Evidence Based Rehab

Lost a patient today to the local hospital PT. Was it because the local hospital had more convenient hours? Better PT's? Closer to home? None of the above. UHC limits her visits to 20 a year with a $30 to come to our PT owned clinic; but the pt had no copay or limits going to the hospital PT.

Where is the equity in that? ACN is horrible enough, now preference is again being given to physicians. Show me the evidence that the hospitals are providing better care at comparable costs and I'll understand. My guess is UHC will be charged more over greater number of visits than coming to a PT owned clinic that emphasizes quality care and outcomes over the bottom line of the hospital.

Labels: Direct access, Healthcare, insurance, over-use

Jason Silvernail recently posted a good perspective on the difficulties with Referral For Profit setups. The title -RFP - Get the Picture? - and the story it is refering to can be found here.

This is a serious situation that has a direct impact on PT's autonomy (or pursuit for autonomy). It is also a negative influence on patient outcomes and freedom of choice. Please read and leave you comments.

Labels: Direct access, kickbacks

Reading one of my favorite medical blogs - Respectful Insolence - Orac posted on a Homeopath in Arizona that had a patient die after performing liposuction on her. To make this even more interesting, the assisting physician had already had 2 patients die after lipo and his lisence had been put on probation.

This got me thinking, do people really know what homeopathy is? Or do they just blindly believe what these pseudo doctors are telling them?

Here is a great video of James Randi explaining Homeopathy and the "4 rules of homeopathy":



My favorite line when referring to a homeopathic medicine:

Has no side effects. That's true. My question is 'does it have any other effects'?

Absurdity, this is. I believe people should be able to choose how to treat their ailments. However, homeopathy is duping the desperate, fearful, and needy. Educate those who ask about the quackery that homeopathy medical treatment is.

Labels: EBM, education, Evidence, Fraud

A Wall Street Journal article reports old docs think new docs (residents) aren't getting the education they need because their weekly work hours are limited to 80 hours a week. That's right, 80 hours. It's actually not that good. That's an average of 80 hours over two weeks. So one could work 100 one week and 60 the next and still be compliant.

Old docs will complain about new docs not being altruistic. What seems to be their definition of altruism? Not working 150+ hours a week like they did in their training. Seems reasonable, right? You have to do it because I did! Here are the "main" findings:

Eighty-seven percent of the doctors thought continuity of care had worsened, and 75% thought the physician-patient relationship had deteriorated.

Sixty-six percent said residents’ education had gotten worse, 73% said residents were less accountable to patients and 57% said residents’ ability to place patient needs above their own had declined.

Half thought residents’ well being improved. But 56% of the teaching faculty found teaching less satisfying.

I find it interesting that in a system in which residents are paid about 20% of the staff to cover nights, weekends, holidays and everything in between, that those in charge are complaining about being able to have less of the resident.

Teaching hospitals provide a great service to our country in terms of educating our future doctors. But don't think it is altruism on their part. They get 5 residents for the price of 1 staff and used to be able to work them at their whim (and bottom line). Now that there is a 'limit' of 80 hours (ha! again I say ha!) somehow it's a detriment to patients and resident education.

Finally, the 80 hours are constantly ignored and subtly understood that that is the way the game is played. Doctors now are being paid less (don't believe big insurance), for more with less kudos than when "old docs" had their training with patients paying cash, receiving gifts and not having to answer to anyone but themselves.


UPDATE: Great response over at Over!My!Med!Body giving a first hand med student perspective on the whole "you have to because we had to" residency issue. Please read. Well written and shows the other side of the coin.

Labels: AMA, Healthcare

I am set to begin somewhat of a "series" on the APTA's vision statement on what our profession should be in the future. It is title "Vision 2020". Here is the meat and potatoes of it:

Labels: APTA, Direct access, EBM, insurance

Orac over at Respectful Insolence posted his views on chiropractor legalities in New Jersey from an MD's prospective. He also has a few nice things to say about physical therapists.

Be sure to read the comments as their are MD's, chiro pt's, chiros, and (of course) me that have chimed in on this subject.

Labels: Chiropractic, clinical prediction rules, EBM, legislation

I have recently begun using a nice new clinical test for meniscus tears. It is called the Thessaly Test (I thought we were going to quit naming things like this after ourselves, lol). It is a weight bearing test, so it's fairly functional. The Abstract can be found on the Journal of Bone and Joint surgery. The test basically requires the practitioner to hold the hands of the patient who is standing on one leg. The patient then bends to 5° and twists medially then laterally. The test is repeated at 20°. Positive test equates to reproduction of pain, catching or popping.

Here is a summary from EBM Online:

Diagnosis Sensitivity (95% CI) Specificity (CI) Accuracy +LR –LR Medial meniscal tear 89% (83 to 94) 97% (94 to 98) 94% 26.9 0.11 Lateral meniscal tear 92% (78 to 98) 96% (93 to 98) 96% 22.9 0.08 *Diagnostic terms defined in glossary; CI and LRs calculated from data in article.

In my experience, the test is easy to administer and less physical work needed by the practitioner compared to McMurray's or Apley Grind. However, like McMurray's or Apley, in the clinic, they don't quit appear as strong individually as they do when grouped.

Labels: EBM, meniscus tear, special test, Thessaly

David Colquhoun maintains a page on "Complementary and Alternative Medicine (CAM)". It is a worth while read. You can find his website here. Below is a fun argument about the dilemma of CAM treatments.

The dilemmas at the heart of 'alternative medicine'

All forms of ineffective treatment, 'alternative' or otherwise, pose real dilemmas that are usually neglected.

The definition dilemma

* Once any treatment is shown beyond doubt to be effective, it ceases to be 'alternative' and becomes just like any other part of medical knowledge. That means that 'alternative medicine' must consist entirely of unproven treatments.

The lying dilemma

* Suppose that a treatment owes all its effectiveness to the placebo effect, e,g. homeopathy (even Peter Fisher almost admitted as much). But in some people, at least, the placebo effect is quite real. It may be a genuine physical response, though one that does not depend in any activity of the drug, or other treatment.
* If the placebo effect is real, it would be wrong to deprive patients of them, if there is nothing more effective available. For example, if terminal cancer patients say they feel better after having their feet tickled by a 'reflexologist', why should they not have that small pleasure?
* If the foregoing argument is granted, then it follows that it would be our duty to maximise the placebo effect. In the absence of specific research, it seems reasonable to suppose that individuals who are susceptible to placebo effects, will get the best results if there treatment is surrounded by as much impressive mumbo jumbo as possible.
* This suggests that, in order to maximixe the placebo effect, it will be important to lie to the patient as much as possible, and certainly to disguise from them the fact that, for example, their homeopathic pill contains nothing but lactose.
* Therein lies the dilemma. The whole trend in medicine has been to be more open with the patient and to tell them the truth. To maximise the benefit of alternative medicine, it is necessary to lie to the patient as much as possible.

As if telling lies to patients were not enough, the dilemma has another aspect, which is also almost always overlooked. Who trains CAM practitioners? Are the trainers expected to tell their students the same lies? Certainly that is the normal practice at the moment. Consider some examples.
The training dilemma

* If feet tickling makes patients feel better, it might be thought necessary to hire professional feet ticklers who have been trained in 'reflexology'. But who does the training? It cannot be expected that a university will provide a course that preaches the mumbo jumbo of meridians, energy lines and so on.
* A good example is acupuncture. It is often stated that one of the best documented forms of 'alternative medicine' is acupuncture. Certainly the act of pushing needles into to your body elicits real physiological responses. But recent experiments suggest that it matters very little where the needles are inserted. There are no 'key' points: it is the pricking that does it. But its advocates try to 'explain' the effects, along these lines.
o "There are 14 major avenues of energy flowing through the body. These are known as meridians".
o The energy that moves through the meridians is called Qi.
o Think of Qi as "The Force". It is the energy that makes a clear distinction between life and death.
o Acupuncture needles are gently placed through the skin along various key points along the meridians. This helps rebalance the Qi so the body systems work harmoniously.
I suppose, to the uneducated, the language sounds a bit like that of physics. But it is not. The words have no discernable meaning whatsoever. They are pure gobbledygook. Can any serious university be expected to teach such nonsense as though the words meant something? Of course not. Well so you'd think, though a few 'universities' have fallen for this, to their eternal shame

Obviously it isn't always neccessary to wait for a treatment to be unequivocally proven before it's use. However, it's basis should at least be plausible.

Labels: CAM, EBM, Healthcare, tips

A new study from Spine concludes that there are muscle changes that, they conclude, are common in those with true low back pain. Here is the abstract:

Study Design. Prospective longitudinal study.

Objective. To investigate, using magnetic resonance imaging (MRI), the influence of bed rest on the lumbopelvic musculature.

Summary of Background Data. Reduced gravitational loading and inactivity (bed rest) are known to result in significant change in musculoskeletal function, although little is known about its effects on specific muscles of the lumbopelvic region.

Methods. Ten healthy male subjects underwent 8 weeks of bed rest with 6 months of follow-up. MRI of the lumbopelvic region was conducted at regular time-points during and after bed rest. Using uniplanar images at L4, cross-sectional areas (CSAs) of the multifidus, lumbar erector spinae, quadratus lumborum, psoas, anterolateral abdominal, and rectus abdominis muscles were measured.

Results. Multifidus CSA decreased by day 14 of bed rest (F = 7.4, P = 0.04). The lumbar erector spinae and quadratus lumborum CSA showed no statistically significant difference to baseline across the time of bed rest (P > 0.05). The anterolateral abdominal, rectus abdominis, and psoas CSA all increased over this time. Psoas CSA increased by day 14 (F = 6.9, P = 0.047) and remained so until day 56, whereas the anterolateral abdominal CSA (F = 29.4, P = 0.003) and rectus abdominis CSA (F = 8.9, P = 0.03) were not statistically larger than baseline until day 56. On reambulation after completion of the bed rest phase, multifidus, anterolateral abdominal, and rectus abdominis CSA returned to baseline levels (P > 0.05) by day 4 of follow-up, whereas psoas CSA returned to baseline level after day 28 of the follow-up period.

Conclusions. Bed rest resulted in selective atrophy of the multifidus muscle. An increased CSA of the trunk flexor musculature (increases in psoas, anterolateral abdominal, and rectus abdominis muscles) may reflect muscle shortening or possible overactivity during bed rest. Some of the changes resemble those seen in low back pain and may in part explain the negative effects of bed rest seen in low back pain sufferers.

This adds to the growing mountain of evidence against bed rest for LBP. One would hope that the current first line practitioners that LBP patients encounter (GP's and, sadly, PA's and NP's) know this; but, as Ellen Degeneres showed us even "stars" are given advice contradictory to the mounting evidence. What's worse is her large audience may also believe that bed rest is the best treatment for their low back pain.

Educate, educate, educate. Tell everyone you know about the harm of bed rest!

Labels: bed rest, EBM, Low back pain, treatment

Here is a YouTube video demonstrating Mulligan taping technique to help relieve lateral epicondylitis (tennis elbow) symptoms:



There have been a number of studies looking at Mulligan Mobilisation With Movement (MWM) technique on Tennis Elbow. I didn't find one directly related to this taping technique though.

References:

Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial
Leanne Bisset, Elaine Beller, Gwendolen Jull, Peter Brooks, Ross Darnell, Bill Vicenzino BMJ 2006;333:939, doi:10.1136/bmj.38961.584653.AE

Vicenzino B. Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Man Ther 2003;8: 66-79.

Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med 2005;39: 411-22

As the baby boomers age, we must look to a new population base for our PT practice. Enjoy!

A Reuters report on MSNBC relates that there has been a 20% increase in hospital and doctor visits since 2002. The article claims

The reason is clear — Americans are getting older. “When you reach 50 things start going wrong, just little by little, and you keep going back to the doctors,” Burt said.

Now, predictably, the Centers for Medicare & Medicaid Services (CMS) has announced a 10% reduction in the fee schedule for Doctors and other health care providers. That's right...to artificially control the cost of providing social insurance to our aging baby boomers, CMS wants to just cut how much they pay. Forget that they are already to lowest reimbursers (well, UHC is getting close to that honor in Physical Therapy) and now they want to pay even less. Anecdotally, many physicians report the costs of providing routine care (salaries, paperwork, compliance measures, etc) are just covered by what Medicare reimburses (read - MD's maybe break break even). Drop that 10% and more MD's will surely exercise their ability to opt out of treating Medicare patients. I'll let you all ponder the consequence of that.

Labels: CMS, legislation, Medicare, physicians

The APTA has announced that Oregon has expanded the amount of time patients have to access physical therapy services before having to see a medical doctor.

Yeah! One step closer to less trained and educated providers of 'rehabilitation' (eg massage therapists and ATC's) who have no limitations on whom they can see. Yes that is sarcasm.

Labels: APTA, Direct access, physical therapy

Here is a good free video posted on YouTube on how to perform the Mulligan fibular glide for inversion ankle sprains.



Kym Moiler et al published a pilot study on this taping technique in the Journal of Orthopaedic & Sports Physical Therapy in September of 2006.

In 1999 Kavanagh published a study in Manual Therapy on the link between distal tibiofibular positional faults and inversion sprains.

Professionally, I like to perform gentle (Grade 1-3) Anterior to Posterior and superior fibular mobilization on acute and chronically painful ankle sprains to relieve pain and increase ROM. Especially dorsiflexion. I've had good success; but, that is my personal experience only.

This taping technique is a nice tool to help emphasize the benefits from the manual mobilizations.

Labels: Mobilization, Mulligan, physical therapy, You Tube

News that Massachusetts (to be referred to as Mass as I'm lucky to spell it correctly more than once) will now require it's citizens to have health insurance. I think this is significant as most people focus on health care improvement by formulating ways the government can provide more social insurance focused on health care. Now we have a state trying to solve uninsured by treating it like car insurance...it's simply something you must pay for.

This will be an interesting experiment. Success would likely lead to a flood of similar legislation through out the country.

I feel this is an excellent possible solution to the growing number of uninsured. I've always felt our health is our responsibility and we shouldn't blindly depend on the government to provide solutions for us.

Labels: Healthcare, insurance, legislation, reform