outcomes. Too often, I have seen providers arbitrarily write a script for PT with no thought of referring the patient to a specific therapist. Would you choose any random orthopedic surgeon to perform your knee replacement? Or would you want someone giving you a referral to a specialist who has outstanding end results? The collaborative relationship between therapists and other providers is extremely important. It has often been said that successful return to function is based on surgery and rehabilitation, with both being equally weighted (at the very least). PT is a combination of exercise prescription (EX), manual therapy (MT), use of modalities, and education of all kinds (pain management, pathophysiology, functional biomechanics, etc.). PT is not synonymous with exercise or physical activity. It is so much more than that.

Referring someone to PT without knowing their skill level is unwise and less beneficial for the patient. How do you know if the therapist is using evidenced based practices (EBP) or if the therapist is proficient with MT techniques? As a physical therapist, my decision to refer patients to a specific orthopedist is based on patient testimonies, the clinician’s involvement in EBP, and the degree to which patients smoothly progress and return to their prior level of function (PLOF). When I hear these phrases, it makes me believe that providers are under the impression that all physical therapists provide the same level of care. That simply is not true. Not providing therapist recommendations is a disservice to all parties involved, especially to the patient. If a provider does not refer a patient to a specific therapist, it can only mean a couple things: (1) the provider believes that all physical therapists provide equal care; or (2) the provider is too busy to care and/or does not personally know any therapists. Regardless of the reason, it undermines the value of the clinician and disregards the clinical decision-making of the therapist.

All parties need to be educated about the following concepts:

1. Physicians need to be aware that not every therapist has the same skill level. Research has demonstrated that a combination of EX and MT leads to the best outcomes. Ask about the therapist’s training and credentials. Are they APTA board-certified? Have they completed a residency or fellowship? While these credentials do not guarantee that you are seeing a superior therapist, it proves that they committed themselves to training beyond their graduate degree (ex. similar to a physician completing a residency and fellowship). For the most part, these types of therapists have a certain level of skill that other therapists may not possess.

2. Physical therapists must communicate with providers about mutual patients. Therapists need to inform providers that the patients are getting better under their care. Many patients will leave PT after feeling better and will not touch base with the provider who referred them. This leaves the provider in the dark, making it unknown whether the patient improved or worsened. Providers are much more likely to send patients to a therapist who has successful outcomes.

3. Patients need to do their homework and understand that there are many companies to choose from. While convenience is a huge factor, don’t make that the primary reason you choose a particular clinic. Read the biographies of the physical therapists and see what kind of experience they have.

I will eventually practice as a primary care provider (PCP); as a nurse practitioner (NP) (and being a therapist), I will not halfheartedly write a random script for PT.  I will be judicious with my referrals and make sure that they are seen by a proficient physical therapist. Sending a patient to a mediocre physical therapist does nobody any favors. Patients need to be referred to a physical therapist, not physical therapy. A proficient physical therapist will use a combination of treatments to optimize patient function. This will ensure that patients are receiving the best possible care.

Why do our colleagues still not refer patients to a PT for basic musculoskeletal conditions?

I recently read an article from JOSPT that revealed that approximately only 7.1% (95% CI, 7.0%-7.1%) of patients who have plantar fasciitis (PF) actually receive a physical therapist (PT) evaluation. A total of 819,963 patients were diagnosed with the condition and seen by providers between 2007 and 2011. Can you believe that? I was pretty surprised, given that the condition is treatable. Many of the problems associated with PF can be reduced/eliminated with manual therapy and exercise (MTEX) (Cleland et al., 2009). Modifiable risk factors can be eliminated with lifestyle and footwear changes (Martin et al., 2014). While the condition is usually self-limiting and resolves over time, there are a number of patients who develop chronic PF or have pain that is debilitating enough to decreased quality of life (QoL) and activities of daily living (ADL). I have a couple theories regarding why referrals are scarce:

1. It is possible that primary care providers (PCP) simply do not believe that PT is warranted for the condition. They may think it resolves over time or that simple pain medications and rest (ex. Tylenol, NSAIDs, etc.) may be sufficient to eliminate the symptoms.

2. PCPs may not be up to date on the current practices associated with PF. Hence, it may not cross their mind to even refer their patients to a PT.

3. PTs may not be educating PCPs enough about the benefits of treatment, particularly MTEX.

4. Patients may receive a referral but choose not to go to a PT due to insurance limitations or financial issues (this is the most difficult, in my opinion).

It may be a combination of these factors (or none at all), but the end result remains the same: there are not enough patients receiving treatment. PF is not unlike other conditions–there are many patients seen by their providers who have musculoskeletal conditions and they are not properly referred.

When patients come in for free injury screens, I often do not refer them to PT (that is probably to the dismay of my managers, of course). The patient may come in with a complaint of low back or foot pain that has been going on for a couple days. Obviously, pain that short in duration does not usually necessitate our services. However, pain that is on the tail end of acute (~4 weeks), sub-acute (4-8 weeks), or chronic (>12 weeks) deserves our undivided attention. When patients visit their PCPs with these issues, it is imperative that an appropriate referral is made. At the very least, refer them for a free functional injury screen (they are basically everywhere). There should not be a hold-up of services given that chronic illnesses usually take longer for recovery, cost more money, and potentially lead to worse outcomes. This goes both ways: when patients are not getting better with PT, I immediately refer them to a specialist for further consultation. I say the same thing to almost every patient I encounter: “If you do not have improved function or decreased pain in any capacity by 3-4 weeks, I will refer you appropriately to another provider. There should be some level of improvement” [obviously, this is assuming the patient is coming to PT and is adherent to their home exercise program (HEP)].

We need to continuously educate our colleagues about the benefits of PT. Likewise, consistent correspondence with providers is essential–discussing mutual patients and updating them on their progress goes a long way. If providers hear and see their patients getting better, writing a prescription for PT will become second nature.

Are you sending patients to see a PT for basic musculoskeletal conditions like PF, ankle sprains, or low back pain? If not, explain why! I would love to hear your thoughts on the subject.


Resources:
Cleland, J.A., Abbott, J.H., Kidd, M.O., Stockwell, S., Cheney, S., Gerrard, D.F., & Flynn, T.W. (2009). Manual physical therapy and exercise versus electrophysiological agents and exercise the management of plantar heel pain: a multicentered randomized clinical trial. Journal of Orthopedic and Sports and Physical Therapy, 39(8), 573-585.

Fraser, J.J., Glaviano, N.R., & Hertel, J. (2017). Utilization of physical therapy intervention among patients with plantar fasciitis in the United States. Journal of Orthopedic and Sports Physical Therapy, 47(2), 49-55.

Martin, R.L., Davenport, T.E., Reischl S.F., et al. (2014). Heel pain—plantar fasciitis: revision. Journal of Orthopedic and Sports Physical Therapy, 44, A1-A33.

Should PT residencies be required before obtaining fellowship status? Should residencies be required to obtain APTA board-certification?

This might ruffle a few feathers, but I firmly believe that residencies should be required before any physical therapist (PT) is allowed to enter fellowship training. In medicine, a physician must complete residency before entering into fellowship. After finishing, they may choose to go into fellowship or “sub-specialty training.” The residency is the stepping stone. For most PT fellowship programs, a therapist can apply as long as they have any of the following: (1) completion of an APTA residency; (2) be board-certified in an APTA specialty; or (3) have a year of experience within the field (APTA, 2013). The problem with these requirements is that they are not created equal. There are too many pathways to obtain certification. A PT with one year of experience does not have the same level of competency as a PT who finished a full-time residency.

Do you see the problem? In medicine, you know that the physician in fellowship has already completed a certain level of training. For a PT who is fellowship trained, you do not know what type of experience or level of skill they have. It could be as little as a year. I think the American Academy of Orthopedic Manual Therapists (AAOMPT) would elevate its fellowship credential (FAAOMPT) even higher with more stringent standardization. Should there be exceptions? Maybe. If exceptions are to be made, the other minimum requirements should be raised across all fellowship programs. PTs entering fellowship without residency should have at least 3-5 years of experience AND be board-certified in a specialty. This guarantees a certain level of competency and provides standardization to obtaining fellowship status.

The same goes for obtaining APTA board-certification without completing a residency: a therapist should be required to work at least 2-3 years before they can even sit for the exam (not after having only 2000 hours of experience). My residency director once told me that finishing a dedicated full-time residency (not part-time) is the equivalent to practicing for 4-5 years (being in the field for almost 5 years, I believe her). How then, does a therapist become board-certified after practicing for one year without a residency? That does not make much sense. Should there be exceptions to this rule? Absolutely. My wife is a pharmacist who has experience in retail and clinical pharmacy. She has interest in becoming a board-certified pharmacotherapy specialist (BCPS); however, she did not complete a post-doctoral residency. Consequently, she must have 3 years of experience before she can even qualify for the exam and obtain the established credential. If she had completed a residency she would be able to sit for the exam sooner. Rich Severin touched on this in an interview with New Grad Physical Therapy (NGPT):

“In many ways, the residency is a process of refining one’s ability to solve problems – and not necessarily just clinically oriented questions either. Of course, there are psychomotor skills that are learned and mastered but the thought process is what I feel is the most important benefit of residency training. This process of refinement can be obtained without completing a residency program if one has access to a motivated mentor in the right practice setting; however having access to both of those components is not too common” (NGPT, 2016, paragraph 2).

By raising the minimum requirement of 3 years clinical experience, it ensures that the PT who is board-certified has some mastery of psychomotor skills (ex. manual therapy/exercise prescription) AND refined thought process (ex. clinical decision-making, differential diagnosis, etc.). Perhaps that is the other problem: while the APTA board-certification is standardized, there is no motor-skill component to ensure that the therapist is proficient with certain techniques within their specialty.

Most PTs do not choose to enter residency after graduating from school. I was one of only two students out of my class to choose this route. Unfortunately, the return on investment (ROI) for a PT is nowhere near that of a physician; consequently, most PTs do not enter residency because of the lower salary (I would love to touch more on this, but that is beyond the focus of this post). It is understandable given that everyone has a different financial situation. I was fortunate enough to enter residency straight out of graduate school because my wife was working at the same time.

A streamlined, standardized pathway for advanced specialty certifications and fellowships is important. It makes more sense and it is less confusing for patients, PTs, and other healthcare professionals. The current system does not guarantee a certain level of competency because the requirements are too low and the routes are too many. Below is a more simplified pathway:

APTA Board-Certification (must have ALL of the following):

Active license to practice PT

Completion of an APTA credentialed residency
OR
Have at least 3 years of documented clinical experience in the related field

Fellowship Certification (must have ALL of the following):

Active license to practice PT

Completion of an APTA credentialed residency AND be APTA board-certified
OR
Be APTA board-certified AND have at least 3 years of documented clinical experience in the related field

© by ThePTNurseGuy, 2017

Resources:
American Physical Therapy Association (APTA). (2013). Presentation objectives clinical residency clinical fellowship. Retrieved from http://www.apta.org/uploadedfiles/aptaorg/national_conferences/nsc/programming/handouts/residency_fellowships.pdf

New Graduate Physical Therapy (NGPT). (2016). Pursuing residencies, specialties, or research: an interview with rich severin. Retrieved from https://newgradphysicaltherapy.com/physical-therapy-residency-new-grads/

Imaging ordering patterns between physicians and advanced practice clinicians. O, and what about PTs?

Advanced Practice Clinicians (APC) are civilian mid-level providers (ex. nurse practitioner, physician assistant) who have the ability to order imaging. Though, some proponents have suggested that mid-level providers may be inappropriately ordering unnecessary imaging for their patients. Hypothetically, this could lead to increased healthcare cost and spending. Hughes, Jiang, & Duszak (2015) used Medicare claims data and sought to find out whether there was a discrepancy between APCs and physicians (PCP). They wanted any potential differences between the two to be observable and quantitative; therefore, the primary outcome was whether an imaging event occurred after an evaluation and management visit (geographic variation, patient demographics, and the Charlson Comorbidity Index Score were all variables taken into consideration). The results were as follows:

-APCs ordered imaging 2.8% per episode of care whereas PCPs ordered 1.9% of the time. In adjusted estimates across all patient groups, APCs were associated with more imaging than PCPs (odds ratio, 1.34 [95% CI, 1.27-1.42]), ordering 0.3% more images per episode.

-For traditional radiographs, APCs ordered 0.3% and 0.2% more images for new and established patients. For advanced imaging, APCs ordered 0.1% more images than physicians.

It is interesting to note that the authors pointed out the potential broader implications of the findings. That is, increased healthcare cost and unnecessary radiation exposure may result on a national level if APCs ordered imaging to the same degree. Therefore, their growing role in primary care access should potentially be limited due to cost, safety, and quality implications. Does that make sense to you? It doesn’t to me. While I do believe more studies should be done on the subject matter, I do not think there is any merit in these statements given the aforementioned statistics. The differences were negligible within the sample study, and I hypothesize that the authors were expecting the differences to be much greater than they were.

The authors examined the imaging rates for two commonly seen conditions in the clinic: low back pain (LBP) and acute respiratory infection. They chose these two conditions because they are frequently seen and are usually managed conservatively without imaging. Interestingly enough, for reasons unknown, PCPs were associated with more images for patients who had acute respiratory infections. The authors hypothesized that APCs referred these patients to PCPs for further evaluation and imaging. If that is the case, why was the imaging rate the same for patients with LBP? It is a bit of a double standard–on one hand, APCs are associated with higher imaging rates. In the same breath, they are also sending patients with respiratory infections to PCPs for imaging? And this is supposed to explain why the rates are higher for PCPs compared to APCs?

The conclusion of the article was as follows: “Greater PCP and APC team coordination, as some have suggested, may produce better outcomes than merely expanding the scope of APC practice alone.” I do not believe any APCs are advocating for expanding their scope of practice without team collaboration (if they are, they shouldn’t be). However, the lack of primary care providers will force APCs scope of practice to increase. We have seen this in a number of states in the country. Rest assured, some studies have already shown that patient outcomes for many conditions are not inferior when APCs are caring for them rather than physicians (Newhouse, Stanik-Hutt, & White, 2011). With that said, patients will obtain the best outcomes when APCs collaborate with physicians. Managing patients is a group effort that requires teamwork from every single member. I believe PCPs should be at the helm, but improving the team’s autonomy will disperse the caseload and it will inevitably make life easier for physicians.

Similar opinions have been expressed about PTs gaining direct access and ordering imaging. Articles were written about how it would be unsafe for a PT to treat a patient without first being seen by a physician. PTs fought hard for their autonomy and proved their competence–now there are 18 states with unrestricted direct access and 26 states with provisional direct access. Rather than wasting a physician’s time to evaluate and write a prescription, patients are being seen sooner and treated quicker. I think that benefits all parties.

As for imaging, military PTs are providers who have been serving as physician extenders for quite some time. Compared to civilian PTs, they can order imaging for their patients and prescribe basic musculoskeletal medications. They have been doing this safely and appropriately since 1972. It has actually reduced the number of unnecessary images ordered without compromising military patient safety (Boyles et al., 2011). Unfortunately, civilian PTs do not have the same scope of practice. If APCs are allowed to order imaging for their patients, it makes sense that PTs should be able to as well.

 

Resource:

Boyles, R.E., Gorman, I., Pinto, D., & Ross, M.D. (2011). Physical therapist practice and the role of diagnostic imaging. Journal of Orthopaedic & Sports Physical Therapy, 41(11), 829-837.

Hughes, D.R., Jiang, M., & Duszak, R. (2015). A comparison of diagnostic imaging order patterns between advanced practice clinicians and primary care physicians following office based evaluation and management visits. Journal of American Medical Association, 175(1), 101-107.

Newhouse, R.P., Stanik-Hutt, J., & White, K.M. (2011). Advanced practice outcomes 1990-2008: a systematic review. Nursing Economics, 29(5), 230-250.

 

Manual therapy: how many techniques do you really need?

There are so many advertisements from various companies that offer courses for manual therapy. Whether it’s joint manipulation, soft tissue mobilization (STM), instrument assisted soft tissue mobilization (IASTM), or dry needling (DN), the companies will promote how these skills will improve your results in the clinic. While that may be true, there are a couple points to keep in mind before signing up:

1. Some of these classes are expensive and it is imperative to spend your money wisely. For example, if you have novice skills with cervical manipulation, taking an advanced course might be beneficial for you! If you are already competent with these techniques, I would highly reconsider and reflect on the cost benefit. Do you really need to know 5 different techniques to manipulate the lower cervical spine? All of which reproduce the same effects? In 2013, I had the opportunity to go into a full-time orthopedic residency at the University of Chicago Medical Center (UCMC). It was here where I became proficient with techniques such as advanced joint manipulation (cervical, thoracic, lumbar) and peripheral joint mobilization. I had great teachers (Craig Hensley, DPT, OCS, FAAOMPT and Michael Maninang, DPT, OCS, FAAOMPT) who helped me refine my skills. While it may come as a surprise, manual therapy is like riding a bicycle–once you master a skill, it stays with you forever (ex. the barriers/end-feels, use of multiple levers, positioning of the patient, etc.). Once you become proficient, additional teaching is usually not necessary. Excel at 1-2 techniques that address all the mobility patterns of that specific joint. Master them and they will serve you well. No matter what the instructor tells you, an upglide is an upglide and a downglide is a downglide in the cervical spine. A posterior glide of the talocrural joint is the same regardless of the position the patient is in (albeit, some positions may be more comfortable). No matter how fancy the technique looks, it still produces the same end result. There is more than one way to skin a cat, but paying extra money to learn how seems a little unnecessary.

I have already touched on why I believe DN should not be used as a first line treatment in many situations. In my opinion, the evidence does not substantiate it as a primary intervention (see previous post). Speaking from experience, I paid a significant amount of money to be certified in DN (half of it was reimbursed from the company). While I have found success using DN for certain situations, I do not use it for the large majority of my patients. They simply don’t need it. Looking back, I probably would have invested in another continuing education opportunity. DN courses are simply too expensive and the benefits do not justify the financial cost. Unfortunately, DN is the newest fad, another tool in the toolbox, and it will take some time for the cost of the classes to decrease in price. Its true value will only be realized when the premium for the certification is reduced (if and when that ever happens). The same goes for expensive instruments used for STM. Do you really need a hawksgrip or graston tool? Or could you use something like this Edge mobility tool that is a fraction of the price?

(https://www.edgemobilitysystem.com/products/edge-mobility-tool?variant=815471351)

Sure, the hawksgrip may give you better user feedback for the mobilization, but these nuances ultimately make no difference. In contrast, I recently spent $110 on a CEU course with Kevin Wilk, DPT, where he discussed shoulder rehabilitation in the context of overhead athletes and rotator cuff repair. It was affordable and the information that was provided justified the cost of the course.

2. Keep an open mind when learning new manual therapy skills, but be weary of claims that go beyond up to date evidence. It is a disservice to our profession and our patients when we falsely advertise information. Yes, there will be times that we have to reshape our patients perception of pain, mobility and function, but we still need to be truth-tellers. Test everything. What is the evidence behind these interventions? Research the information and then decide if the class is truly worth it.

3. Lastly, remember that no matter how many manual therapy techniques you learn or courses you take, empowering patients to move is what matters most. The majority of techniques are passive in nature. These tools are a small piece of the puzzle, and while they may “jump start” a patient in the short term, movement is the key to long-term success.

If the course you are looking into is affordable and paid for by your company, by all means, go for it! If it is super expensive, consider seeking out other opportunities that will help you address your weaker areas. You will be a better clinician by continuing your education judiciously.