How PTs Can Help Patients With Medication Reduction & Tapering with Aimee Perron, PT, DPT

Patients often find themselves in a pickle of having prescribed different medications for different purposes, which eventually overlap and do more harm than good. Thankfully, this alarming situation can be solved through medication reduction and tapering. Dr. Joe Tatta explores the role of physical therapists in this process with Aimee Perron, PT, DPT. They explain the keystone position every PT can take in upholding safer medication management and implementing deprescription in the most responsible way. Aimee also discusses the importance of holding counseling sessions with patients to better understand their health goals and minimize their fear of polypharmacy.

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How PTs Can Help Patients With Medication Reduction & Tapering With Aimee Perron, PT, DPT

In this week’s episode, we’re going to be talking about deprescribing medication or tapering different types of medication. Our guest this is Dr. Aimee Perron. She is a Licensed Physical Therapist as well as a Neurologic Certified Physical Therapist who is working at the forefront of deprescribing medications and medication management for people with pain and other neurologic conditions. This can be a trigger and hot-button topic for a lot of people and we’re not suggesting on this episode that medication does not have a place in chronic pain or other chronic conditions.

However, we are suggesting that when medication or medication management is not tracked properly, it could be potentially harmful for people living with pain and other conditions. We talk about how to use medications appropriately in this episode. Also, combining that with strategies like physical therapy to help people recover and manage pain as well as other chronic conditions. It’s a super important episode. I thank you all for joining us. Let’s get started.

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Career Path

Aimee, thanks for joining me in this episode.

Joe, thanks for having me. It’s very nice to meet you.

I’m excited to speak with you about this role of deprescribing as a physical therapist. I’m excited because I’m not sure if you’re aware, but years ago, I did one interview with a British physical therapist. You’re probably aware that in the UK, they can obtain a license where they can prescribe and deprescribe. I would love to see that in the United States and maybe we’re moving in that direction.

I came across your work at the CSM and I said, “I have to get Aimee on the show and learn about her work in the area of polypharmacy and deprescribing.” I think a good place to start is to tell us a little bit about your background in physical therapy and how you became interested in the role of deprescribing as a physical therapist.

I’ve been practicing for about many years and a huge part of my practice has been in post-acute like inpatient facilities working with older adults as well as those with neurological conditions. I have like two examples as to why I got into this. One is not even a physical therapist, but I’ll start with my physical therapist. I was working at a facility with folks who had a traumatic brain injury. The short version is that I was working with them and the medications they were being put on to help them with their recovery from their brain injury or maybe some of their mood disorders as a side effect or secondary consequence of the brain injury was making them more spastic or fatigued. It’s all of the things that were interfering with my ability to do their physical therapy.

It’s because of that, I had a conversation with the psychologist, and fast forward a little bit, I became involved in the medication review rounds. We started to see how coming together as an interprofessional team made a difference. It was in a situation where I was very fortunate that they tracked. Also, because these individuals needed to be checked on frequently, they were able to track their moods.

Whenever medications were changed, we were able to look at the data and say, “This is working,” “It’s not working,” and then work together. I know we don’t always have those circumstances, but that was the beginning of the journey. Also, I was very involved with my grandparents, asking questions about medications they were being prescribed, and seeing how much medications get layered on and layered on.

Also, asking some questions about that and saying, “Why don’t you take them off of this medicine instead of putting them on this?” I’ve since learned there’s a lot of science and data around that. The thing is called the pharmacy cascade or the polypharmacy cascade. I didn’t know that at the time. It was the combination of those two things that got me more interested in being involved and realizing the importance of this in our practice.

I’m sure this is resonating right now with a lot of physical therapists and other health providers who are seeing patients and that cascade to me is an interesting term because we see this. Patients come in with a couple of medications and oftentimes, we’re seeing patients for a long time so we’re getting to know them. Their medication history is evolving or cascading as you were saying.

Understanding Polypharmacy

With that cascade, what happens is there are multiple medications that are being prescribed, sometimes from one provider, sometimes from multiple providers. Tell us what polypharmacy is in your own words. Maybe make it simple for those who are not healthcare providers and why that should be a concern for both healthcare providers and for the general public.

I love starting with definitions, but more importantly, because I’ve been asked this question a few times. In my interest in this, I’ve looked at it. Partly, pharmacy oftentimes or foundationally is described as more than five medications and people focus on that. However, when you dive into the literature, what’s more important is it could be a couple of medications, but if they’re not appropriate or they’re causing harm, than benefit, it also falls into the definition of polypharmacy.

Certainly, we see more concerns when you have these older adults with chronic conditions and you have this polypharmacy cascade where you have multiple health providers layering on medications. That is certainly a part of it. However, the big question to simplify it as you’ve asked is are they on a medication that’s causing harm and not giving a benefit or the benefit isn’t outweighing that harm?

Can you give us an idea of what those harms are? It’s because I think people who read this are very aware of the potential harm of long-term or high-dose opioid use for people with pain. However, I realized and we spoke a little before we started this show, that you are working with whole classes of medications and not just opioids. You’re working with a whole realm of medications that are probably going to be surprising to a lot of physical therapists. Tell us a little bit about that as well.

One that I like to start with is acetaminophen.

It’s Tylenol basically.

Yeah or the non-steroidal anti-inflammatories. Over time, it’s easy to get. It can be prescribed and it can be over the counter. When it’s prescribed, it’s a higher dosage, but I think it’s because it has that over-the-counter ability then there are these myths that it can’t be unsafe. We can see chemical toxicity from too much of that in the body. We can see GI bleeds from that.

We’re even seeing some data coming out that it’s changing cardiovascular responses. That’s the number one that often comes to my mind. However, the other medication that comes to my mind that I see so much that I’m quite surprised that it gets prescribed as easily as it does is the benzodiazepines. We talk a lot about substance use disorder and addiction or we’re talking about opioids in relationship to pain but many times, those individuals are also on or on the benzodiazepines because they have anxiety because of the pain or for whatever reason or they’re using it for sleep.

Not to get too down the weeds of the pharmacology of it but we all had to learn that in school. The longer that is, the higher it is. Also, the benzodiazepines are pretty bad. I’ve seen some cases where individuals have a tough time coming off of that. There’s that side of it but then as a physical therapist, we see dizziness.

We see postural hypertension and falls are a big concern. Those are the top ones that I’m thinking of that’s coming into my head right now. I think you raise a good point, Joe, that there are a lot of medications that we should be looking at and being aware of because they can impact our patient’s ability to function and then perform and meet their goals and the highest outcomes that we’re trying to achieve as therapists.

We should be aware of these. Opioids, were aware of. The benzodiazepines, the ones that are over the counter can cause toxicity and harm too like basic Tylenol, Advil, and all the other non-steroidal anti-inflammatory drugs. How about the gabapentins? It’s because oftentimes they’re prescribed for pain or for anxiety. They’re not quite a class of benzodiazepine, but oftentimes, they’re used because they’re seen as having fewer side effects or causing less dependency, shall we say?

I’ve never been asked that question so thank you for the question. Some of my experience with that is the fatigue that I see with the patients from gabapentin and sometimes they’re taking that in higher dosages and they’re very tired like falling asleep during the session and having some of those other consequences of maybe some postural hypertension. I don’t know. I’ve seen that and I’m thinking of cases. I can’t say for sure that’s exactly what it’s from, but I know the fatigue is something that I’ve seen. Have you had experience with that as well?

I have. Once the opioid awareness came in, people were looking for other physicians because it’s primarily what they do. I admire a skilled prescriber, shall we say and then there are prescribers. I think this is where all of our work starts to come in as conservative professionals and as a safety gap in some way where I’ve seen people placed on things that are high doses or they’ve been placed on medications like the gabapentin where they haven’t been monitored.

Safer Medication Management

I’d love to get your feedback on this. Oftentimes someone goes to their primary care doctor, their pain management doctor, or their psychiatrist, and they’re prescribed a medication. The physician because they’re busy and we don’t have a system for this doesn’t call the patient and say, “How are you doing or let’s follow up?” Do we have a role in that area to both advocate for the physician and for the patient in a safe approach to medication management?

This is exactly where I think we belong in this space. I like to say that there are a lot of physical therapists that at least gather a medication review. They’ll say, “What are you on?” There are probably certain classes of medications that therapists will focus on. “I’m treating you post-op. When do you get your pain?” “I’m treating you and you have Parkinson’s disease. When do you get your Medicaid?”

I think there are certain things that we see that are typical in practice. What I encourage physical therapists to do and I would like to see more of it. I would love to talk to more people who are doing this and are spending the time asking about like, “What are you on? Why are you on it? Are you having any side effects?” What’s fascinating about the conversation when you do start doing this is the lack of knowledge that individuals have about their own medication regime and then to tie and connect that this medication’s matching that side effect.

They don’t even know why they’re on something and I agree with you. I don’t think that our organizational structure in the healthcare system right now is set up for those good-quality conversations. Also, what we are afforded as physical therapists is more time with our patients. I know that sometimes when I get the question, Joe about this, it’s like, “I have so much to do with that. How am I going to do this too?”

I always challenge individuals back saying, “You’re going to be more successful.” It’s going to create a roadblock if you don’t address it. Either address it now or you’re going to have to address it later. It’s that old saying. I think there is a huge role in us being part of that care team and not to go too much of a tangent, but we’re are starting to see the payers appreciate us a little bit more in this space. We’ve seen that we’re now being paid for remote therapeutic monitoring. Also, the caregiver codes are coming out.

I know that’s a sidebar but there are things that are happening in our physical therapy world where the payers are starting to see the huge role that we play. I think as professionals we’re advocating. To go back to a statement you said. Having people being able to prescribe, we can see that already in folks, the physical therapists who work in the military. They can do a little bit more.

I think that the more that we show that we have the skill, we have the knowledge, and we have the case outcomes, we’ll be able to do more of that. There’ll be fewer barriers for us and sometimes what stops individuals is the organizational barriers and that’s what puts the patient in this predicament in the first place.

Confusing Media Campaigns

I appreciate the lens on the patient because we’re all here to improve people’s health and well-being. It can be very confusing for the public because of media campaigns. It looks like medication is the only option. “If I was placed on this, why should I now be taken off it?” I think there’s a lot of fear around that too. I’m not sure if you have experienced that with patients where they’re very fearful of coming off the medication so to speak.

When you look at the research, Joe, it’s one of the top reasons as a listed barrier to the deprescribing world. If we’re going to work in deprescribing and helping reduce dosing, deprescribing isn’t coming off a medication. Sometimes it’s reducing dosing and it’s layered because again, to go back to what I was saying before. If the patient doesn’t understand what they’re on a medication for, you have to start there because there’s certainly going to be fear and we’re not the ones prescribing it.

They then are in this conundrum where they’re conflicted because I have one healthcare professional telling me one thing and another healthcare professional telling me something else. They probably have a more intimate patient-to-therapist relationship than they do with their physician. Maybe or maybe not but they also understand the hierarchy of culture that still exists. The physician has that say. All of that leads to confusion and fear for certain.

What we have to come to the table is providing an alternative to them to minimize that fear and there’s some research out there too that looks at what you should do. You should introduce a choice and part of that is those non-pharmacological approaches that we can offer them and talk to them about the risks and benefits of if they do this with us in physical therapy, what are the risks and benefits? We do that in practice anyway. That should be part of our patient education and all of those things have been shown to minimize that fear but it is a real thing.

I’m curious because I know a lot of therapists are probably wondering what this looks like in practice. We still have this traditional view of physical therapy where you come in and people are getting stronger and more flexible. Also, their function is improving and all that is important but still in the very impairment-based model. We have these other psychologically-informed care and health promotion models that are very important and I would say rapidly rising to the top at this point.

Counseling And Coaching

With those models, there is a lot more counseling and coaching that’s happening. The therapists I know who are in those types of roles are very comfortable sitting down with someone for 30 minutes and saying, “I noticed that you’ve been complaining about dizziness. When I evaluated you, your vestibular system seemed fine but when I look at your chart, I think this might be coming from an adverse side effect to X, Y, and Z medication.” Are you comfortable sitting down with someone and having that conversation for 30 minutes? Also, should we be doing that as a primary intervention at some point when people are having adverse reactions?

I am comfortable and I absolutely agree with you. I’m thinking of these comments and statements that I’ve had with different individuals and defining us as hands-on therapists. I have tons of examples where I can challenge individuals back.

These are the naysayers so to speak.

Yeah.

Are the naysayers PTs or are they other people as well?

Both. I’ve done a lot of telehealth in the COVID years and even before, I was challenged by colleagues and others but I was pleasantly surprised and inspired by what patients can do when they are on their own. They’re coming to the table. They know they have to do something on their own and it’s taught me a little bit more about what I can do in this space about being okay without not having to touch somebody.

I can do tons of tests and measures. I could do a six-minute walk and a gait speed and a Berg balance test and never touch the patient, watching them, listening, observing, and gathering information. How’s that any different than a conversation as part of the assessment? I think it’s an important piece. I don’t think as therapists we also spend enough time talking to patients about their goals.

That’s foundational practice. I’ve been practicing for a long time. We learned about patient goals. How many times we’ve asked patients and I’ve been also in an administration type of role? I’ll ask patients, “What are your goals in therapy?” “I have goals,” is the response that I get back. I’ve been using a tool called the Patient Specific Functional Scale a lot to gather goals and have them score their goals on that. It takes a little bit of time sometimes to go through that and explain it to them and gather their goals but it’s so insightful in my treatment plan. Anytime that you can have that conversation with them to gather more information, it’s assessment.

I’ve been preaching this from the top of the Empire State Building here in New York City. Coaching and counseling are an essential part of what we do as physical therapists. We have always done it. I think you and Aimee have been practicing for probably more than 20 to 25 years so to speak. We started practicing before all this terminology of coaching, counseling, and psychology-informed care. I’m like, “I’ve been doing this since day one since 1997.”

Now, we have a name for it. It makes people sometimes a little bit nervous but once you start doing this you realize, “I can sometimes have a bigger impact on people if I start to educate them, work on goals, work on all the things that you’re talking about here, and not necessarily place my hands on them.” I think it’s higher-value care.

I would imagine you would probably think or you’d like to let our readers know that if you want someone’s function to improve but they’re on a medication that’s causing them to be dizzy, that conversation has to happen first before you can move on with some of the essential musculoskeletal care or neuromusculoskeletal care so to speak.

I think you’re not going to get them to where they need to be. Also, the downstream consequences of that can be so large too. Now, you have a patient who says, “I went to physical therapy. It didn’t help me.” They have friends that they’re going to talk to and say, “That doesn’t work.” They may even lose their own self-reflection. Maybe they have now a new outlook on, “I went to physical therapy. That was my last hope, and now what,” which leads them to other problems. We don’t always think about those things.

I think we saw that a lot with the opioid epidemic where we realized, “This drug an opioid is having an adverse impact on neuroplasticity because it’s causing pain to get worse.” I’m coming in with all my tools and skills I’m trying to move neuroplasticity or plasticity in a positive direction but unfortunately, this dose of medication is preventing that versus someone looking at a medication where it’s going to fix something so to speak.

I think kind of the general public doesn’t always understand that although they may have a better understanding of all the movies on big pharma and what you just explained it’s not fixing it. You’re going to just need more and want more kinds of things because it’s not getting to the problem. I think this also opens up a space for us as physical therapists to do more education to our patients so that we can potentially treat the root cause if we do a root cause analysis and figure out what’s going on and match our patient needs to our patient care.

Also, that is not always the case. As you said, some medications can get to the actual problem and create a treatment that will minimize the progression of the disease or the cellular problems that are going on but you’re also right. Other medications are treating the symptoms and not getting to the root cause. I think that’s what opens the space for us as physical therapists because we know we can do more.

Impact On Older People

Speaking of opening the space, I know there are providers reading this who are probably getting charged up by this because they’re seeing this happen whether they’re working in a nursing home because polypharmacy is oftentimes seen in our older population. Maybe we should touch on that because I think whenever we start talking about opioids, people tend to think of one single drug or maybe a younger person who’s working and who has back pain but this is essential for older people, right?

Absolutely, and while you’re talking, I’m thinking of this one case of an individual who was ambulatory living in a skilled nursing facility who stopped walking and became bedbound. It was because of the combination cocktail of adding one more medication to an already long list of medications and encouraging the therapist to have the conversation. When the team came together and said, “Why is this individual on all these things?” It elevated that this polypharmacy cascade was occurring and it was, “Put them on this to treat this and then treat this.”

The patient got lost in that and became pretty much bed-bound and not an alert patient. The next step was to get the patient off the medications and that’s where it comes in as a team because we are also again spending time with the patient, how are they doing as these medications are being tapered off? Some need to be tapered in a very specific prescriptive way and we can provide information along the way that can help drive more success in that space. That individual came off of four meds and became ambulatory again and that’s the stuff we love as therapists. We want to see our patients succeed always.

Also, I think it’s a little bit easier in this space when the team is at rounds in the morning and we can talk. It’s a little bit harder in the private practice space where you have to pick up the phone and make a call. Although I think technology allows us to be able to communicate a little bit better in that space and then inspire and encourage the patient to have the knowledge to bring to their physician as well. We certainly do see that much more in facility-based because maybe sometimes the patients can’t articulate or advocate for what their needs are. The team’s doing the best that they can, but they’re guessing at it.

As you had said earlier, we tend to be in a culture of fix-it with meds. If they have a problem, give them a med. Again, where we need to advocate and be change agents for physical therapists is to educate continuously still even in this state and where we are as a doctoring profession. Also, explaining to the other healthcare professionals what we can provide because I think there’s a misunderstanding as to what we can do as physical therapists.

If someone comes with this new problem, maybe they’re not sleeping well because they’re in pain and it comes down to positioning. We have a lot of skill in that space. It would be great for the physician instead of giving them pain medication and/or on top of it a sleep aid, why don’t we have physical therapy go in? This may mean changing the time of day that we see the patient in a different setting, not in the gym, and providing treatment that addresses that problem but that’s not always usually the case. That’s not usually the order of events.

Advice For Physical Therapists

What would you recommend to a physical therapist who wants to start in this area? I know there are places to start in your own practice with your own practice habits and there are probably places to start with interprofessional collaboration. I would imagine also educating yourself on some of the medications that we’ve already spoken about in some way. I appreciate you being here on this show is a nice intro for people to say, “Here are some things I have to start to learn more about,” but what would you say those key areas are?

I think it’s doing a good self-assessment as to where you are. For me, I graduated before I became a doctor in the profession, and in a way, I feel like I was more of an adult learner ready to learn in a different way when I went back to get my doctorate, and part of that was taking pharmacology. I think I probably took more away in my late 20s or early 30s than I would’ve when I was younger and was able to put that into practice.

First, start with education. Where do you sit in this space with knowledge about medications and not be intimidated by them? There are a lot of great websites, tools, and apps now that are so helpful to make it easy and they put it in layman’s terms. When I say be aware of the medications, I’m talking about not just the name but the classes. Also, the key side effects, but the side effects that jump out to us that we know are going to impact our ability to work with patients.

Also, comfort level and being okay with being vulnerable on the interprofessional team that you’re on, whatever space that’s in to be able to stay where you are in that space. It’s because I think sometimes physical therapists have shared with me that they’ve brought it up and they haven’t been received well enough to be having a conversation around medication. Someone said to me not too long ago that it’s easier to have difficult conversations with your partners and your colleagues if you have a relationship.

It starts with making sure you have a relationship with those people and maybe that means the pharmacist. Maybe it’s having a conversation with them. Also, what tools do you have? Again, going back to the question around inpatient care, be comfortable with the eMAR. I use that all the time. I have used it in the sense that I’ll sort by patients who are on opioids. It’s the big data tools that we have now to be able to sort that way.

If you’re in an organization based, not just private or maybe even private practice, you’re able to pull out some data depending on the system that you’re using but in home health, you’re probably able to do that. Also, patients in skilled nursing, assisted living, or independent living may not be on services, but they may come up as people that you can screen and do specific screening events and be more proactive in nature. That’s another way.

I would say those are kind of the big things. We are committed to lifelong learning, which means it’s a journey. Where you are in the journey of understanding medications? Maybe you classify it into a specific space to start so it’s not overwhelming. Maybe it’s around pain medications. Maybe you bring a certain skill. I think a lot of the readers bring a skill in treating pain so let’s look at some of those specific classes of medications and understand we’re not the ones that are going to take the patients off the medication. It has to also include developing skillsets and having conversations with patients and then developing skillsets to have conversations with interprofessional partners.

I think there’s a lot of power in the position you’re talking about because for so long we’ve looked at ourselves as allied health professionals, which we’re not, and I want to make that clear. However, the fact that we can sit in the position where we can advocate for the patient and also, in some way advocate for the prescribers to make sure that they’re aware that their patient’s not doing well because there’s liability there as well for them. It puts us in a nice keystone position where if we weren’t there if we weren’t a part of that episode, then there might not be communication between the patient and the doctor maybe until things get too severe. I think that’s exciting for us to kind of think about.

I love that example. It’s a good point.

Closing Words

Aimee, it’s been great speaking with you. I love the work that you’re doing and I know other people are going to be interested in hearing about this and sharing it on social media. If they want to reach out to you, they want to follow you and your work, or learn more, how can they find you?

I am a faculty at the Northeastern University in Boston. That’s one way to find me but I also have a pretty active LinkedIn account. That’s usually how people find me. That’s a great place to reach me.

I know many of you’re interested in this topic of deprescribing and physical therapy so make sure to share this with your friends and colleagues or whatever social media handle that you’re active on. I’m oftentimes on LinkedIn or Instagram. You can find me @DrJoeTatta. It’s been great being here with you and we’ll see you next time.

Important Links

• Dr. Aimee Perron – LinkedIn
• Northeastern University in Boston – Aimee Perron
• LinkedIn – Dr. Joe Tatta
• @DrJoeTatta – Instagram

About Aimee Perron

Aimee E. Perron is a Board Certified Neurologic Clinical Specialist (NCS)and a Certified Exercise Expert for the Aging Adult (CEEAA). She is currently Regional Clinical Director for Genesis Rehabilitation Services, serving CT, MA, RI where she guides and directs consistent and efficient evidence‐based practice in patient identification, comprehensive assessment using standardized tests and/or objective measures, and patient‐centered interventions in order to achieve targeted clinical outcomes and also directs regional leadership in establishing an education plan and provides access to educational and mentoring resources.