Wellness Visit With a PT???...Our Worsening Identity Crisis

Not a single PT from this previous post regarding our profession's identity crisis responded that they make their living at health and wellness PT. Now we exacerbate the problem by having our professisonal organization recommend that consumers get an annual health and wellness check-up? Initiatives like this discredit what we do well and make our identity even more ambiguous. What's next? See a PT for bed wetting or depression? This is very painful for me to publicly admit here, but we are now no different than chiros who advocate that consumers get annual spine health check-ups to correct vertebral subluxations.

For the life of me, who is driving all of the health and wellness initiatives at APTA? Mr. Barnes, please save us from ourselves before we self-destruct. We need focus on our core identity.

John

Comments

[Selena Horner]

I believe we are well-versed in our training in the area of health and wellness, especially for the populations at risk with potential decline in function due to comorbidities. I don't necessarily believe that every person requires an "annual" visit with a PT, but it sure would be nice to have the opportunity to work with people who have received recent diagnoses to educate them on exercise and activities. I view our role more in the realm of consultation or education. If the person required more assistance for incorporating change than we could assist in the process. Granted though, to be effective the person needs to be ready to change - I don't know psychologically at what point in time a person with a recent diagnosis would be ready to learn from us and make the required life changes.

I am all for the addition of PTs being included in the "Welcome to Medicare" visit. It would be a good thing if we could have a role in potentially reducing falls, improving balance, educating on osteoporosis, and discussing activities that might be beneficial to help improve the likelihood of independent living. This population would have increased awareness about factors that can affect their independence and at the same time provided with a familiar professional for future needs. Depending on how that visit with the PT was structured, some good baseline data could be provided to the PCP which may assist the PCP in referring to PT when changes in function occur in the future.

[Cameron MacDonald]

All,

The promotion of an annual visit to a PT is being rolled into already planned marketing strategies by the APTA. When CMS set up the welcome to Medicare visit within 6 months of turning 65, they chose to recommend PT ivolvement in this screening, thus we are looking to be recognised as experts in musculo-skeletal assessments and to be part of this process. It was not the general consensus to try and generate a large body of new paying clients to support our practices.

There are many intertwining issues here, the House bill for the promotion of the annual visit to PT and the Medicare welcome visit was modified to lessen the financial impact of the policy, and to also not detract from the associations primary purpose of allowing direct access for all patients to a PT in whichever jurisdiction that they live in. This is part of the overall approach to attain 50 states and 2 districts (DC & PR) with direct access. We currently have 44 states with direct access in some form.

Discussion in the house specifically took place to not have these bills detract from a more focussed approach to marketing what PT's are, musculoskeletal injury and movement experts. It is important to note the big picture, health, wellness, screening, and preventative medicine that are all important issues currently in the US House and Senate with regard to reforming healthcare, and making legislative decisions on health care provision.

PT does have a very unique skill set to lower the cost of health care, but we need to see people with musculo-skeletal dysfunction earlier in thier episodes of dysfunction to be able to exert this influence/ provide the care needed. Consider the 16 days and LBP.

With due regard to the issue of following the DC's down the path of screening to find subluxations, this is a valid concern, and it is encumbent on each PT to recognise first that a patient needs PT, and where skilled care needs to be provided versus enabling a patient to take an active role in their own care. With autonomy comes responsibility, the evidence trend is that when PT's initiate the plan of care themselves (i.e no referral), the cost of care and the number of visits is less.

It is a complex discussion to view the motions of the HoD, the motions brought forth by the Geriatrics section to the HoD and the change in PT due to the DPT and vision 2020 from a marketing perspective. ONe can easily be lost trying to identify where the APTA is trying to go, the answer is where we send them.

As John says, if you do not like the policies make sure you are a member and be involved.

One other thought, and one that I work by is that the greatest form of marketing is word of mouth. What each of us do daily in the clinic frames the opinon of one more person at a time as to what PT is, what its value is and wether they will be coming back in the future or wether they are going to recommend another health care provider to their family and friends.

Cameron

[John Ware]

I'm going to go with the APTA marketing department on this one, John, at least in regards to the "Welcome to Medicare" inclusion of PTs. For instance, if we know that 8/10 people have a LBP episode at some time in their life, then by the time someone is 65, the odds are probably even higher- and how many of those got timely PT, or any for that matter! They likely have some lingering impairments, and maybe even disabilities, that they have just gradually gotten used to and written off as "old age."

Perhaps we could focus the annual check up campaign towards certain groups of people, like senior citizens or people with hx of NMSK disorders, kind of like physicians screening for prostate cancer in men over 50 and mammograms for women over 40 with family h/o breast cancer. I agree with you that we don't want to come across like the chiros looking for problems that aren't there.

I'd like to see more epidemiolgocal studies brought up for PTs to look at, like those on the incidence of hip OA in people with certain structural variations or dysplasias, to find out what kind of preventative role we may be able to play in certain groups of people with potential problems down the road.

We have something to offer in the wellness and prevention areas, I think. We just have to be smart and creative (versus greedy and "turf-conscious") about how we market it.
John

[John Childs]

The comments dealing with the 'Welcome to Medicare' initiative make me think we are confusing RCs. I completely agree with the 'Welcome to Medicare' initiative (RC 30-07) and that PTs may have a role in fall prevention screening, etc. However, the notion that all consumers (ie, every adult in the US) should "visit a physical therapist at least annually to promote optimal health, wellness, and fitness, as well as to slow the progression of impairments, functional limitations, and disabilities" (RC 28-07) is a complete farce and a recommendation without any substantive evidence-based rationale. The RCs were adjacent to one another in last week's PTB Online email, hence the confusion? These are separate recommendations. Bottom line, I am fine with targeted screening where it makes sense and there is come compelling rationale. However, blanket recommendations to annually see your PT is a complete joke and makes us look foolish.

John

[Selena Horner]

In regard to the annual PT visit, well, you have to remember that the APTA is tackling that, but with who? I mean, the APTA HoD can say whatever it wants and can have recommendations for every person in the US, but reality is that means what in the big picture? Who is going to listen to that recommendation? Who really and truly cares about the recommendation? Is the target audience consumers? Is the target audience third party payors to include an annual PT visit in preventative care? Is it just something sitting there within the APTA to assist those few PTs moving into the wellness/fitness world to substantiate themselves?

If the target is third party payors, something like what is written as written won't be accepted - if it were accepted it would be negotiated down to something like every 5-10 years starting at the age of 40 or 50 and maybe define the population that might require sooner assessments. Third party payors would probably look at what age their costs increase and for what diagnoses. At what time does it cost to not have optimal health? If the greatest costs tend to fall on Medicare, do other third party payors care?

[Greg Specht]

I remember hearing that in the 1950s, dental professionals focused on fixing problems rather than prevention and at the time the average American's teeth were in pretty bad shape. Based on experience many dentists began to recommend regular check-ups and cleaning and over time the twice-yearly visit to the dentist became recommended by their professional organizations. I’m sure there was concern at the time that this was a bad move for dentistry however it seems that it has been good for society http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1116309.

I think APTA is moving in the right direction although we might find that a yearly PT exam for all individuals is a little more than necessary. With that said, I think that most musculoskeletal disorders are more often than not preventable (much like tooth decay and gingivitis) and physical therapy should be involved with treating these problems from both perspectives. This is a great discussion!

Greg

[Carina Lowry]

This discussion is absolute absurdity. We as PT's want to have it both ways? Do we complain about wellness related issues--obesity, heart disease, and couch potato-ism? Then we rant about having a wellness visit where we as PT's can address this and make recommendations? Am I the only one that can't understand this?

The ability to be included in the Welcome to Medicare screening is good news. It will MARGINALLY improve the bottom line, but more over will be excellent marketing for PT's. OR do we leave health and wellness for ATC's who are already trying to limit our scope of practice. We can hide our heads in the sand, but this is happening in MN...with the new ATC bill allowing them to see "patients". This inclusion will make direct access more readily available and make it easier for those states who have restrictions (like MN) that only allow for 30 days of direct access to provide health and wellness type services.

Thinking that it will only lead to PT's taking advantage of the system by diagnosing ills that are not present is a valid concern but this could happen anyway and should be a part of our code of ethics--oh wait it is--it's called "professional behaviours".

As primary care providers for musculoskeletal complaints why are we limiting ourselves by not supporting the ability to be first line providers in the populations most likely to have knee and hip OA, spinal stenosis, and obesity??

I support our professional organization on this one. The picture is much larger than we can see right now.

Carina

[John Childs]

Carina:

It is not an either/or scenario. The reality is that although annual health and wellness sounds like a great idea (baseball, Mom, and apple pie), we live in reality. Who is going to pay for this? Also, very few PTs operate in a health and wellness niche (I am still waiting for the first one to comment here that they make their living providing health and wellness services.). Therefore, we don't have any scope of practice to lose because we're not doing it now! All sorts of health and wellness initiatives can supplement the traditional care model.

Marketing is about highlighting where we fit best and our core identity, which is the management of patients with neuromusculoskeletal conditions. All other areas of practice could ride far better coattails on this campaign than smaller diluted campaigns of their own.

And as far as ATCs or any other practitioner, I am more concerned about ourselves. If we focus on who we are, we have absolutely nothing to fear, and the public will figure it out.

John

[Greg Specht]

John,

Is prevention of neuromusculoskeletal conditions not a part of their management?

Correct me if I am wrong but you appear to be making an argument in support of the status quo. Instead of evolving into a profession that places an emphasis on prevention, you would have us… get better at treating, promote how good we are at treating and do more research? Don’t get me wrong John, I respect your contribution to EBP in PT and I understand your concern about diversifying the PT “brand” so much that people do not understand what we do. It is a valid concern but one that needs to be handled while moving forward.

Health insurance is changing with insurers giving incentives (lower rates) to subscribers who engage in wellness activities http://www.projo.com/health/content/projo_121806_healthcare.20831f7d.html and Medicare has their Prevention and Wellness Initiative http://www.cms.hhs.gov/MyHealthMyMedicare/02_HealthierUS.asp.

This is the future and we will do well by educating the public about our ability to prevent, as well as treat neuromusculoskeletal disorders to become known as the health care professionals of choice for these problems.

Greg

[Carina Lowry]

John,

I'm afraid I just have to disagree with you. I am soon to be 31, I run at least 10 miles/week, and have a BMI of 23.8. Despite this, I have all kinds of "wellness visits". I see the dentist twice a year, see the optometrist once a year, check my glucose and cholesterol, see my ob/gyn once a year and have been since I was 16. That's 15 years of poking and prodding disguised as "health and wellness" visits paid for by insurance. I also encourage my spouse to get his cholesterol and glucose checked among other things that are much less pleasant to discuss. My point is that insurance does cover other health and wellness visits.

I am not sure why PT's don't operate in more of a health and wellness mindset. I do know of a colleague who does a lot of health and wellness here in town and he had exclusive referrals from the bariatric center. That's pretty good business. Another colleague works exclusively with high school athletes and the parents private pay. Still another colleague works at the only PT clinic in a 25 mile radius who also offers gyrokinetics, yoga, and pilates as classes for their patients.

There is only opportunity if we see it. RC's such as these improve probability to get reimbursement, improve our ability to change legislation to garner unrestricted direct access, and improve marketing to supplement with health and wellness programs. I don't know about everyone else, but my patients are my best referral sources....

Carina

[Selena Horner]

Does the general population really need a "wellness" visit with a physical therapist to promote a moderate-intensity physical activity for 30 minutes or more every day of the week? For the general population, if exercise isn't being performed, is the recommendation to exercise by a physician adequate enough? Don't most gyms have personal trainers that can motivate and initiate the exercise process? For the generally healthy population, are our skills necessary?

I can see having a role in health and wellness for individuals with comorbidities, but for the general population I don't believe our level of skill or knowledge is required. The general population in the most simplest terms requires a definition of moderate-intensity physical activity. How difficult is it to implement 30 minutes or more of physical activity a day once you know what moderate-intensity means?
Sure, it's physical, but it isn't "therapy." It's more like babysitting. I believe my time is more reasonably spent with someone with co-morbidities who requires my skill set to effectively implement a program that considers the various interactions between their additional variables.

One could argue that "preventative" is the key before any co-morbidities occur. Well.. I'd say that the majority of the US population knows about the hazards of smoking, the risks of poor nutrition, the impact stress can have on their lives, and the importance of exercise.

I'm treating a lady right now with asthma, emphysema and COPD... she was a smoker up until the end of last year. She had the lung problems supposedly for the lasat 8 or 9 years and smoked all the way up until the end of last year. I'm very sure she knew all about the risks of smoking, but she did it anyways. I'm sure every annual visit with her PCP, the issue of smoking was brought up and she was educated on the risks of smoking and advised to stop and probably even offered ways to stop smoking.

What impact would having an annual visit with a physical therapist have on the general population? Would it really lead to increased exercise habits at the appropriate intensity for the recommended duration and frequency? I'm assuming impacting exercise habit would be the goal for an annual visit with a physical therapist.

[John Childs]

I am not disagreeing that health and wellness initiatives are important. However, we should be focusing our marketing efforts on differentiating skill sets that we offer that few others can. Many types of health and fitness professionals are well qualified to provide health and wellness services, many of which are not skilled interventions in the first place. For aspects that are (ie, body fat testing, ECG, etc.), there are other professionals as capable or more capable than we are (ie, exercise physiologists). It baffles me as to why we feel so compelled to be all things for all people and insist on marketing ourselves like personal trainers and fitness professionals rather than a health care professional. The public already thinks we're your stretching partners...why do we want to further cloud the difference by making ridiculous arguments that our recommendations to exercise will somehow be more effective than when said from others. This reminds me of the acute care setting where we try to make a science out of getting someone out of bed and walking them. This is not a skilled intervention any more than making health and wellness recommendations, the large majority of which are common sense. Consumers need fitness professionals and life coaches in this area, not a physical therapist. We have more business than our entire profession could ever handle if we would simply differentiate ourselves rather than insist on looking like and being afraid of everyone else.

John

[Diane]

"Also, very few PTs operate in a health and wellness niche (I am still waiting for the first one to comment here that they make their living providing health and wellness services.)."

I submit that we already ALL do, that we already *are* health and wellness experts. PT already *is* a health and wellness provider, as an entire profession, and always has been.

If you aren't a medical doctor who deals with emergent ill health or tries to keep someone alive against high odds, you are then nothing *but* a health and wellness provider, a feel-good (or at least feel-better) provider. We've always done this and done it the PT way - there's no need to copy anyone elses' 'health&wellness' marketing ploys or try to occupy any niche but the one we already have and always have had. The idea sounds fine to me, raises the whole profession's profile. Sounds like recognition will be given where recognition is due.

[Dale Avers]

John and others,
As a member of the Exercise Task Force of the Section on Geriatrics who conceptualized this motion, the Welcome to Medicare and the PT as role models for healthy lifestyles and exercise motions, I feel compelled to respond to this discussion.

First, RC-28 as originally proposed, only mentioned older adults. As is typical, the motion was modified to increase the chances of passage. Thus “all individuals” was added. I will let others reply to the "all individuals" addition and confine my comments to the older adult issue.

Most of us are aware of the insidious loss of strength and power that occurs with aging (1-3%/year depending on the degree of physical activity). This loss of strength and power has functional consequences and leads to disability including increased physician and PT visits, nursing home placement, increased fall risk, and increased risk of morbidity and mortality. There is unequivocal evidence for these consequences (I will be happy to provide references).

This motion was stimulated from the preventative stance of the dentistry profession - of which one comment has already alluded. Is it such a leap for us to address potential impairments BEFORE they cost society lots of $$$$$ and produce devastating effects on older folks health, function, and quality of life? I think this sort of movement to prevention for older adults is not only prudent from a societal perspective but also is our ethical responsibility. We know that the more an older adult slips down the slippery slope of aging, the less likely he/she will be able to recover significant functional abilities. Prevention of the loss of these functional abilities is the key and has ramifications on health care costs.

John, I wish I could say I make my living from offering wellness services. While I do conduct wellness-oriented classes for fall prevention and fitness, I don't make my living off of them. But many PTs are moving in this direction and I know of several PTs in the Section on Geriatrics that do this for their living - only accepting private pay. They may not be aware of this blog and thus have not spoken out.

We do need to differentiate ourselves - and I feel exercise is one of the ways to do this. Thus the Section on Geriatrics is promoting the PT as THE exercise expert for older adults. These motions are ways the task force is promoting this initiative. I am thrilled so many people on this blog also believe this is an opportunity for PTs that is important for the profession to address. Perhaps it is prudent to view these motions as how they will affect the profession in its entirety, rather than from how they will impact any single individual.

Dale

[John Childs]

Dale:

This history is very helpful and explains everything. I would argue that the motion started as a very good idea (exercise in older adults, balance and fall screening, etc.) and morphed into a 'if a little is good, then a lot must be better' strategy. When it comes to Medicare, geriatric exercise, etc. count me as the biggest supporter because evidence clearly suggests a potential huge benefit. The aging of our population positions physical therapists perfectly for this area of practice. There are also many perplexities about exercise in the older adult (osteoporosis, fall considerations, etc.) that put this in the category of skilled intervention. We should market the heck out of a physical therapist's role in this area. In fact, if I were a new PT and/or primarily in clinical practice, I would start pursuing specialty certification in geriatrics tomorrow. This will be the fastest growing specialty area in the next 10-20 years for sure. However, I completely disagree that it's a good strategy to extend annual screening recommendations to every healthy human (kids?, marathon runners?, etc.). There is virtually no data to suggest that identifying musculoskeletal impairments in healthy people and attempting to modify them has any protective benefits whatsoever, similar to the fact that there is absolutely no data to support chiropractic claims that manipulation is protective against illness and injury. The other issue is that 'healthy lifestyle' recommendations, 'fitness coaching', etc., albeit important, can readily be effectively provided by others in a more efficient manner and at a less expensive cost. I agree that all of us are already in the health and wellness business and to the extent recommendations are coupled with the traditional care model, great! This is a perfect time to remind consumers on the importance of exercise and healthy living...they are a captive audience in the midst of pain! I also do not take issue at all with physical therapists being involved in 'health and wellness' arenas outside of the traditional care process. I just don't view it as necessarily a skilled intervention that we should be marketing, any more than I view ambulating patients in an acute care setting as a skilled interventions. The PT running alongside their patient will replace the PT dragging the IV pole as the next worst possible picture of differentiating PT as a skilled health care provider. Unfortunately, the 'feel good' side to our profession, peace gene DNA, etc. kills us in decisions like this in my opinion and causes us to do things that are not in our best interests. This has been a very healthy debate with lots of valuable inputs. Our profession would benefit from much more argument and debate.

John

[Jon Newman]

Ian Stevens posted some relevant reading over at SS. Check it out. (I'm not certain the link will work and sorry for my inability to truncate it in this venue.)

http://www.somasimple.com/forums/showpost.php?p=32956&postcount=18

Also consider this by Frank Furedi

http://www.frankfuredi.com/articles/healthobsession-20050323.shtml

I agree with John on this even though part of my job is acute care.

[Greg Specht]

Dale,

I think you and the others on the geriatrics section Exercise Task Force have helped PT to take a great step forward with RC 28-07 and 30-07.

Thank you for spearheading these motions and I applaud your great passion for this area of practice.

Greg

[Dan Pinto]

John

I am the supervisor of physical therapy and wellness at Denver's transportation agency. I primarliy see patients, however my role is to promote wellness within the organization and save $$$ by instituting new programs. I think this should certainly be an area of study. Perhaps another point of contact by a musculoskeletal expert would improve health in society to a financially reasonable degree.

Dan

[Anne]

I need to thank Dale for sharing some of the history behind these RCs and would like to add a bit more as a delegate and as the Vice President of the Section on Geriatrics and the Board liaison to the Task Force that developed these motions. I am only going to address the RC on the annual visit as many of the posts are mixing discussion on the Welcome to Medicare visit as well.

Dale is correct that our original intent was to introduce the motion as an annual visit for older adults. Anyone who is familiar with the House of Delegates process will know that it is rare to be able to pass a very specific narrowly focused motion and I would say, especially one focusing primarily on the older adult. We know that there is good evidence for prevention with the older adult population but in reality, there is not evidence that an annual, bi-annual, every five years, etc visit is most effective with any population, including older adults. One could argue that APTA should do pilot studies then larger trials to determine what is effective and then adopt a position of support for this. In reality, we need a position adopted by the House to tell APTA- we want to see this become a priority- please work on it.

We envision this being a relatively long process of internal marketing- teaching PTs how to screen healthy individuals, how to promote to your current patient population the concept of returning for a re-check instead of waiting until they re-injure themselves- before any big external marketing push to the public could begin. That is why we withdrew the subsequent motion asking for a PR campaign associated with this concept- it is too early to market this- we need to develop the groundwork first, let some pilot studies or at least case studies get done, have some practitioners use the concept and provide feedback to APTA on how to better educate the entire membership to accept this responsibility, and not abuse it as we feel other healthcare practitioners do.

Once we posted the motion and even as early as February at CSM when we shared the concept, immediately some asked, "why only adults? Why not all individuals?" From our standpoint, we wanted to keep the focus on adults as we recognize that there is little to no evidence yet for annual visits with an adult population and we felt that extending it to everyone, ie including kids, was too broad. So we responded consistently that we intended to keep it as adults and others could try to amend it as they like on the House floor. There was discussion in House forums, though not much on the House floor, about the change to "individuals". The Pediatric Section felt that we can have a huge impact on childhood obseity, juvenille diabetes and other disorders by early intervention. Not practicing in that area, I have no idea if there is research to support that or not. The House voted to change it to individuals, perhaps in a "feel good" attitude or perhaps knowing that APTA will use the position to begin the process and begin to try to define what are appropriate intervals for different populations. I believe that it is the latter. There was some discussion in House forums about changing "annual" to "regular" but it did not get amended on the House floor. As work begins in this area, the position may need to be revised as House positions often are.

Personally, I see the motions brought forward by the Section as potentially having a huge impact on our profession. Many years from now, I hope these ideas are so ingrained into our profession that new graduates will assume we have always had regular screenings and visits with certain populations and that Medicare beneficiaries have always been given the opportunity for a PT visit upon entrance to the system if needed. Much as early PT pioneers championed the idea of PTs doing diagnosis before there was likely much/any solid literature on the topic, yet we now clearly have integrated that into our profession, I would hope to see the day that the same occurs with the concept of an annual visit to a PT though it will likely be modified based on research by that point. I want to see the day that just as many patients talk about "my chiropractor" or "my physician", they also will talk about "my physical therapist" and I think this position will begin us down the path towards this idea.

Thanks for the discussion- this is exactly what our profession needs.
Anne Coffman

[Selena Horner]

Anne and Dale, I completely agree with the original intent of an annual visit for older adults.

I disagree with how broad the RC became. Granted, I'm not one to play political games; that is not my strength. The way it reads right now, it appears to me we're jumping on the healthy fad wagon (maybe with a goal of increasing our bottom lines from a business perspective) without any supporting evidence that we would effectively improve the wellness of all individuals AND do it better than any other professional. We may have the goods, but can we deliver?

I believe we can and do increase the awareness of certain issues with individuals, but increasing awareness is definitely not the same as increasing wellness or actually having a lifestyle change effect.

[John Ware]

After reading Ann and Dale's recounting of the birth of the "annual PT check ups for all" RC, I have to say it does sound like altruism run amock. The comparison with dental check-ups has its limitations, too. Actually, I'd be satisfied to just see a good hygeinist to clean and screen my mouth once a year. The dentist usually comes in for about 2 minutes, pokes on a few of my teeth, and then charges my insurance his check-up fee. You could argue that an annual or semi-annual check-up in a dentist's office is running up dental insurance rates. Do we really want to go that route?

I think we should focus on targeting populations, like the previously injured (e.g. high school ACL reconstruction), those with h/o symptomatic scoliosis and those with significant structural variations/deformities that the orthopedic epimiological research shows to be at high risk for early degenerative disease. Annual PT check-ups for "all individuals" is really an arrogant suggestion based on where our research evidence is now.
John

[Sue Scherer]

I came across this discussion and am interested because I have been participating in many community based wellness activities. It's a different role to sit on a guidelines committee or a prevention program. I am dismayed at how many public health programs are being developed in areas where our expertise would really help the program be more safe and effective. Take falls prevention for example; a local health department set up a falls program, got grant money for it and it was only by chance that a PT sat on the committee. We have much to contribute.
While the main focus of PT is to use our skills to improve impairments, function or quality of life for the individuals we treat, if we are going to participate as a doctoring profession, we also have a responsibility to address some needs of society. We could potentially get paid for consultation, not just individual treatment. We should pay attention to this emerging area of practice and participate to be integral players here instead of followers. It does not detract from our main role of treating individual patients, but adds to our credibility in society, if done right.

[Sue Scherer]

I felt obliged to respond to this comment posted by John on May 22. John said "This reminds me of the acute care setting where we try to make a science out of getting someone out of bed and walking them."This is not a skilled intervention any more than making health and wellness recommendations, the large majority of which are common sense." I take offense at your lack of knowledge of the science of acute care and your willingness to so easily dismiss the skills of your colleagues. Please hope that if you are ever in the hospital and need physical therapy acute care that it is a physical therapist , and not an athletic trainer or aide that treats you. This was my first venture into reading and posting on this site, and it is not the evidence based discussion area I was hoping to find.