Private practice owners are frequently drawn to ownership due to the autonomy it gives them to specialize in a given patient population or demographic. Sports rehab. Children with sensory issues. Back-to-work cases. If there isn't a niche, you can create your own.
For a growing number of entrepreneurial practice owners, that niche is becoming balance rehabilitation. You don't need to look too far to appreciate the magnitude of balance-related disorders in the aging population, or the effect of fall-related health complications in otherwise healthy seniors. When you combine a therapist's passion for this subset of America with an unmet community need, practices will thrive.
That's essentially the backstory of Bridgett Wallace, DPT, president and owner of 360 Balance, a practice specializing in treating balance, dizziness and hearing disorders located in Austin, TX.
"I've always had a strong interest in differential diagnostics," said Dr. Wallace, who began specializing in neurological patients with two area private practices after graduating PT school in 1995. This evolved into a sharp specialization into patients with dizziness and balance disorders, and before long she co-founded balance clinics with area physicians to handle these cases.
In 2002, she opened 360 Balance, a comprehensive balance center providing treatment for dizziness and balance disorders that can contribute to falls. Her balance retraining therapy (BRT) is a hands-on approach that begins with a thorough functional and lifestyle assessment identifying areas of deficiency and culminates in a customized plan of care plus home exercise prescription.
'Changing the Model'
Dr. Wallace also staffs a clinical audiologist, Kathy Samaniego, AuD, to help identify and correct conditions such as BPPV, inner ear conditions and vestibular dysfunctions that may be contributing to a person's balance difficulty.
As Dr. Wallace explains, balance is a highly coordinated system that requires input from visual, vestibular and proprioceptive origins. If one of them is off, a person's sense of balance will not functrion properly. Other factors such as weakness, medications, environmental obstacles and blood pressure changes can heighten one's risk of falling.
"We're trying to change the model," said Dr. Wallace, of the typical funneling system that sends patients first to their primary care physician, then to an ENT, and finally to a balance specialist. While initially concentrating on primary care providers as her main referral source-and she still receives a fair number of referrals that way-over time, Dr. Wallace felt that targeting the ENT providers in her area directly would be more worthwhile.
As she built her practice and her reputation, she found that ENTs often didn't have the time or the specialized equipment for comprehensive vestibular testing, and she jumped at the chance to take these services off their hands. She also became more involved in concussion management and has consulted for for the University of Texas for over 10 years.
"For [physicians] who refer to me, I stay in tight communication with them," said Dr. Wallace. "I want to know if they're happy or not happy. I wouldn't have a practice without physicians, but we're valuable to them as well. I want to keep that rapport."
In Edina, MN, Nicole Rennie, PT, GCS, has a similar tale of wanting to serve at-risk seniors without corporate constrictions or bureaucratic barriers.
"I'm kind of stubborn," said Rennie, who parlayed her experience as a nursing home therapist and director of rehabilitation to found Senior Abilities Unlimited, a private pay enterprise that specializes in treating seniors with balance deficits, fall risk, deconditioning and other age-related complications in their homes.
She currently staffs seven physical therapists serving the greater Minneapolis-St. Paul area, and hopes to expand to other areas of the country.
In her previous clinical life, Rennie would become frustrated at the endless stories of a client's Medicare coverage running out, and leaving them with lingering functional deficits that could be addressed by skilled physical therapy.
"I'm always trying to push the envelope," Rennie said. "I always knew I couldn't work for anyone else."
Rennie is a firm believer that balance challenges and falling are not foregone conclusions for people entering their retirement years. She has identified the nine causes of falls in the elderly, posted for patients to view on her website, and is quick to stress that "aging" is not one of them.
Rennie's flagship clinical service is Tandem Strength and Balance®, a private-pay home-based program designed to get clients mobile and independent. Initial consultations are free and cover both task-specific assessments and conversations with family members to get the full clinical picture.
Because Medicare is taken out of the equation, Rennie doesn't have to worry about documenting visit-to-visit progress and can focus on maintenance, general fitness, life-specific skill building, wellness or whatever challenge the client would like addressed.
"Medicare has its purpose," said Rennie, such as an acute event or necessary equipment purchase. "I'm always telling [clients] to use their Medicare benefits. Typically we'll see them after [their Medicare program] is complete."
For long-term health and maintenance, Rennie fills the void between covered visits and a community gym, which can be inaccessible to her clientele, who average 80 years in age and often have dementia and difficulty traveling.
Another point of contention for Rennie is the typical way walkers are relied upon under the managed care model.
"Older people are given walkers like aspirin," she said. "They're not given rehab or instructions. They come to rely on it. [Then] they go to brush their teeth, and they're scared to death."
While Dr. Wallace offers computerized balance testing, vestibular diagnostics, hearing tests and other high-tech services, therapists can often make a profound difference in patients' lives with little more than their own expertise and a few low-cost purchases.
Louis DePasquale, PT, MA, is a home care therapist specializing in aging and balance-deficient clients in the New York City area. Throughout a career that spans over 30 years, DePasquale has come to rely on simple yet proven assessment measures that are reproducible and predictive of fall risk. He developed the Repeated Incremental Predictable Perturbations in Standing (RIPPS) Method, an assessment and treatment approach that provides objective postural response measurements quantified as percent of total body weight. The procedure can be performed by a single therapist and is comprised of repeated rounds of incremental predictable manual waist-pull loading forces while standing.
Results are quantified by a linear spring scale strain gauge attached to a padded five-inch belt secured around the client's waist. The method is performed on a firm unpadded or minimally padded support surface in a normal stance position while wearing normal footwear and without any assistive device.
The RIPPS method is administered in two separate directions, anterior and posterior. Anterior direction limit testing is performed with the examiner facing the client to assess rear stepping limits. Posterior direction limit testing is performed with the client's back to the examiner to test forward stepping limits.
DePasquale published his findings in a 2009 issue of the Journal of Geriatric Physical Therapy, and feels it can bring an objective and visual dimension to a specialty that often relies on subjective observation, patient reports and instinct.
"Even in otherwise healthy people, often you'll dig a little deeper and notice that there's something there," said DePasquale, adding that preventive measures in patients not deemed at risk of falls are an important component of best practices.
A Fight Every Day
The therapists who spoke with ADVANCE view this area of practice as a passion-an underserved clientele that often goes overlooked by providers and insurance carriers. They value the difference they make in the lives of a grateful patient population and their families.
"Many of them have lost hope," said Rennie. "We're able to definitively tell them, 'here are the reasons you're having trouble. And we can fix them.'"
And operating under their own roof means they're not beholden to outside forces attempting to limit care and resources.
"It's a fight every day," said Rennie, who estimates she's personally helped hundreds of patients over 12-plus years of operating her practice. "You're building relationships. You might stay with them for six months. We become part of these people's lives."
Jonathan Bassett is on staff at ADVANCE, and can be reached at email@example.com