PTAs and Joint Mobilization – A Follow Up.

I wanted write a follow-up to last week’s blog that I wrote.  I knew it would create discussion and wanted to tie up some of what I have gleaned from the conversation. It has been great to get historical perspectives, economic perspectives as well as professional perspectives that add to the depth of this topic.

Some folks have asked: “why are you bringing this discussion up?  This is old news and we have better and more productive things to talk about.”

OK.

But, if you get to the root of my fellowship training, I was charged to always challenge my biases.  This doesn’t hold true for just clinical hypotheses or interventions, but in life as well. I see it important to see perspectives that were outside my own biases and try to look at the other side.

Even though this topic has been had time and time again, I think it is important to continue to discuss.  We learn new things.  Perspectives.  Ideas.

The intent of the original blog was to continue discussion based on what I have experienced over the past few years.  I hope to have at least stimulated some thoughtful reflection and comments to add to the reader’s perspective.  Below are a couple key comments/thoughts from the conversation.

  1. Steve McDavitt’s original comment adds much depth to the historical and professional aspects to this conversation.  I am glad that Steve commented (had a feeling he would!).  Check this out to gain more insight on this topic.
  2. The discussion is old, but the information is not well known or followed.  Brian D’Orazio alluded to this on one of his comments.  We all have seen the practice variation that I brought up and is demonstrated in the comments.  If anything, I hope this blog helps educate PTs and PTAs alike on the background here.
  3. Check out Jim Rivard’s comment.  Nicely worded and sums up many points regarding economic drivers.

It had been stated several times that we need to move the discussion to more talks about best practice, reimbursement, etc.  So, below are a couple of discussion questions that I am curious about.  I have my own biases here, but want to read other perspectives to gain a better insight.

  1. What does the PT-PTA team look like within a best practice model?
  2. What is your decision-making process for PT’s using joint mobilization and transitioning care to a PTA?  Go beyond “when I don’t need to continuously evaluate” as this seems to mean different things to different folks in different situations.
  3. Does anyone have a win-win economical PT-PTA model worth sharing?

As always, thanks for reading and adding your thoughts.

@ShepDPT

2 responses to “PTAs and Joint Mobilization – A Follow Up.

  1. Patrick says:

    Thanks for the great articles here. In response to the questions you posted:
    1. I think the ideal PT-PTA model looks more similar to what the dental and dental assistant model looks like right now. In the comments to your previous post I saw many people comparing the PTA to the physician assistant, but I don’t think that is really a good comparison. PTA’s and dental assistants have similar levels of education, and I think in an ideal world, the way that a therapist and PTA work together would be similar to the way a dentist and dental assistant do. In other words the dental assistant performs routine tasks such as cleanings and taking x-rays so that when the dentist comes in he can examine you, or perform more advanced procedures like ….drilling…ugh. I think this is what ideal would probably look like for physical therapy as well. Each time a patient comes to therapy they would see the PTA for routine activities, and be seen by the PT for more advance procedures. The question is, what would we consider routine, and what would we consider more advanced. In my opinion this would be something like the PTA gets patients started on the Treadmill or Bike, sets up and performs modalities, monitors and assists with routine exercises, and performs some basic PROM and stretching activities. The PT would then perform more advanced manual therapy (joint mobs, manips, dry needling, IASTM, other soft tissue mobilization) or more advanced exercises (e.g. exercises that require assessment of body mechanics or physiological responses).

    2. Generally I don’t delegate joint mobilization to PTA’s but most of those that I have worked with don’t seem to be comfortable with this anyway so it isn’t really an issue. Unfortunately, right now, I don’t think I see many PTs, and PTAs working together on the same patient on the same day, so when I do delegate to a PTA, usually I try to reserve more of the less involved exercise based interventions for a day that my patients might see the PTA, though I don’t think this is ideal. Ultimately, I think in our clinics, PTA’s are used as a cheaper staff alternative and not truly as assistants, which I think limits how integrated our care can be.

    3. I think the only way this starts to get worked out is with advocacy and getting our reimbursements to come back up. Unfortunately, I don’t see this happening any time soon. The problem is that physical therapy is different from other health professions in how we deliver care. A regular daily visit of PT isn’t (or shouldn’t) be filled with routine tasks that we complete time after time. In dental offices there are many routine tasks that assistants can complete and short amount of highly skilled work that the dentist needs to perform. The same is true in Physician practices. Medical assistants might take HR, BP and temperature and take your history, and the physician then steps in for 5 or so minutes to do his skilled assessment. Physical therapy does not work like this. We perform skilled interventions for 30 to 60 minutes. Unfortunately, the fact that we are different in our delivery of care, does not seem to make much sense to regulators or insurers. So, our reimbursement drops. And employers look to save cost by hiring fewer PTs and instead hiring PTAs, and it seems to me that this will only make the problem worse. If an employer can pay a PTA $20,000 (or more) less than what they pay me, what is there incentive to raise my salary? Underpaid and overworked leads to burnout, which leads to poor care, which leads to poor outcomes, which leads to lower reimbursement, which then perpetuates the cycle. This is certainly a complicated issue.

    Again, thanks for the posts, very thought provoking.

    1. Susan says:

      I wanted to respond to Patrick’s comments. First, let me start by stating that I am a physical therapist assistant (PTA) educator and have been in PTA education for over 12 years. PTAs are well educated in 99.9% of interventions provided in physical therapy practice, often at a deeper level than the PT because they are not educated in the evaluation, diagnosis and prognosis components of the patient/client management model. Therefore, the bulk of their education is in the proper application of skilled interventions (this includes manual techniques and more advanced therapeutic exercises that involve the assessment of body mechanics and physiological responses). PTAs are well educated in yellow and red flags. They are also well educated in when to request the PT be involved in the patient’s care.

      I am a physical therapist, I have worked with PTAs in clinical practice for over 15 years. The collaborative team approach of patient care has worked very well in all setting I have worked (acute care, SNF, and outpatient ortho settings). It is true that my PTAs would see my patients on days that I would not – but if there were questions or they wanted me to take a look at a patient, we were able to accommodate those needs. The PTAs I have worked with have always been able to provide skilled therapeutic interventions (including peripheral joint mobilizations) that advance the plan of care and the patient’s progress toward the established goals. Even if I am off-site, I was always able to provide the appropriate supervision to my PTAs if questions arose.

      In my experience as a clinician and an educator, the true difference in the role of the PT and the PTA is that the PT is the driver of the plan of care, the individual responsible for making the final decisions on the direction the care should move. However, the PTA can make clinical decisions, apply the appropriate interventions (even the manual ones), and advance the established plan of care, at the minimum, 90% of the time for the majority of patients. Yes, there are patients that are less stable and their anticipated progress is not as predictable, therefore these patients may not be appropriate for delegation to the PTA.

      I do not intend to be argumentative, but I am continuously surprised by the lack of knowledge that many PTs have on the education and role of their assistant (which has been around now for 50 years!). I hope we can move our discussions forward and find a way to progress our profession together so our patients may benefit from cost-effective care that is provided by the least expensive provider. We already know physical therapy can be a cost saver when our patients get to us in a timely manner (and even through direct access). I argue that some patients may benefit from seeing the PTA more frequently than the PT in order to keep the cost of care down. This is happening in medical offices when patients see the NP or PA instead of the MD or DO. Could we do the same? Could our PTAs be the primary clinician for our health and wellness patients? What about a simple post-surgical ACL repair or TKA? I feel strongly that with the education PTAs currently receive, they could perform this triage role well. If these more “simple” patients do not present with any yellow or red flags that would require the involvement of the PT, then they would be able to proceed with treatment.

      I look forward to more discussion! Thank you

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