A vision of the Future of Physical Therapy

Have been toying with writing this post for some time now.  Even started writing it a few times, then deleted it, started over, and deleted that one (damn you maladaptive perfectionism!).  But this time I'm going in hot and will attempt to get these ideas down on the screen.  Full disclosure: this has been written in bits and pieces as the mood strikes me, but hopefully it flows well enough to be interesting enough that it sparks a little discussion.

So the question is this: what does physical therapy look like in 10-15 years?  Of course the answer is "no one knows".  I'm going to offer a set of perspectives that come from someone who thinks a lot about these kinds of things, ear to the ground tea-leaf reading type stuff really.  But something could happen tomorrow that renders many of these predictions completely moot.  Such is the life of someone who fancies himself a futurist.  An additional caveat - while I do my best to keep an eye to global trends, I can't possibly shake my Canada-centric biases, so some of these predictions may be applicable to a relatively small swath of the physical therapy profession (e.g. those in Ontario, Canada).

So, without further ado, here come my predictions for Physical Therapy over the next 10-15 years:

1.  Cloud computing, Artificial Intelligence, the Quantified Self, and other tech that's not even on our radar yet will be a huge thing.

So this one may be an easy prediction to make.  Technology will advance - bold prediction there Dave.  But here's where I'm not sure PTs are entirely prepared - in their book 'The Future of Professions', Richard and Daniel Susskind make a very convincing argument that many of today's professions - PTs, doctors, lawyers, teachers, etc.. will have their profession radically altered by the increase in ability and accessibility of adaptable and increasingly 'smart' machines.  Already professions like paralegal are being replaced by computers who can sift through far more information far more quickly and for far less money while make fewer errors than humans.  Clever programmers are harnessing open-source code such as Google's Cloud Vision API to create smart computers that can analyze an x-ray or MRI and spot very minute problems that may have otherwise gone unnoticed by humans, and then go out to the web and collate all the available information on what it may mean and what the person ought to do about it (radiologists should be scared). Wearable devices now mean, for quite literally the first time in history, clients will start coming into physical therapy visits with a quantified, objective record of their daily activity habits over the past X months and say "there's your outcome, right there - when I'm doing that again, I'll be satisfied".  While PT is likely to be a slower target of advanced computing than some of the other higher profile professions, it would be naive to think we're immune.  Here at Western we're harnessing accelerometers such as those embedded in almost every piece of tech we own to identify small deviations from normal movement patterns that would go unnoticed by human observers to help identify and even diagnose joint pathology.  Open-source platforms like Kinovea allow people to video record themselves performing a movement, then go back and analyze it with very user-friendly and highly accurate biomechanical tools, for free, from their kitchen.  Then go ask WebMD what they should do about it.  Looking forward a few years, we should expect to see augmented reality systems where you as clinician put on a headset that overlays digitized holograms on the real world, and conducts these kinds of biomechanical movement analyses in real-time using a head's up display.  And these are just examples - the point is that physical therapists need to be leading in this field; 3D printing, augmented, virtual, and mixed reality, artificial intelligence, cloud computing and big data, wearables and the quantified self.  You know who are making the really big innovations in rehab right now?  Computer scientists and biomedical engineers, many of whom have never touched a patient.  PT needs to start thinking now about where they fit into this technologically-focused future - are you ready to prescribe virtual-reality based treatment?  How about prescriptions that include home gaming platforms?  Many futurists believe we will look back at the period we're currently in as the third industrial revolution - are PTs leading this revolution, or getting dragged along behind?

2.  The PT of the future will be working with augmented humans

Keeping with the tech theme, beyond augmented rehabilitation using peripheral devices, physios of the future will find themselves met with making rehab decisions for augmented people.  Already advances in nanotechnology, smart 'skins', and brain-machine interfaces will lead to injectable nanobots that seek out and repair damaged cortical or spinal cord neurons, are allowing people with amputations to regain a limb and plug it directly into their brain, will provide sight to the blind and hearing to the deaf.  Literally the potential is endless, I can't tell right now where it will end.  Literally science is identifying the key genetic switches for ageing, and it's very likely that within the career lifetime of people reading this post, humans will be living to a mean age of 120+ years.  What does that mean for rehab?  What kinds of new challenges will this new cohort of, uh, 'ultra-geriatric?' people present?  For that matter - when you're 120, what kinds of things will you be expecting of your care providers?  And of course this is to say nothing of the potential of gene-splicing/hacking and genetic programming approaches like CRISPR/Cas9 or whatever the next iteration of that will be - what genetically-mediated conditions will be extinct in the future?  What new ones will pop up as a result?

3.  Your hours and dollars spent on mastering hands-on 'technical'  skills for managing common neuromusculoskeletal disorders are going to lose their value.

I fully realize I'm stabbing directly at the very heart of what physical therapy has been for the past 100 years, and it's this section in particular that I've deleted and re-written several times.  But I can't ignore this trend and every time I think I'm overreacting, I see something that reminds me once again that we are likely to start losing out to cheaper allied health professionals who are generally able to perform most of the same maneuvers that we do and, at least according to whatever empirical evidence exists (which is very little), get similar outcomes that we do.  I'm thinking about clinical kinesiologists (there's that Canadian bias), athletic therapists, physical therapy assistants, registered massage therapists and new allied professions that likely don't currently exist.  There are already training programs for clinical kinesiologists here in Canada that are teaching them to perform many of the manual therapy techniques that have traditionally been the exclusive domain of the physical therapist and maybe chiropractor.  And it's unlikely that anyone's going to find much funding support to conduct PT vs. other provider RCTs to determine whether one gets better outcomes than the other.  In the absence of evidence to support one over the other, and with simple dollars and cents pushing the decision, I don't see how we can ignore the fact that the days of PTs pushing on spines and watching people exercise are likely nearing an end.  So where does that leave PT?  Well, if we choose to resist this change, dig our heels in and stomp our feet, we may delay this shift for a while but eventually we'll lose.  Perhaps an alternative, more fruitful endeavour is to create the future that we want - what if PTs instead become the primary care providers, diagnosticians and gatekeepers to the rest of healthcare services for problems related to mobility?  And we continue to possess an advanced level of technical skill for highly complex patient problems but leave the routine stuff to those who can do it cheaper?  What would a future look like where you walk into your 'Family Health Clinic' and turn right to see your family physician if you've got a weird rash or the sniffles, and turn left to see your family physiotherapist if you've got a mobility problem?  There may well be other approaches, I'm just predicting the future not telling anyone how to prepare for it, but I feel like we need to be strategically planning for this future now.

4.  Regardless of whether no. 2 comes to pass, we'll likely see fewer neck and low back problems in the future.

Not because they won't exist, but because I continue to see policy makers attempting to legislate these problems away.  There has long been a pervasive belief within the world of healthcare funders that things like chronic neck and low back pain are at least partly due to overly generous compensation paradigms, and they point to studies showing the, for example, chronic whiplash symptoms doesn't exist in places like Greece or Lithuania where compensation for WAD is neither available nor expected (I've been involved in several such conversations).  Perhaps the most grievous and explicit example of this thinking are a new set of WAD guidelines from the UK's government that state, and I quote: " ...measures to disincentive minor soft tissue injury claims & arrangement for personal injury...".  So the UK government appears to be quite openly stating that they feel the problem with chronic WAD is that the claims process is to easy and generous.  A similar approach is about to be launched by Ontario's provincial insurance body that amounts to essentially an ability for clinicians to select from a very narrow 'menu' of treatment options for acute WAD and a very small funding pot, each of which will be better delivered by professionals other than physical therapists.  A few years back Ontario's Workplace Safety and Insurance Board (WSIB) introduced a series of Programs of Care (PoCs) for common workplace injuries including low back pain and upper extremity pain - while I find these PoC's more acceptable than the upcoming WAD guidelines, they continue to restrict the type and amount of treatment that patients can receive, and if we look at trends, there's no indication this will reverse any time soon.  It won't be long before it's simply not viable, at least in Ontario, for PTs to continue to treat WAD and LBP, which will end up going to other professionals who can provide care for less money.  Of course, much of this may be made moot by, for example, autonomous (self-driving) vehicles that, once everyone in the road is in one, should remove the human error component of driving and result in far fewer MVC-related traumas.  That said, wouldn't surprise me at all if a different type of trauma increased (perhaps car-pedestrian?) in the short term, but eventually self-driving vehicles should make our roads safer and result in fewer whiplash problems in the first place.

5.  Training programs in Canada will have to radically change

Fully accept my Canadian bias on this one, and am cognizant of painting all programs with the same broad brush.  However, the writing is quite clearly on the wall that training programs will need to be reformed.  The easiest prediction to make here is that the DPT, or some other doctoral-level training credential, will become the minimum standard for entry into the practice as it has south of the border.  10-15 years may be a little quick for that to change, knowing the pace of change at all levels of administration and legislation that would be required, but it will happen.  And this isn't only going to be a response to the US push - as an educator myself I'm acutely aware that our current 2-year MPT programs are not going to continue to be sufficient as the profession evolves and as new controlled acts (e.g. ordering diagnostic imaging, prescribing certain meds, providing a diagnosis) fall within the scope of PT practice.  Again my language here is Ontario-centric, but I know similar shifts are happening elsewhere.  Additional skills that may not be adequately addressed in existing training programs include interdisciplinary communication, advocacy, working with technology, and so on.  So, like it or not, prepare for 3-year DPT-type programs from Canadian universities (Canadian universities will not offer 3-year master's level programs, so the only option will be to transition to a doctoral level, or go back to bachelor's level which is highly unlikely).  

6.  The process of critically appraising scientific literature will change dramatically once all the data are known

Think about this - most healthcare providers that I know view the world through a post-positivistic epistemic lens, which (in a very brief nutshell) says that we can never prove a hypothesis because it would be impossible to capture all of the data in the world to test it.  Rather, the best we can do is disprove competing hypotheses ('null' hypotheses) such that we become more and more confident that the data we have are accurate representations of all possible data on a question that exist.  We use p values, confidence intervals, standard error, that sort of thing to provide a quantitative metric of how confident we are that our data would hold true under different conditions.  But what if we could capture LITERALLY ALL THE DATA on a question, everywhere.  There would be no further need for estimating population level data - we'd have it.  Cloud computing, the internet of things, big data, machine learning, and the quantified self mean that, at least in health research, it's very likely that research in the next 10-15 years will no longer consist of RCTs or exploratory cohort studies of a selected subset of a population, but the entire population itself.  Want to know the mean resting heart rate of every 20-25 year old in the US?  Here you go, no need to estimate from a smaller subset.  The world?  Might take a little longer, but it will get there.  And then what about knowledge syntheses (e.g. systematic reviews/meta-analyses) - we'll have bots for that.  Program a bot (there are already plenty of open-source ways to do this) that trawls the internet for new evidence on a topic, applies a set of algorithms to determine the quality of the research (like it or not, much of what we do in an SR is algorithmic now) and then incorporates into an existing knowledge pool so you no longer have to wait for a new systematic review on a topic, it's right there, up to date, all the time.  10 years is probably too long on this one, I give it 5 tops.

A Note on Reacting to Change

I fully realize that some of these predictions may seem undesirable at first blush, and in some cases may even cause an emotional reaction in some readers.  And, let's be clear, I fully realize that I may be dead wrong on every one of these.  But short of a nuclear or zombie apocalypse (or both) I'm fairly confident that most of these will come to pass in the next 10-15 years or so (granted, it will be several decades before we're all in self-driving cars).  

As someone who's always been interested in the future and the questions of 'what next?', I've learned a few things about how people react when confronted with change.  In fact, in the spirit of Elizabeth Kubler-Ross and the 'Change Curve', I've fashioned my own stages of accepting change like this, they are:

  • Fear it: An actual emotional aversive response where people fear and try to escape from the potential change.
  • Actively resist it: Less fear, and more belligerence or perhaps some form of tenacious nostalgia, people here actively speak out against the change, attempt to undo it, and discourage others from embracing it.
  • Ignore it: Neither fear nor resistance, this is more a passive 'head in the sand' approach - if I don't see it, it doesn't exist sort of thing.  Ambivalence would fit here.
  • Accept it: Here people, either through force (e.g. policy change) or personal intrinsic motivation, people at least accept and embrace the change and are willing to implement it.
  • Lead it: At this stage people become 'agents of change', championing whatever the change or innovation is, encouraging their colleagues/coworkers/family members to embrace through active and vocal support of the change.
  • Create it: The highest level, people at this stage are the ones creating the change or innovation.  Asking then answering their questions of 'what could I do to help myself and others make this a better, more effective, safer, or more efficient world?', these are the folks that roll up their sleeves and create the change that leaders and accepters can then implement.

What stage are you at?  Where would you like to be?  Don't like any of my predictions here?  Then create your own future.  Let's not just ride the curve that others are setting us on - let's create the curve!  Let's lead the charge into the future of healthcare such that we as PTs ensure we remain not only relevant but critical to provision of effective healthcare in the future.

And to be clear, I'm not personally super excited about all of these myself - part of what attracts futurists to looking for trends and predicting the future is a fear of what could happen if these (and other) advancements are allowed to continue to iterate and advance unchecked.  Do I want designer babies? no.  Do I really think it's wise to be tampering with natural processes and, say, reverse or halt ageing or eradicate all disease?  Essentially render Darwinian natural selection (and, hence, evolution and adaptation of the species to new demands) obsolete?  Not without at least some very serious thought.  So this isn't a call to blindly accept all new advancements, rather it's a snapshot of one man's thoughts and predictions and a call to become more involved in guiding the future rather than following it.

Have any comments?  Any thoughts of your own re: the future of PT?  Think I'm totally daft and off base here?  Comment below, it's only through open discussion that things move forward.