Evidence Based Rehab

Seattle, Washington, October 30, 2008- Physical therapists from around the world are converging on Seattle this week for the annual conference of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). Pain: From Science to Solutions, the conference theme, speaks to the unique role physical therapists have in combating pain. Pain from musculoskeletal problems such as back and neck pain is a leading cause of healthcare utilization. Manual physical therapy techniques such as spinal manipulation play an important role in pain relief for patients throughout the United States. Manual physical therapy includes the use of hands-on techniques including joint and soft-tissue mobilization designed to restore motion and reduce pain. AAOMPT members will be discussing emerging research suggesting that spinal manipulation has the ability to positively affect the brain’s processing of pain signals. Keynote speaker and distinguished researcher, Richard Deyo, MD, MPH, will open the conference. Dr. Deyo is the Kaiser-Permanente Endowed Professor in Evidence-Based Medicine, Oregon Health Science University Department of Family Medicine.

AAOMPT president, Tim Flynn, PT, PhD, said about the conference, “This is an exciting time for physical therapy and for health care. On one side, we have a tremendous amount of research emerging in support of manual physical therapy for pain relief, and on the other side we see the stars aligning for great change in the health care industry.” Flynn continued, “As a patient, your choices come down to drugs, surgery, or physical therapists. Physical therapists can offer a low-cost solution for patients with pain and high-quality research supports what we do.”

For more on the benefits physical therapists can provide in the management of back and neck problems, contact your nearest physical therapist or visit the American Academy of Orthopaedic Manual Physical Therapists website at www.aaompt.org. AAOMPT represents physical therapists by promoting excellence in orthopaedic manual physical therapy practice, education and research.

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Jason L. Harris

Labels: AAOMPT, evidence based medicine, manipulation, physical therapy

Seattle, Washington, October 29, 2008- Washington is one of only two states in the nation that prohibits physical therapists from performing spinal manipulation. Back and neck pain are two of the most common reasons patients seek medical care. The ability of physical therapists to perform spinal manipulation is supported by numerous high quality randomized clinical trials. This body of research, much of it developed by physical therapists, has demonstrated the proven efficacy of manual physical therapy interventions, to include mobilization AND manipulation, for patients with back and neck pain. Physical therapists have produced landmark research in the area of low back and neck pain which is recognized by national and international physician groups. This month’s issue of Spine, reports on the results of a randomized clinical trial, which demonstrated that patients with neck pain who received a physical therapy program of spinal manipulation and exercise had twice the improvement in symptoms compared to the current guideline group (Walker, 2008). Unfortunately, the current law prevents the citizens of the state of Washington from receiving physical therapy treatment that is evidence based, proven to be effective, and recommended in clinical practice guidelines.

Tim Flynn, PT, PhD, president of the American Academy of Orthopaedic Manual Physical Therapists, expressed confidence that, "Given the overwhelming evidence of the benefits of physical therapy I would expect that this limitation will soon change. It is time to bring health care in Washington into the 21st century.” Flynn continues, “The American Medical Association, the Department of Defense, the American Physical Therapy Association’s Scope of Practice, as well as 48 other states in our nation recognizes physical therapists’ ability to perform spinal manipulation. Furthermore, the American College of Physicians and the American Pain Society (Chou, 2007) have published clinical practice guidelines recommending manipulation by physical therapists as the only proven treatment for patients suffering with acute low back pain.“

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It is my opinion that the chiropractic associations continue to push and agenda portraying "patient safety" as a reason to continue to prevent PT's in the state of Washington to manipulate. However, manipulation is taught to all PT's in our training, just as examination, evaluation, therapeutic exercise, and physical modalities skills are taught. "Safety" is a red herring covering-up for the real reason which is profits. Legislators in Washington need to hear from patients in particular about how this law is negatively affecting their health care potentially leading to chronic conditions and significantly increased costs.

Jason L. Harris

Labels: AAOMPT, evidence based medicine, legislation, physical therapy

Osteoarthritis (OA) is no doubt a growing cause of loss of function in our society. MSNBC's Health department recently reported on this growing epidemic related to total joint replacements. They are worth a watch. The first video found here discusses the financial impact on Medicare and the second seems more of a marketing clip for total joint replacements. What caught my ear was in the second video the surgeons comments on why total joints. To paraphrase he states total joints are done when "conservative" treatments don't help. He lists conservative treatments as "medications and drugs..". Wow, is it any surprise that these failed? Not many of us can manage chronic progressive pain with medications.

What is disappointing is the utter lack of mention of what literature shows helps and what is a first line recommendation for pain and dysfunction related to OA. That is Physical Therapy. PT is less expensive, can lead to independence in pain management, has good long term outcomes, and has little to no potential negative effects. These qualities are almost completely opposite of what pills and injections offer.

I've seen total joint replacements completely change a persons function, but if we truly want to decrease costs of conservative management of joint pain, we need to shift away from expensive drugs and injections, eliminate unnecessary imaging, and encourage the return of individuals control over their physical well being.

So, you've got drugs, you've got surgery, or you've got Physical Therapy. Let's let individuals know about their choices.

Jason L. Harris

Labels: Direct access, Medicare, Osteoarthritis, physical therapy

Tallahassee, Florida, October 20, 2008 – Neck pain is one of the top 10 reasons for a patient to visit a doctor. The lead article in the most recent issue Spine reports on the results of a randomized clinical trial which demonstrated that patients who received manual physical therapy and exercise had twice the improvement in symptoms compared to the current guideline group. The subjects in the study experienced both short and long term improvements in their neck pain. The study compared the use of manual therapy and exercise compared to the current guidelines of advice, rest, and range of motion. The results of this study are comparable to those reported by Hoving et al in 2002, which also demonstrated that manual physical therapy and exercise resulted in excellent clinical results in the treatment of neck pain while also providing a significant cost savings compared to usual physician care (Kothals-de Bos et al 2003). Manual physical therapy includes the use of hands-on techniques including joint and soft-tissue mobilization, designed to restore motion and reduce pain. Hurwitz et al (2008) concluded in a systematic review on neck pain also in the journal Spine, “Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain.”

Tim Flynn, PT, PhD, president of the American Academy of Orthopaedic Manual Physical Therapy, expressed confidence that, “This study broadens the base and depth of evidence that manual physical therapy is the first line treatment for patients suffering from neck and arm pain.” He continued, “Year after year the physical therapy profession continues to produce high quality randomized, controlled trials that demonstrate conclusively that our profession provides better outcomes for less money, while also being substantially safer than other medical interventions. Wake up America, to a new day without pain.” If you have neck or back pain or the aches and pains of musculoskeletal problems contact your local physical therapist today.

Jason L. Harris

Labels: AAOMPT, Direct access, evidence based medicine, manipulation, Mobilization

Web-based academic discussions could well be the way forward for cost-effective and tailored continuing education for health professionals. China’s interactive Orthochina.org wiki project for orthopaedic surgeons is an example of the potential of such internet training for continuing medical education. Zhen-Sheng Ma of the Fourth Military Medical University in Xi’an, China, and his colleagues thoroughly evaluated this online tool and will publish their results¹ in the October issue of Springer’s journal Clinical Orthopaedics and Related Research.

Until recently, the primary vehicle for continuing medical education has been the more traditional conferences and training courses. However, the content of these sorts of courses is not necessarily tailored to meet the individual or immediate needs of professionals and their cost-effectiveness has yet to be established. Created in 1998, Orthochina.org uses an interactive case-based format and is structured using the wiki concept, where the content of the website is created collaboratively by users through an Internet browser. Information in Chinese and English is posted, edited, deleted and updated by carefully screened participants and is academically monitored by its orthopaedic users. Ten years on, the site boasts nearly 34,000 users and counts over 6,000 visits and over 2,000 posts every month.

Real patient cases are submitted for discussion by orthopaedic surgeons. They include the patient’s complaint, findings from physical examinations and relevant images. Professional discussions between participants take place anywhere, anytime, giving suggestions for diagnosis and treatment. Multiple opinions can help the surgeon who has posted his complex case, and is seeking advice on how to treat it, to make an informed decision about his treatment plan.

The authors firmly believe that “surgeon-to-surgeon communication is the most important, the easiest, most closely related to clinical practice, and cost-effective method of patient-problem-orientated continuing medical education.” By using the Internet, orthopaedic surgeons from different backgrounds and geographic locations can work together to enhance their quality of care, something workshops and meetings cannot provide in such a tailored and timely manner.

As a profession that is hampered by practice variation and difficulty adapting (changing) to more evidence based treatemt, I feel physical therapy could really fourish with a similar approach. While we do have great sites to share ideas (EIM, Rehabedge, SomaSimple), often time the forum type format can be disonjointed and hard to follow or return to in the future.

Jason L. Harris

Labels: EBM, physical therapy, Wiki

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LEXANDRIA, VA — The American Physical Therapy Association (APTA) is urging female athletes — particularly soccer players — to consider a new warm-up program to help lower their growing risk of anterior cruciate ligament (ACL) injuries. The announcement comes as APTA celebrates National Physical Therapy Month this October, an annual observance designed to educate the public about the important role physical therapists and physical therapist assistants play in the health care system.

Concurring with a new study published in the American Journal of Sports Medicine (August 2008), APTA says specialized stretching, strengthening, agility and jumping exercises could lower the overall ACL injury rate among female athletes.

The study evaluated outcomes of NCAA Division 1 female soccer players who performed the Prevent Injury, Enhance Performance (PEP) program, designed by physical therapists at Santa Monica (CA) Orthopedic and Sports Medicine Group. Those who performed the PEP program had an overall ACL injury rate 41 percent lower than a group of female athletes who did their regular warm-up. This was one of the largest studies conducted in the NCAA with 1,435 athletes participating.

The PEP program, one example of the many physical therapy-based programs that have demonstrated an equal ability to reduce ACL injuries among female athletes, consists of sport-specific agility exercises and addresses potential deficits in the strength and neuromuscular coordination of the stabilizing muscles around the knee joint. Physical therapist and APTA spokesperson Holly Silvers, MPT, who helped develop PEP, says, "The program was created to address the deficits that are seen in female athletes, particularly weakness in the lateral hip muscles, gluteal, and core muscles." These deficits can contribute to ACL injuries, notes Silvers.

According to physical therapist and APTA spokesperson Mark Paterno, PT, MS, MBA, SCS, ATC, coordinator of orthopedic and sports physical therapy at Cincinnati Children's Hospital Medical Center, recent research published in the British Journal of Sports Medicine found that ACL tears occur four times more frequently in females than in males involved in the same amount of sports participation. He says the difference in neuromuscular control, or the way our muscles contract and react, is one of four primary factors contributing to why women are more susceptible to knee injuries than men. Other discrepancies are anatomical (men and women are structurally differently), hormonal (women's hormonal makeup affects the integrity of the ligament, making it more lax), and bio-mechanical (the positions our knees get in during athletic activities).

Sample exercises athletes can perform to avoid ACL injuries can be found on the APTA Web site, www.apta.org/consumer.

"Women perform athletic tasks in a more upright position, putting added stress on parts of the knee such as the ACL, resulting in less controlled rotation of the joint," said Paterno. "While men use their hamstring muscles more often, women rely more on their quadriceps, which puts the knee at constant risk. To combat these natural tendencies, physical therapists may develop a treatment program to improve strength, flexibility, and coordination, as well as to counteract incorrect existing patterns of movement that may be damaging to joints," he added.

Silvers notes that physical therapist-designed programs can teach athletes how to avoid abnormal movement patterns and lessen stress on the knee, which may include exercises to strengthen hamstring and core muscles.

"Whether patients are athletes or not, physical therapist expertise includes not only rehabilitation and restoration of normal levels of function, but also education regarding how to prevent further injury," says Silvers.

Labels: APTA, Direct access, evidence based medicine, exercise