Good Therapy Adds Bounce to Your Rebound

May 31, 2005
Good Therapy Adds Bounce to Your Rebound
Published in The New York Times
By JANE E. BRODY

As the demand for physical therapy grows, the supply of qualified personnel is not keeping up, mainly because health insurers keep cutting back on reimbursements for their services, making it less and less profitable to pursue as a career.

As someone who has just spent over four months in physical therapy after surgery to replace my worn-out knees, I can attest to the value of these services for a vast array of clients, from babies with birth defects to the elderly trying to stay active.

I have also learned a lot about how to judge the quality of physical therapy. As one reader, Tina Mosetis of Great Neck, N.Y., noted, "Most therapists do not spend enough time analyzing what is wrong with the patient, and after the initial session they simply direct the patient to do exercises on the gym equipment."

The reader's mother, Hope Mosetis, who has osteoporosis and arthritis, tried six different rehabilitation centers before she found a therapist who treated the whole person, using hands-on therapy and techniques like deep tissue massage and Pilates, as well as tailored exercises to make her joints more flexible, relieve her pain and increase her mobility.

What Therapists Can Do

The American Physical Therapy Association says, "Physical therapists are experts in the examination and treatment of musculoskeletal and neuromuscular problems that affect people's abilities to move the way they want and function as well as they want in their daily lives."

Physical therapists work with people who have sustained injuries to muscles, nerves or joints, suffered strokes or heart attacks, or undergone neuromuscular or joint surgery. They also help people prevent injury and loss of mobility.

Among people commonly treated are those with low back and neck pain, knee and hip replacements, problems with balance, mobility-limiting arthritis, sprains, muscle strains, hip fractures, pregnancy and postnatal movement problems, and chronic respiratory problems.

Therapists can help cardiac and stroke patients regain stamina and mobility and help maximize the functioning of patients with diseases like multiple sclerosis, Parkinson's disease or rheumatoid arthritis.

A properly trained therapist has, in addition to a college degree, a master's degree (and sometimes a clinical doctorate) in physical therapy. Therapists must pass a national examination and be licensed by the state. Some receive additional training in specialties, like hand, sports or pediatric physical therapy.

For example, a hand specialist might be especially helpful to people with carpal tunnel syndrome, a sports specialist to a golfer with back problems, and a pediatric specialist to children with cerebral palsy.

Many people with injuries like badly sprained ankles or shoulder pain from too much swimming think it is best to tough it out. Too often, however, they suffer residual disabilities that are then much harder to treat. Getting physical therapy early on can result in faster recovery and prevent more costly treatment later.

For example, patients who delay physical therapy after knee replacement may never gain full extension and as much flexion of the joint as the prosthesis will allow. As a result, they may limp or have lasting difficulty descending stairs.

Patients who are not able to travel to physical therapy can often obtain services at home from therapists who make house calls.

Cost should not be an obstacle. Medicare and Medicaid cover needed physical therapy, federally qualified health maintenance organizations are required to offer physical therapy, and nearly all health insurers cover some physical therapy. But check with your insurer since precertification is sometimes required.

While most states do not require a physician's referral, New York and Connecticut do, as do Alabama, Georgia, Hawaii, Indiana, Kansas, Michigan, Mississippi, Missouri and Oklahoma.

Sorting Through the Policy

Your policy will define who is eligible for the therapy and the amount of care that is covered. Some policies limit sessions by the year, others by the condition being treated and still others by a strange designation called "per episode of care." One young man's ridiculous policy covers 30 sessions a year but only within a 30-day period.

Almost no one can arrange for outpatient physical therapy seven days a week for 30 days. It could even be harmful since muscles need a day of rest between strengthening sessions.

If you or your doctor believe you need more physical therapy than your policy will cover, you are entitled to appeal. Call the insurer's member services department to find out how to file an appeal.

As with any profession, there are good physical therapy practices and not so good ones. Boris Gilzon, a physical therapist in Brooklyn, outlined important criteria patients should look for. First and foremost, the therapist must be licensed by the state and have a reputation among patients and local physicians for providing good service. For example, the Hospital for Special Surgery in New York, which visited Mr. Gilzon's center and watched how the therapists worked, lists it as a recommended center.

The space in which therapy is provided should be adequate and the therapist should use a variety of techniques, not just gym equipment but perhaps also yoga, electrical stimulation, heat and ultrasound.

The first visit should include an objective history and a look at the total person, not just an isolated body part that is the current complaint. The therapist should also discuss the patient's goals. Therapists who take a narrow view can limit a person's ability to achieve desired goals.

For example, after total knee replacements, my goal was not simply to be able to walk to the subway and go up and down stairs. It is to return to favorite activities my arthritic knees forced me to abandon, including tennis, ice skating, cross-country skiing, cycling, hiking and gardening.

While I may not be able to do all of these, I want several to be on my postoperative agenda, and that means I need to achieve more flexion and stronger supporting muscles than, say, a person whose only goal is to walk a few miles.

During prescribed exercises, both stretches and strengthening ones, the therapist should pay attention to details and observe the patient's technique, since, as Mr. Gilzon said, "doing an exercise incorrectly doesn't do any good." Only after patients have mastered an exercise should they be left to do it on their own.

Consider as well how much time the therapist spends with the patient. The therapist should not be constantly hopping from one patient to another, giving each a minute at a time. The purpose of each exercise should be explained, as well as what you should feel while doing it so you can tell whether you're doing it right when the therapist isn't looking.

Finally, the therapist should give patients exercises to do on their own, between treatments and after therapy is completed. You don't want to lose what you gained through all that hard work.

Jane E. Brody can be reached at personalhealth@nytimes.com.