Privatization of adult outpatient physio in Manitoba the latest symptom of a bigger problem

As the Physio Moves Canada team prepares for the long drive from Ottawa up around the Great Lakes and into Winnipeg this weekend, we are learning about the Winnipeg Region Health Authority's decision to remove public funding for outpatient adult physiotherapy services, effectively meaning that the largest segment of the population who requires these services for their livelihood (working age adults) will very often find these services inaccessible.  I'm referring in particular to the middle class, those who will not pass the 'means test' on income because they are not in the lowest income brackets, yet also struggle to get by on a monthly basis leaving very little left over for 1 or 2 physio visits per week at, say, $45-$90/visit (or up) depending on where you go and the level of service needed.  This has been touted by WRHA as a cost saving measure, possibly saving the authority somewhere in the range of $1.5 - $3 million in the first year (of an apparent $83 million reduction target mandated by the province).  This is bad, this is bad not only for the profession but for the Canadians that rely on physiotherapists for their pain and mobility management needs.

Physiotherapists are medically-trained rehabilitation experts for issues of mobility and non-pharmacological pain management.  If we start with the second of those, non-pharm pain management, it is gob-smackingly shocking in our current opioid climate that WRHA should be restricting access to an alternative pain management approach.  It would be over-reaching to say that we should expect to see an increase in opioid abuse as a result (far far over-reaching) BUT when the rest of the world is looking at ways to increase access to opioid alternatives, Manitoba appears to be heading in the wrong direction.  

The mobility piece however may be the even more concerning issue but one that isn't currently as sexy as pain.  If there's anything I've learned as we near half way through the Physio Moves Canada project, it's that mobility forms a critical component of the identity of Canadians.  If your mobility is impaired, you may have difficulty working (and earning an income, so that you can now pay for physiotherapy... ugh), you may have difficulty looking after your family, maintaining your home, or living without depending on other people.  All of these things have the potential to increase costs borne by the tax base, possibly through greater reliance on social support services, disability or unemployment insurance benefits, mental health services (I've become convinced of the intimate tie between independent mobility and mental well-being), and in what should be the most ironic twist in all of this - greater burden on public health services!  We've already seen this in Ontario, where adult outpatient physiotherapy has been delisted from from the Ontario Health Insurance Plan (OHIP) since 2005.  For those unable to access appropriate physiotherapy care, their only options are to look for less expensive (and less trained) alternative providers often meaning they are off work or otherwise disabled longer, or go to medical clinics and emergency departments for help and advice.  So while the delisting from WRHA may indeed save let's say $2.5 million in the first years of their budget, it will very likely end up costing the authority overall much much more in chronic disease management, orthopedic surgeries, psychological and social counseling services, and primary care visits (to speak nothing of the burden on social assistance systems), all of which can be ameliorated by timely access to good quality physiotherapy care.  Of course it's not as though the WRHA will see that link, and suddenly reinstate adult outpatient physio - it will be lost to the sands of time, and 5 years from now they will note that costs were not in fact reduced as expected, and some other service will be changed, cut, 'optimized' or even added, all of which could likely have been avoided in the first place.

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And now we come to the title of this post.  I'm continuing to hear from clinicians and clients that physiotherapy has a branding problem, and we also appear to have a problem supporting our national advocacy body.  Now I'm not saying for sure that these are the driving forces behind this decision (the driving force can be more easily described as dollars and cents).  But, why physio and OT are being cut, why not orthopedic surgery?  I know right, that sounds insane.  But why does it sound insane?  There's an increasing tide of evidence to suggest that many common surgical procedures, especially for knees, backs, and shoulders, have no better outcomes than a good course of physiotherapy while being far more costly and risky.  Yet can you imagine the outcry, from the Canadian Medical Association, consumer advocacy groups and the general public if something as hallowed as orthopedic surgery was suddenly something Manitoban's had to pay for?  One wonders what would have to happen for physio and OT to trigger the same level of emotional response in the public as this bonkers idea of delisting orthopedic surgery.  My suspicion, based on nothing more than my experiences engaging clinicians (and as a 20 year member of the profession myself) is that there are not enough members of the public, or even our colleagues in other professions, let alone health care administrators and policy makers, that adequately understand the value that physiotherapy brings.  I keep saying this, and perhaps at some point I'll try it: if I were to ask members of the general public walking down the street what an orthopedic surgeon does and when you should see one, chances are most could provide a reasonable answer fairly easily.  What a chiropractor does and when you should see one, again I suspect the answer would come easily (whether or not it's entirely accurate) because chiropractors as a profession have done a superb job claiming a key piece of the public mindshare.  What about what a physiotherapist does, and when you should see one?  I expect this to be a more difficult answer especially for those who have never engaged physio services.  I could point to several reasons for this, and am hearing about many more from clinicians in Canada, but regardless of the mechanism(s), we appear to be suffering an identity crisis.  Even within our own profession there appears to be far too much infighting - one only need to spend a half day on Twitter to see evidence of that.  So when a group like the Winnipeg Regional Health Authority is looking for a professional body to cut from its funding model, which one is likely to cause the least outrage?  How about this one over here that can't seem to even sort its own self out as to what it's meant to be?  

Which brings me to the last point of this lengthy post, and that is this: only through strong and healthy national and provincial advocacy bodies can we earn back some of this highly valuable stakeholder mindshare.  In Canada that means the Canadian and provincial Physiotherapy Association(s).  Full disclosure here is needed: most of these bodies are providing some part of the funding for the Physio Moves Canada project, though are doing so at an arm's length meaning they have no control over the findings and publications.  So take what I'm saying with the appropriate skepticism you should be giving to all such online 'talking forums' - but rest assured I am saying this from a position of someone who wants to retire in 25 years as a physiotherapist, meaning that there will need to be a physiotherapy from which to retire at that time: we need ALL Canadian physios to participate in the advancement of our profession, and currently the best way to do so (in my mind) is through supporting the CPA and its provincial branches.  These are the people that are advocating and fighting on our behalf.  Winnipeg is simply the latest consequence of a professional voice and brand that needs to be clearer, louder, and prouder - we need to come together.

Mobility as the 6th Vital Sign?

Will be fashioning this vision as we progress through the PMC project, so consider this just getting the thinking juices flowing.  Some readers will be aware of the American Pain Society's 'Pain as the 5th vital sign' initiative that was introduced in the mid-90s and ramped up in earnest in the early and mid-2000's.  The intention was to elevate pain and its management to the level of other vital body functions that are routinely assessed in medical contexts, along with temperature, heart rate, blood pressure and respiration rate.  It's hard to objectively say how well it actually worked, with evidence generally indicating that patients were having their pain assessed more frequently, but that pain management was still inadequate.  Of course, many of you will also know that there have been recent calls to remove the pain as the 5th vital sign owing to the ongoing public and political movements around the so-called 'opioid crisis'.  So, hard to say at this time what that initiative will end up looking like, but at least I would say the spirit of the initiative was in the right place.

So on to mobility.  I'll cop to the fact that I've often said that physical therapy doesn't save lives, but it gives lives back.  And I thought that was a very admirable and supportive thing to say about my profession.  But as we're traveling across Canada to better understand the concept of mobility, I'm realizing that I was very likely wrong - adequate mobility may well save lives.  I'm going to have to tiptoe slightly around the precise nature of the qualitative narratives I've been capturing as they are part of an ongoing research study, but I can say it has become clear that without adequate mobility (and the 'adequate' word is intentional here as it differs by person and context, more on that in a later post) the lives of many may well be at risk.  Consider the fishing villages in the Atlantic provinces, at which residents must work HARD during the summer months to ensure they have enough food and supplies to last what are often fairly harsh winters.  No one else is going to do it for them if they can't.  Consider our military personnel for whom mobility (defined broadly and in different ways) is what may save the lives of you, your squad mates and the people you're trying to protect in active combat zones.  Just today I see that the province of British Columbia has issued a state of emergency and has evacuated thousands from the province's interior due to raging wildfires.  Those who are immobile must rely on the aid of others or perish.  And then there were even more unexpected things that have emerged through these conversations, from more than one physio patient, who have stated that their mobility is such a key aspect of their personal identity that without it, they were in danger of losing the will to live.  

So, what would a 'mobility as the 6th vital sign' initiative look like?  Could we adequately argue for mobility as a basic function of human life?  What would that mean for nursing staff on inpatient wards - they were trained to assess pain better, could they be trained to conduct basic mobility assessment?  Does that then mean increased demand for physiotherapy services?  Would that mean mobility intervention would have to become a publicly funded service in our socialized health care system?  Does that then lead to more physios in primary care and preventative roles?  Would that mean physios are required on all inpatient wards in hospitals?  Long term care facilities?  Does the public then get an annual 'mobility check up' in the same vein as annual physicals or dental checkups?  Could there be any potential fallout, as per the pain as 5th sign initiative?  Is this all taking the concept too far?

I don't yet have a clear vision of what this can or should be, or if it's even worth pursuing, but one has a lot of time to think when driving for several hours at a stretch, so consider this little more than a musing at this time.  Would love to hear your comments though.

Cross-Cultural Validation of PROs is more than language translation

A fairly late night and long day today, so missed our chance for a good video update as the sunlight burned off quickly.  We've spent the day in Twillingate Newfoundland, a historic city of just over 2,000 permanent residents originally settled by the french.  It's gone through several hundred years of ups and downs and according to the local residents, is currently experiencing a bit of a down in terms of economy and jobs especially for younger people.  In wandering around this town not only have I been awestruck by my first experience seeing icebergs (they are STUNNING!), but it also got me thinking about the way we use patient-reported outcomes (PROs) to measure mobility issues in our patients.  Some of you will be familiar with common physio PROs like the Lower Extremity Functional Scale (LEFS) or the Upper Extremity Functional Index (UEFI).  My mind immediately went to some of the questions on the LEFS, in particular ones asking about difficulty walking a block, walking a mile, or running on even or uneven ground.  While having a wander round Twillingate I tried to imagine how residents of this quaint fishing town with its homes shoved literally into the side of some of the hills around the area would answer those questions.  There are no 'blocks' here, so a question about difficulty walking a block would have no meaning.  I doubt many of the residents I've seen run all that often, yet in some cases the 'simple' act of walking from their home to their outbuildings is likely biomechanically and energetically speaking just as difficult as running (at least running on even ground), so they may indicate they don't run on even ground, yet mobility-wise are likely very capable - perhaps moreso than those of us who run on even ground.  And then there was the story of a patient who described the mechanism of her lower extremity injury to her doctor as 'I jumped off my bridge' to which her doctor (not a local) responded with concern about her clear suicidality.  As it turns out, your 'bridge' in newfoundland-ish is the front step of your house.

Here's my point of this - many scales we use (or arguably should be using) have been tested for adequate properties of validity and reliability.  The good ones will then usually get picked up by people from other global regions but before then can be implemented they must be 'cross-culturally adapted'.  In every single case I can think of, cross-cultural adaptation has been in fact the process of a language translation, with the presupposition that people who speak the same language, or at least who live in the same country, must necessarily interpret the items in the scale the same way.  Yet this is the value of the firsthand experience I've already gained on this project - clearly this presupposition is incorrect.  Perhaps it's time we start looking at our tools, in particular in a country as geographically and culturally-diverse as Canada, as requiring cross-cultural 'validation' (or even translation) in the same language and within the same country.  I seriously can't think of a single time this has happened so correct me if you know of one, but I can tell you the good, hard-working folks here in Twillingate would have a rough time fully completing the LEFS, and I'm fairly certain the way they do respond would give their clinicians an inaccurate view of their actual mobility.

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