Evidence Based Rehab

The American Academy of Orthopaedic Surgeons (AAOS) recently released their Guidline on the Treatment of Osteoarthritis of the Knee. AAOS' guidlines join those made by the Osteoarthritis Research Society International (OARSI) guidlines released in February of this year. AAOS makes recommendations on topics ranging from lifestyle modifications to, of course, surgical interventions. However, there were a couple of recommendations/statements that stood out to me.

The first was they recommend AGAINST the prescribing of Glucosamine, Chondroitin, or hydrochloride. I would have to say that my observation in the clinic that greater than 50% of my patients over the age of 50 are taking one or all of these. I haven't read any studies that show a strong benefit from any of these. However, they are marketed hard. Will like to know if there are any side effects from long term use of these.

The last issue I wold like to discuss is AAOS', in my opinion, obvious choice to avoid the term/word "PHYSICAL THERAPY". This is in stark contrast to OARSI's recommendation which specifically recommends physical therapy. AAOS recommends many treatments used by physical therapists and education routinely provided by physical therapists. However, at no time does the 265 page document use the terms "physical therapy "or "physical therapist" in reference to it's recommendations. The did have 2 PT's on the review board (one the president of the orthopaedic section of the APTA) and get the nod of acceptance from the APTA. However, I feel this is just a continuation of, specifically, orthopaedic surgeons refusal to aknowldedge the importance of our profession instead of something the own and direct as just a small aspect of their patient's recovery.

Besides the hypocrisy of direct access for PT's (may go to a massage therapist with a certificate for back pain w/o MD ok but not a PT with a doctoral degree), this concerted effort by orthopaedic surgeons in general to make sure PT's stay subservient gives me the most angst in my professional life. In the end, our working together and respecting each others discrete knowledge for orthopaedic patients should be paramount. Instead, it's unilateraly ignored and buried.

Good recommendations and good information for us all to read. Hope future editions of these recommendations can include the recommendation skirted through out - the referral to a physical therapist.

Jason Harris

Labels: AAOS, evidence based medicine, knee, OA, OARSI

New Study Shows Manual Physical Therapy and Exercise ProducesSignificant Improvements in Neck Pain

ALEXANDRIA, VA, December 12, 2008 — The American Physical Therapy Association (APTA) is urging patients with musculoskeletal pain to consider treatment by a physical therapist, in light of a new federal survey showing that more than one-third of American adults and nearly 12 percent of children use alternative medicine - with back and neck pain being the top reasons for treatment. Results of the 2007 survey of more than 32,000 Americans were released December 11 by the National Institutes of Health's National Center for Complementary and Alternative Medicine.

According to APTA, physical therapy offers an evidence-based, time-tested solution to these common conditions in comparison to alternative treatments.
For neck pain, for example, a recent study published in the medical journal Spine found that when patients received up to six treatments of manual physical therapy and exercise, they not only experienced pain relief, but were also less likely to seek additional medical care up to one year following treatment.

"This study, demonstrating the efficacy of physical therapy for a condition as widespread as neck pain, is particularly relevant in today's challenging economic environment," according to the study's lead researcher and APTA spokesman Michael Walker, PT, DSc, OCS, CSCS, FAAOMPT. "The Kaiser Foundation, for instance, recently found that more than half of all Americans are not taking prescribed medication and postponing needed medical care in an effort to save money. It is important for consumers to know that there are effective, conservative solutions such as physical therapy available.1"

Walker's study compared the effectiveness of a three-week program of manual physical therapy and exercise to a minimal intervention treatment approach for patients with neck pain.
Study participants consisted of 94 patients with a primary complaint of neck pain, 58 (62%) of whom also had radiating arm pain. Patients randomized to the manual physical therapy and exercise group received joint and soft-tissue mobilizations and manipulations to restore motion and decrease pain, followed by a standard home exercise program of chin tucks, neck strengthening, and range-of-motion exercises. Patients in the minimal intervention group received treatment consistent with the current guidelines of advice, range-of-motion exercise, and any medication use prescribed by their general practitioner. Patients did not have to complete all six visits if their symptoms were fully resolved.
Sample exercises to relieve neck pain can be found on the APTA Web site, www.apta.org/consumer.

Results show that manual physical therapy and exercise was significantly more effective in reducing mechanical neck pain and disability and increasing patient-perceived improvements during short- and long-term follow-ups. These results are comparable with previous studies that found manual physical therapy and exercise provided greater treatment effectiveness (Hoving et al, 2002)2 and cost effectiveness (Kothals-de Bos et al, 2003)3 than general practitioner care.
"Physical therapist intervention can be an effective, high-value, conservative solution for treatment of musculoskeletal pain," said Walker.

"Physical therapists can help individuals improve mobility and quality of life without expensive surgery or the side effects of pain medication. We give patients the tools they need, such as the home program we used in the study, to help them prevent or manage a condition in order to achieve long-term health benefits."

Physical therapists are highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility — without expensive surgery or the side effects of medications. APTA represents more than 70,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide. Its purpose is to improve the health and quality of life of individuals through the advancement of physical therapist practice. Learn more about conditions physical therapists can treat at www.apta.org/consumer, and find a physical therapist in your area at www.findapt.us.

1 http://www.kff.org/kaiserpolls/h08_posr102108pkg.cfm
2 Hoving JL, Koes BW, de Vet HC, van der Windt DA, et al. Manual Therapy, Physical Therapy, Or Continued Care by a General Practitioner for Patients with Neck Pain. Ann Intern Med 2002;136 (10):713-722
3 Korthals-de Bos IB, Hoving JL, van Tulder MW, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ 2003;326 (7395):911

Labels: APTA, evidence based medicine, manipulation, Mobilization, neck pain

The folks over at Evidence In Motion have announce the winners of their "30 Second Elevator Pitch Contest" asking participants to answer the question:

- Why physical therapy is the best first choice in musculoskeletal care.

The grand prize winner was the entry submitted by BJ Lehecka from Wichita State University. You can see BJ's winning entry below. To see the full list of winners and other information, please go to EIM's blog found here.

Labels: Direct access, media, physical therapy, public relations

Looking back on my first year of blogging, I noticed I liked a few posts that likely did not get much viewing exposure back then. Therefore, I plan to occasionally repost a few of these select posts from that first year. Here is the first offering.

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After many question from my patients and the general public regarding "alternative" treatments (e.g. magnets, craniosacral, dietary supplements, etc) I decided to sit down and write up an educational handout to summarize how to approach evaluating treatment options. This includes treatments in so called "Alternative Medicine" and main-stream medicine alike.

I am very concerned that many alternative treatments are blatant attempts to take advantage of persons in desperate situations. Such as end-stage cancer and progressive disease processes like arthritis.

Below are some ideas on how to approach decisions about "new" therapies to allow you to maximize your potential gains and to protect your money from those offering up only a big handful of woo.

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EVALUATING INTERNET MEDICAL ADVICE

Jason Harris, PT, DPT

Our modern internet has opened the door to a vast arena of medical advice and information. With this information, it is important to critically evaluate the information and the author’s credibility. How does one pick between credible and worthless? It can be hard, but I will outline a few rules for judging the value of the information you are reading.

I suggest you look for "Red Flags" while researching medical information on the internet. In medicine "Red Flags" are signs and/or symptoms that warrant immediate attention as they indicate a potential life threatening situation. I will use the term to indicate immediate problems with information that is being evaluated.

"RED FLAGS":

1. Any site that use the terms "alternative", "holistic", "integrative", "natural", and/or "miraculous" (Barrett). The vast majority of websites using these terms should replace them with “unproven” and/or “ineffective”. They also tend to push Herbs, vitamins and supplements. Do not trust a salesman to tell you the whole and complete truth. Their job is to sell you the product.

2. Claim large effect on symptoms with out side-effects. Causing a large change in body function (or dysfunction) has a cascading effect that leads to known side-effects and occasionally adverse reactions. No side effect most often indicates such low doses as to have no real effect.

3. Claim that a treatment can cure multiple problems/pathologies. Nothing can, or ever will, cure your shoulder pain and skin melanoma.

4. Claim that everyone will experience the same positive results. Humans are not all the same. Disease processes are complex and include multiple organ systems to varying degrees. Due to this, you cannot expect all to respond the same way or to the same degree. This is why well run clinical trials are essential. Which brings us to the next point…

5. The use of testimonials as sole proof that treatment works. A positive experience one person has cannot be generalized to anyone else. This is a complex topic as we rely on recommendations and advice from our neighbors to function efficiently in society and these salesmen attempt to take advantage of this.

6. Person is touted as a “Guru” with many impressive sounding “credentials”. Often claims are made that your problems can only be cured by the seller. Often it is because of some procedure or test named after them that only they can do. In the end, only they can do it because there has been no published research to support or refute it’s ability to do what it is purported to do. Also watch for the use of “Dr.” when referring to this guru and/or unusual credentials (e.g. not common known credentials such as MD, DO, PhD). The use of the doctor title is an attempt to make the person appear more authoritative then they are.

7. Must buy to see results. Any reputable treatment/product should have peer-reviewed published literature that shows it can do what it claims. You should never have to first buy something to know or experience how it works.

Medical information from the internet must be reviewed wisely and used as a supplement to the advice a trusted healthcare professional has given you. When in doubt, bring the information you have found to your MD, DO, or PT and discuss it with them. These “red flags” are a good start to filtering out the majority of bad from the good.

Works Cited Barrett, M.D., Stephen. " How to Spot a "Quacky" Web Site." 06 September 2006. Quackwatch. 7 July 2007 .

Jason Harris

Labels: alternative medicine, evidence based medicine, repost, woo