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Editor's Notes |
jules-rothstein@attbi.com
You've heard it a thousand times before: the physical therapy profession is changing. Contradictions abound. On one hand, for instance, we have the seemingly random evolution of reimbursement policies, such as the regressive Medicare cap, and state licensing laws that would allow us to see patients without referral but not necessarily allow us to bill for such services. On the other hand, we look toward a future with an educational enterprise that honestly rewards new physical therapists for the depth and breadth of their education by giving them the degree they deserve—the professional doctorate.
Whether changes are for good or for bad, we humans tend to look for anchors that keep us tied to where we have been and that make us feel "comfortable." This month's Journal offers both constancy and change. If you like being in a profession that must adapt to the changing needs of patients and society, I believe you will feel invigorated here; but if you want constancy, you'll find that here, too. One constant of our profession is that physical therapists are problem solvers, and this issue is chock full of possible solutions.
There is a "but," however: If you believe physical therapists should practice within very defined boundaries, this is a month when you might want to relegate your Journal to the "do not read" pile. If you choose to do that, though, you will have to consider that this profession may be moving beyond your reach. This month's articles are filled with information from many areas of practice and also include research on education. They are a testament to diversity—not ethnic or cultural diversity, but the equally important practice diversity that allows us to offer so much to those who need our services.
Frese and colleagues (pages 1192–1200), for instance, raise concerns about clinical instructors not following the advice related to vital signs that is given in the Guide to Physical Therapist Practice. Is this a troubling observation for educators and practitioners—and, I might add, for patients? Or, is this a case of practitioners justifiably differing from the Guide? You decide.
For some physical therapists, the use of iontophoresis for plantar warts might seem like something out of prehistory; for others, iontophoresis has always been a key modality in their armamentarium. Soroko and colleagues (pages 1184–1191) describe the application of sodium salicylate iontophoresis for plantar verrucae, contending that the intervention seems to be as beneficial as "other office-based interventions in diminishing the size of plantar warts and their associated pain." The work of Soroko et al is part of the changing face of physical therapy. They describe application of an intervention in great detail and allow for replication of what they did. They have moved from anecdotal description to scientifically credible details.
The study by Soroko et al is descriptive in nature, but the paper provides all that is needed for someone to now conduct a clinical trial, preferably a randomized clinical trial. This is an example of how our profession can grow and garner new clinically relevant knowledge. Out of necessity, research often takes place in small, measured steps rather than in giant leaps. Soroko and associates have given us a first step and have launched us on a desirable course. Because of the research design, we cannot claim with any certainty that iontophoresis caused the benefits observed, but an argument can be made that this intervention seems reasonable to try in the absence of evidence for something more effective and that the results set the stage for research at the next level.
Sander and colleagues (pages 1201–1212) have set us on another desirable path. In the newfound enthusiasm for addressing the often-overlooked problems of postmastectomy lymphedema, too many physical therapists have been willing to settle for outcome measurements that have dubious quality or that are difficult to obtain. Sander et al show us that there are alternatives to the commonly used water displacement methods, and thus they provide for practical and reliable outcome measurements. They also remind us that not all measurement techniques are the same or interchangeable. In February, Karges et al will address this same measurement topic—which means that we will have additive research. The credibility of our practice is becoming less dependent on single studies that are never replicated or reinforced. This is a relatively new phenomenon for the physical therapy profession and should be celebrated.
Because of researchers who care about interventions and measurements used in women's health, we are beginning to see research that establishes the role of the physical therapist in this vital area of practice. Long ignored, this area of practice now requires focused research efforts so that it can be not only something we believe in doing, but something we can justify with evidence. Physical therapists in nations around the world have long recognized their role in women's health and have contributed to research on the topic, whereas the vast majority of physical therapists in the United States apparently have had a lesser interest in this role. This month's Journal suggests, however, that those days have passed.
Few physical therapists would be surprised to find an article on low back pain in the Journal, but even in a paper on that familiar topic, we see signs of change. Strand and colleagues (pages 1213–1223) discuss a back performance scale that focuses on "mobility-related activities." Their efforts reflect our profession's sharpened focus on disability and issues related to function, rather than a fixation on impairments or what we imagine to be relevant pathologies.
Strand et al enter an area of controversy, because physical therapists often disagree about what reflects function. The willingness to conduct research and publish in such a controversial area is, in itself, a sign of changing times. Because we were unable to differentiate the personal from the professional, the physical therapy profession was for too long deprived of the kind of vibrant dialogue that nurtures constructive disagreement and professional growth.
Two other articles, both case reports, also illustrate what our profession is becoming. Greene (pages 1224—1231) discusses the management of a patient with idiopathic tendinopathy following a course of antibiotics. From my perspective, one of the great weaknesses of our literature has been our failure to address and understand treatments that were provided to patients by other health care professionals at the same time that we were providing our interventions. This case report is a reminder that there is one patient—and that all therapies affect the patient. We also are reminded that practitioners who think in isolation do a disservice to the patient. Similarly, Wills (pages 1232—1237) discusses screening for skin cancer in a 79-year-old patient with spinal stenosis. Once again we see an illustration of how physical therapists are a part of the health care system—sometimes a life-saving part, not always because of the interventions we provide, but because of the expertise we bring.
We are moving from practice based on tradition, authority, and anecdote to practice based on diverse and credible peer-reviewed research. Our profession's changing face is reflected in our changing body of literature, and we should all celebrate the variety that shines in these Journal pages.
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