Evidence Based Patient Care in Physical Therapy


Inertia is the resistance of a physical object to any change in its motion; the tendency of matter to keep moving in a straight line at a constant linear velocity, or to keep still.

In other words, inertia is maintaining the status-quo.

There are things in each of our lives that we continue to do, not necessarily because they are the best (or right) thing to do, but because they’re what we’ve always done.  In many cases, we know that there are better alternatives, but we end up doing nothing simply because changing is harder than not changing.

In fact, it’s exponentially harder to do something than to do nothing.

The phenomenon of inertia is so prevalent in our society that behavioral scientists have dubbed it “The Status-Quo Bias”.

Here’s an example of the Status-Quo Bias at work: in most countries, 25-33% of people opt in to become an organ donor when the default position (status-quo) is to not be an organ donor. In the opposite situation, when the default position is to be an organ donor, what do you think happens?

Yeah, only 25-33% of people opt out of being an organ donor—the exact same percentage as those who opt in.

You can imagine the implications if 75% of the population were organ donors compared to 25%, and vice-versa.  These are matters with highly significant implications, and they’re being decided by arbitrarily setting one condition as the default.

In short: We tend to stick with the default despite our preferences, mostly because it’s exponentially harder to do something than to do nothing.

As physical therapists, there are many clinical (and reimbursement) practices that we can instantly identify as existing today solely because it’s what we’ve always done.  While there are many such practices, which I invite you to talk about in the comments, I’d like to bring a very specific one up that is near-and-dear to my heart: Home Exercise Programs.

I’m sure this is a big shocker coming from a guy that co-founded a company that produces an HEP. Read on, I promise I’m not going to try to sell you anything.

You and I both know that HEPs don’t work.  I’m sure you won’t even bat an eye when I tell you that the vast majority of patients don’t complete their exercises at home consistently (Only around 35% are fully adherent- what a bunch of lousy, unmotivated patients we have).

We know that the biggest reason that HEPs don’t work isn’t that our patients are lazy.  We know we’re giving them crappy materials. We know we’re giving them no support.

I can’t be the only PT that felt bad about what I was doing-  I knew I was doing a disservice to my patients every time I handed them a piece of paper with line-drawn photos adorned with chicken-scratch notes.  I knew that they weren’t doing what they were supposed to do at home; I knew it had a direct effect on their outcomes, and it bothered me.

But, the handouts were super easy to make.  After a little while, I became adept at knowing exactly how many clicks I had to make to find the exercises I needed.  I even printed out a few copies of common HEPs so that I could just go into my little HEP bin, grab my sheet, hand it to the patient, and be done with it in less than twenty seconds. They have their home exercises, and now it’s up to them- out of sight, out of mind.

I knew that every bit of research said that compliance with PT was terrible, I knew that giving these resources to patients reflected poorly on my clinic (despite the widely-held premise that putting our clinic logo at the top of the page meant we were participating in “branding”), and I did nothing.  And I probably would still be doing the same thing if it wasn’t for our co-founder Scott.

The HEP process didn’t pass the sniff test for Scott either, and luckily he had a little bit more willpower to overcome the status-quo than I did.  He laid out a plan, and I jumped on board soon after (It’s a lot easier to overcome inertia once someone’s done most of the thinking for you).

We all say we apply evidence-based principles in our practice.  But, we have a very narrow view of what EBP is; we only think of EBP in terms of specificity/sensitivity of special tests, the effectiveness of modalities, the efficacy of specific mobilizations, and our ability to reach desired outcomes.  But, there are many other areas that we should be applying EBP (areas where we have the research to back us up), and one of which is how we interact with our patients.

There is a wealth of evidence that suggests that there are a ton of easy-to-implement techniques and strategies that improve patient adherence, satisfaction, and engagement. All of these things lead to an improved patient experience and outcome.  None of these techniques and strategies include giving a piece of paper to a patient and sending them on their way.

This isn’t wishy-washy marketing talk, it’s evidence.  Evidence that is every bit as strong- and in many cases stronger- than the evidence we use to justify our treatment of choice.

Note: If you’re interested in looking at the evidence, shoot me an email at ryan@theravid.com and I’ll send it over.

Here’s my plea: look around your clinic, and take an objective look at what you do on a day-to-day basis.  Identify the things you are doing that have questionable efficacy, the ineffective things that you do only because they’re what you did yesterday and the day before.  Make a list, and think about what you can do to make a change.  I guarantee you it will not be as difficult as you think.

As for Home Exercise Programs- do one of two things:

  1. Stop giving HEPs, or
  2. Adopt a new process

Seriously, if you’re doing something that doesn’t work, you should just stop doing it.  You can either stop entirely, or replace the bunk practice with a better alternative.  If you do adopt a new process, I hope you’ll consider TheraVid.  But, I’d be happy to know that you signed on with another company that’s trying to solve this problem in different ways (Perfect Fit Health, Home Stretch Health, or Force Therapeutics, to name a few).  Because when you switch, you’ll finally do something.  You’ll overcome inertia, follow the evidence, and improve your clinical practice.

Are there any other glaring things I’ve missed that fall into the Status-Quo Bias?  Share them in the comments!

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