Evidence Based Rehab

A subject that is, again, seeing some light in PT world is Physician Owned PT clinics or POPTS as they are often referred to (acronyms are cool). This subject is also being discussed over at Evidence In Motion and Rehabedge (a rehabilitation forum).

Why are these a problem or concern to those outside the PT profession? This is an excellent question, because this situation does affect the general public as well as my profession.

I'll forgoing making any claims of the ethical nature of a physician owned clinic or those PT's that work for them. Suffice to say, it IS bad policy. While the mantra of these setups is that it is an attempt to provide convenient care with better oversight, in the end it is more about improving the revenue stream than patient care. An MD wanting to make money is not a bad thing. But, POPTS do present specific problems:

1. Inherent conflict of interest. The MD stands to profit from referring a patient to the clinic THEY OWN.
2. Doing so restricts a patient's CHOICE in regards to PT consultation.
3. When a patient can be used as an additional revenue source, the trust between that patient and the doctor is seriously compromised.
   
4. POPTS directly impact the autonomy of an individually licensed, regulated, and recognized profession. Doing so can affect the quality of care a patient seeking consultation with a physical therapist receives.
   

Additionally, a well known study done by Jean M. Mitchell, PhD, published in the Journal of the American Medical Association (JAMA) found the folowing in regards to POPTS:

• “Visits per patient were 39% to 45% higher in joint venture facilities.
• “Both gross and net revenue per patient were 30% to 40% higher in facilities owned by referring physicians.
• “Percent operating income and percent markup were significantly higher in joint venture physical therapy and rehabilitation facilities.
• “Licensed physical therapists and licensed therapist assistants employed in non-joint venture facilities spend about 60% more time per visit treating physical therapy patients than licensed therapists and licensed therapist assistants working in joint venture facilities.
• “Joint ventures also generate more of their revenues from patients with well-paying insurance.”

For those being referred to a physical therapist, ask you MD if they have financial interest in where they are sending you (seems as though they should tell you upfront, doesn't it?). If you are not comfortable with this situation, request that they refer you to a more convienient or non-physician owned PT clinic. You can also go HERE to do a search for local physical therapists and how to contact them directly.

Jason L. Harris

Labels: AMA, APTA, Direct access, education, kickbacks, physical therapist, physical therapy, physicians, POPTS, referral-for-profit

The APTA recently released an article on the benefits of seeing a Physical Therapist (PT) for back pain. They point out that despite a recent article in the Journal of the American Medical Association (JAMA) that even with rising costs associated with back pain there has been no improvements in care, PT's have an excellent track record with the public, and more importantly, in the literature showing our effectiveness in treating back pain with out surgery or drugs.

Consumers need to know that physical therapist management is a low-cost, high-value alternative to drugs and surgery to deal with musculoskeletal pain," said APTA President R Scott Ward, PT, PhD. "The judicious use of appropriate physical therapist treatment based on best evidence can improve the function of people who struggle with back and neck conditions." Ward added, "Because patients with chronic, disabling low back pain account for a disproportionate share of health care expenditures and workers' compensation costs, the potential cost savings of an early, effective intervention to prevent individuals from progressing to chronic disability may be considerable.

Here is the link to the press release.

Labels: AMA, APTA, evidence based medicine, LBP, Low back pain, manipulation, outcomes, physical therapist, physical therapy

Drugs, Surgery, or Physical Therapists

A great post over at Evidence in motion on good news coverage on the benefits of physical therapy. I usually don't like to make post on other posts, but this seems to scream to be an exception. Please click the link above to read.

Here is the link to the video on back pain and physical therapy.

Labels: Direct access, evidence based medicine, LBP, Low back pain, physical therapy

A committee formed by the Osteoarthritis Research Society International (OARSI) released a document on what they feel are evidence based recommendations for treatment of hip and knee Osteoarthritis (OA). The stated goal of this committee was:

To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world.

A very noble goal indeed. What I'm excited about is that the committee did not include a single physiotherapist/physical therapist, yet our profession figures very prominently in most of the "non-pharmacological" treatment recommendations. The paper goes on to state, specifically, that referral to PT for symptomatic knee and hip OA was "strongly supported" and recommended by "100% of the experts" on the panel.

Good news for us. Now if we can get this into the hands of the public, all would be even better.

Jason L. Harris, PT

Labels: Direct access, evidence based medicine, Healthcare, OA, Osteoarthritis, physical therapy, special test

As promised, I am presenting my response to James Scifers comment regarding the NATA's lawsuit against the APTA. I will attempt to address all of the, in my opinion, important positions James Scifers wrote in his comment to the "NATA Attacks Our Profession" post.

James Scifers said:

Finally, as a professor who holds each of these credentials and teaches both entry-level athletic training and entry-level physical therapy students, I can honestly state that in terms of their ability to perform an evaluation and differential diagnosis of both orthopedic and non-orthopedic dysfunction, I see absolutely no difference in abilities between graduates from the two programs in which I teach.

Furthermore, given the choice to be evaluated and treated for an orthopedic condition by either group of graduates, I would, without a second thought, select the entry-level athletic training professional. The depth of their knowledge regarding the evaluation, differential diagnosis, treatment and rehabilitation of orthopedic conditions is far superior to that of most physical therapists.

First, this is just one man's opinion. I think red heads are the best physical therapists, hands down. But, unfortunately, that is just an anecdotal claim. However, in terms of evaluation and diagnosis, we do know that:

Experienced physical therapists had higher levels of knowledge in managing musculoskeletal conditions than medical students, physician interns and residents, and all physician specialists except for orthopaedists.

So, while my opinion is just that, research can help speak for a physical therapists skills in managing musculoskeletal conditions compared to a wide variety of other healthcare professionals.

James Scifers said:

Additionally, students in the entry-level athletic training program receive a far more extensive education in terms of therapeutic exercise, therapeutic modality selection and application, orthopedic assessment (including a full course of evaluation and treatment of the spine) and diagnostic imaging than the PT students at the same institution.

Don't know how to address this statement really. I know what my education was, but my alma mater did not have an ATC degree program for me to compare against. I did look into Seton Halls curriculum and course descriptions for the DPT and MATC programs. Things I do know:

1. Seton Hall DPT must be real new as board pass rates are not available

2. The clinical imaging class is the same for both the DPT and the Masters ATC

GMED 6017 Clinical Imaging
This course emphasizes imaging of musculoskeletal connective
tissue, central neural tissues, and peripheral vasculature. Survey
of current technology used in structural and functional imaging
of the body is discussed as well as interpretation, documentation,
and communication of clinical imaging information.
2 credits

3. Seton Hall MATC Therapeutic Ex vs Seton Hall DPT Therapeutic Ex

GMED 6022 (GMED 4022) Basic Rehabilitation Procedures
Provides the student with an introduction to the principles of
patient care. Topics include: Patient interviewing, documentation,
monitoring of vital signs, positioning, transfers and the
use of assistive equipment for ADL activities. Students will also
be introduced to physical examination skills including:
goniometry, range of motion, manual muscle testing, reflex
testing and sensory testing.
GMED 6018 Therapeutic Exercise
This course provides a foundation of knowledge and skills used
to manage the majority of musculoskeletal problems using
appropriate exercise principles and rehabilitative techniques.
Additionally, this course will examine current concepts in
strength and conditioning designed to assist individuals in
achieving maximal performance without incurring injury.

VS.

GDPT 6445 Therapeutic Exercise
Therapeutic exercise is one of the key tools that physical therapist
utilize to restore and improve a patient’s neuromusculoskeletal
well being. This course provides a foundation of
knowledge and skills used to manage the majority of neuromusculoskeletal
problems using appropriate exercise principles
and techniques. Using a problem-solving model, patient care
intervention for musculoskeletal dysfunction includes medical
screening, physical evaluation, and goal setting. Students will
develop skill in therapeutic exercise techniques and learn how
to integrate these techniques with other therapeutic modalities.
GDPT 6030/PTFY 4030 Clinical Skills I
This course will promote skills acquisition in basic elements of
patient services. Emphasis is placed on basic physical handling
skills, health care record information collection and documentation,
general screening for all systems, and essential of
patient-practitioner interaction.
GDPT 6031/PTFY 4031 Clinical Skills II
The course promotes skills acquisition in basic elements of
patient services. Emphasis is placed on basic handling skills,
health care record information collection and documentation,
general screening for all systems, and essentials of patient- practitioner
interaction. The course will prepare the student to
integrate elements from examination procedures into basic
treatment approaches.

4. Seton Hall Modalities MATC vs. Seton Hall Modality courses DPT. Wait...again, same course for both:

GMED 6013 (GMED 4013) Therapeutic Modalities
This course emphasizes the use of heat, cold, compression,
traction and electrotherapeutic techniques in the management
of patients with impairments and functional limitations due to
a variety of orthopedic, neurological and medical conditions.
This course will stress a problem solving approach for the selection
and application of appropriate procedures to manage pain,
edema, limitations in motion, muscle weakness and wound
healing.

So, from the information I can access, the statement that Seton Hall MATC students receive a greater amount of therapeutic exercise and modality education seem unfounded.

Finally, James Scifers says:

This is only one example from one University in the country, but I think it illustrates the need to allow each profession to practice according to their educational competencies and professional qualifications and not according to title alone.

and

Joint mobilization is not physical therapy.

Fair enough. I cannot argue with those statements.

I'm not convinced by any stretch of the imagination that the average MATC graduate tomorrow has the same, and definitely not superior, skill set of an average DPT graduate tomorrow in regards to patient evaluation and differential diagnosis. That doesn't mean they won't get as good results with joint mobilization (including the spine) that a PT would. Joint mobilization as a skill is not a magical tool at all. The skill is knowing when, and more importantly, when not to utilize it.

In the end, I guess, the profession that proves itself to the general public and healthcare policy makers, will ultimately be held as the first choice in treating neuromusculoskeletal conditions. No amount of blogging will change this.

It's unfortunate that a much needed and skilled profession such as Athletic Trainers (ATC's) feels the need to waste everyones time and money with an unfounded lawsuit. Instead, maybe spend the money on research on ATC manual skills and outcomes.

Labels: APTA, evidence based medicine, NATA, physical therapy

Rich-Mar announces the first FDA approved combination Laser/TENS unit. Because if separately one is questionable in it's effectiveness, together they must be able to cure the blind.

Somewhere Chiropractors are lining up to buy these units by the dozen.

From the release:

One of the biggest challenges physical therapists and chiropractors faced, up until now, is the fact that laser treatments were not reimbursable by health insurance,” said Douglas Johnson, ATC, EES, CLS, and medical consultant to Multi Radiance Medical. “These professionals knew that therapeutic lasers worked, but struggled with both the initial purchase of the unit and determining what to charge patients for the treatment without reimbursement. The LaserStim accessory and its unique design changes all of that. Time spent administering light therapy with LaserStim is now being reimbursed by insurance. Most physical therapists and chiropractors will see the unit pay for itself in less than one month of treatments.”

Ahh, the truth comes out. Insurance companies (rightfully, for now) won't reimburse for Laser treatment, but they do for E-stim. Well, hell, strap a couple of electrodes to the laser and call it "LaserStim" and you can now charge for it!

Labels: EBM, evidence based medicine, Fraud, Low Level laser therapy, woo

Irecieved a well written response to my post about NATA's attack on the APTA. In fact, it think the author deserves his response to be brought to our attention and not hidden away in the comments section. I present it here with out comments to allow for you to make you opinions. However, I will post a follow up response to some of his posts, separately.

I commend you for doing your homework before commenting on the educational qualifications of the ATC. Unlike the vast majority of physical therapists who oppose athletic trainers on almost all issues with little to no knowledge of the profession, educational preparation, qualifications and clinical proficiencies of the ATC, you have actually taken the time to investigate the profession and become educated.

I have to state that I disagree completely with your argument that ATC are unqualified to provide manual therapy to orthopedic patients. I also disagree that ATC are not trained in systems review.

While this may have been true a decade or more ago, the curriculums of athletic training programs have greatly expanded to include differential diagnosis and system review courses that do not involve the evaluation or treatment of orthopedic or sports injuries.

While I acknowledge that the program you selected appears to lack a manual therapy course, I would offer that, without course syllabi, we really have no idea of the didactic content of many of these courses. Instruction in manual therapy techniques is a requirement for accreditation for athletic training. The same can be said for an assessment course that includes a systems review of non-orthopedic conditions (in the case of Seton Hall this course is most likely titled General Medical Conditions).

Therefore, although it is not apparent from reviewing course titles, I assure you that students at Seton Hall and all other accredited Athletic Training Programs are receiving education in each of these content areas.

Finally, as a professor who holds each of these credentials and teaches both entry-level athletic training and entry-level physical therapy students, I can honestly state that in terms of their ability to perform an evaluation and differential diagnosis of both orthopedic and non-orthopedic dysfunction, I see absolutely no difference in abilities between graduates from the two programs in which I teach.

Furthermore, given the choice to be evaluated and treated for an orthopedic condition by either group of graduates, I would, without a second thought, select the entry-level athletic training professional. The depth of their knowledge regarding the evaluation, differential diagnosis, treatment and rehabilitation of orthopedic conditions is far superior to that of most physical therapists.

Additionally, students in the entry-level athletic training program receive a far more extensive education in terms of therapeutic exercise, therapeutic modality selection and application, orthopedic assessment (including a full course of evaluation and treatment of the spine) and diagnostic imaging than the PT students at the same institution.

To be fair, the breadth of knowledge that the PT students possess in terms of non-orthopedic conditions (neurological, cardiopulmonary, integumentary, etc.) is far superior to that of the entry-level athletic training students.

This is only one example from one University in the country, but I think it illustrates the need to allow each profession to practice according to their educational competencies and professional qualifications and not according to title alone.

While I wholeheartedly agree that physical therapy should be provided only by licensed physical therapists (not ATC, DC, OT or MD), I would remind you that joint mobilization is a treatment technique provided by a wide variety of qualified practitioners. Joint mobilization is not physical therapy.

I applaud you for taking the time to become more educated on the matter. I wish more physical therapists would follow your lead. However, I would caution you that until you walk in each professional's shoes (as a student and/or an educator), you should reserve judgment on exactly who is qualified to deliver various treatment interventions.

James Scifers, DScPT, PT, SCS, LAT, ATC

Here is my response to these comments

Labels: APTA, NATA, physical therapist

Irecently read an article regarding a great Firefox extension called Zotero. I'll get to what it is in just a minute; but, this find got me thinking about Evidence Based Medicine (EBM) and how to keep up to date easier and with better organization.

For me, the big barriers to practicing EBM are keeping up-to-date with information from a multitude of sources and then trying to effectively organize that information once received. Fortunately, the internet and free software can help me/us with both of those barriers.

First, a great way to keep current on new information from multiple sources is taking advantage of a technology called RSS that is a web feed format that automatically updates information from it's source. How do you use RSS? Feeds can be 'subscribed' to and kept in one place such as your Google Homepage, My Yahoo page, aggregators, or RSS readers. I'm not an expert on the pro's on con's of each, so some trial and error will need to be done on your part. However, I did find a nice explanatory article on many of these.

For those of us that are technologically inept (you should work on that), EvidenceInMotion has a service called Evidence Express that does the work of aggregating all the information for you then sends it to you in daily Email right to your in box.

For those who want to collect the RSS feeds themselves, a previous payware reader called FeeDemon is now Freeware. I currently use FeedReader because it is free, updated regularly, and is straight forward to use. Take a look at them both and choose for yourself.

So, now you've got the latest update on new research from, say JOSPT, now what do you do? I would download the PDF, put in a folder with a name I'd hope I'd remember down the line, and then either never find it again or take hours to do so. Now this problem can be solved. Zotero is an extension (aka - an add in the works inside firefox) for Firefox that automatically sites, stores and allows you to make notes, attach items, and more for all of our evidence we find. There is a slight learning curve, but it is well worth it. You can then search key words to find the exact article you are looking for.

The tools are available for us to be efficient with how we find and store evidence for our clinical practices. We just need to take advantage of them, and not be afraid for flail a little when learning to use them.

Looking forward to any comment regarding other great EBM tools out there.

Labels: EBM, evidence based medicine, physical therapy, RSS

Arelease from the APTA states the NATA (athletic trainers association) has filed a lawsuit against them for "anticompetitive" activities. The main point relates to MANUAL THERAPY, specifically rib and spinal manipulation. Now, as the few of you that read my posts know, I'm a big believer you don't need 4 years of hot air and philosophy to manipulate the spine, but you do need to have an excellent background in systems review, examination skills, and a wide knowledge of differential diagnoses. Chiros have this and PT's have this, but I don't see this with ATC education. And I choose a "masters" level education, which is the "new and improved" ATC degree, to highlight this.

I make no claim that I could effectively manage the day to day sports injury needs of a sports team or walk the sidelines of a game and provide the triage care that an athletic trainer can. However, ATC's are beginning to push their limited rehabilitation education into the realm of PT, and I guess DC. This is just another example of people wanting more than they are willing to go to school and get the education for. Heck, internally we even exclude PTA's from MT courses because IT IS OUTSIDE OF THEIR educated abilities. Here is the statement from the APTA:

APTA Responds to NATA Lawsuit

The National Athletic Trainers' Association (NATA) on February 1, 2008, filed a lawsuit against APTA and the Orthopaedic Section, APTA, Inc. in the U.S. District Court in Dallas. The complaint alleges that the APTA and the Section have violated the antitrust laws by seeking to deny athletic trainers (ATCs) access to the market for manual therapy and by coercing physical therapists to refrain from educating ATCs in certain techniques. APTA's counsel is currently reviewing the complaint. APTA believes that the NATA lawsuit is wholly without merit.

Physical Therapy can ONLY be provided by lisenced PHYSICAL THERAPISTS. Not by ATC's who wish themselves physical therapists.

For more fun reading, here are some additional links:

• NATA's Letter to the APTA - laughable
• Addendum to the above letter
• APTA's letter to NATA
• NATA's Injunction Filing

What is sad, is that we NEED ATC's. They are an integral part in the healthcare field. However, they are not physical therapists and yet they not only want to act like PT's their informational pamphlets boast about how ATC can be abused for economic gains being used as PT's by physicians and hospitals:

The value of certified athletic trainers isn’t limited to the
sports field. While ATCs have worked with orthopedists and in
rehabilitation clinics for the past 40 years, they can provide
a great deal of assistance – and additional revenue – to a
hospital, physician office or clinic, whether it be a large,
university-run complex or a small, private practice.

Then from a "FACT SHEET":

1. FACT: All athletic trainers have a bachelor’s degree from an accredited college
or university. Athletic trainers are health care professionals similar to physical,
occupational, speech, language and other therapists.

Sure, and I have a Doctorate degree similar to medical doctors then. What? It's not? Somebody better tell the NATA then.

To me, it seems the NATA may be trying to convince the lay public that they are in fact physical therapists with out having to go to physical therapy school. I hope you don't make the mistake of taking your grandfather s/p CVA or your mother with a diabetic ulcer, or your uncle who is trying to recover from a heart attack to a professional with out the educational background to effectively, and possibly, safely treat them.

It one thing to wave the magic wand (ultrasound) over someone and educate them in therapeutic exercise (which I believe ATC's surely do well) it's another thing to claim to be on par with THE experts in neuromusculoskeletal evaluation and rehabilitation.

Labels: APTA, Direct access, EBM, Healthcare, NATA, woo