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When I was training to become a physiotherapist, sitting in a sweaty tutorial room in the nations capital; the image of healthcare that was promoted to us as students was an idealistic world where you would interview your client, clinically reason your way to an accurate diagnosis through a series of subjective and objective examination procedures and then finally provide a targeted treatment plan that would restore them back to full health. Fast forward to when I began working in a private practice and most of this ran true, however what I wasn't prepared for were the late cancellations because their kids had to get raced to the doctor; the client who could only afford to attend physio once per month; the one that just fell off the face of the earth when you were almost ready to discharge them and all the concepts that fell in between primarily centred around re-booking their sessions.
All I wanted to do was focus on developing my skills and delivering a treatment plan, yet my main focus and attention was not around the years that I had spent at university being trained at how to fix their problems, it was around making sure that I could keep them coming through my doors long enough and frequent enough that I could deliver the quality of service that I wanted to and that they deserved. Now I know what most people at this point will be thinking... "If you do a good job they will trust you and keep coming anyway". This is entirely true, however how many of you finished a rehabilitation process with an athlete and thought "I really would have liked to have spent more time with this person?" I know I definitely have! In many instances I would have liked to have been afforded the time to appropriately coach my athlete through all their exercise based interventions and progress / regress them on the spot, after all, that is part of our job (to be an effective educator) and at least in the S&C field coaching is the bread and butter of the industry. Providing home physiotherapy programs is akin to being an online S&C coach... great for business, terrible for outcomes!
This leads me to the point of this post. Physiotherapy is currently still living off an old outpatient model of healthcare to which access was slim and thus the minimum effective dose of contact was provided. Decades ago, there was likely one physiotherapy clinic in your suburb / town making access to appointments difficult and practitioners had to prioritise time appropriately to ensure they could spread themselves across their entire population list. These days, there are clinics on just about every street corner and yet the same attitude is promoted, not to mention that most of those clinics usually are just a few small cubicle based plinths separated by some curtains and if you are lucky, there might be an exercise space in the building. We want our patients to receive better outcomes and leave their rehab journey in a better place than prior to entering it however we deliver a model that disincentives attendance, we charge them each and every time they step through the door and even if we wanted them in more we don't have the ability to deliver effective rehab programs.
This model works in the medical industry, namely because there is only so many times that your GP can say that you have a virus and that simple rest and paracetamol along with a normal functioning immune system will fix the problem. In contrast when we are talking about sports rehabilitation there is high value in not only understanding what the patients injury is but also in understanding how they move, what motivates them and their attitude towards training. If I rarely get to see my athlete change direction after their injury how on earth am I best positioned to tell them that they can return to their sport? If I rarely get to see how they move in the gym then how am I best positioned to tell them that they can progress to more challenging load parameters?
In my eyes, the industry of sports rehabilitation in the private sector has an identity crisis at the moment whereby an outdated system is resulting in poorer outcomes for athletes. Just look at the return to sport and re injury rates following ACL reconstruction in the amateur athlete compared to the professional athlete, the difference is chalk and cheese which is a reflection in the starkly contrasting models of performance and rehabilitation that takes place in the pro sector and private sector.
The problem in business is that the world is competitive, cut throat and it results in that too many businesses try to be everything for everybody! Just as you wouldn't go to your GP to get an orthopaedic surgery done nor should there be the same level of expectation that your standard physiotherapy clinic can accomodate for high end return to sport rehabilitation.
There are three possible solutions to the problems currently at hand:
Continue being a wide net catching all fish, however when you catch a salmon you send it to the salmon farm
Upgrade facilities, up skill staff and update business systems to accomodate and facilitate regular athlete attendance
Expand you staff network to include those that can regularly provide rehabilitation coaching services (usually involves upgrading facilities in the process)
For the purpose of providing some context to this blog I am not attempting to attack the profession of physiotherapy. It would be counter-intuitive to do so as it is my own profession, I merely use it as an example as that is what I have experienced in my own career however many other health professions dealing with sports rehabilitation fit into the same boat, whether that be chiros, osteos, EPs; Allied health in general needs to understand that a generalist triage approach will only get you so far. Athletes returning to sport following long standing musculoskeletal injury face a tough set of obstacles in their way. As an industry we need to better position them towards achieving their goals by changing the way we approach their rehabilitation. Triage based models are effective for exactly that purpose, injury triage... not rehabilitation.