Evidence Based Rehab

ALEXANDRIA, VA, July 13, 2009 — The American Physical Therapy Association (APTA) is urging elderly adults who use canes and walkers as walking aids to be properly assessed and fitted by a physical therapist to avoid fall-related injuries. This advice comes in response to a study published in the Journal of the American Geriatrics Society (June 2009), which found that 47,000 senior citizens end up in emergency rooms each year due to falls from improper use and fit of walkers and canes.

The study, conducted by government researchers, examined six years of emergency room records and found that the walker was associated seven times more with injury-related falls than was the cane. Physical therapists advise that these results indicate a strong need for proper fit and assessment.

According to physical therapist and APTA member Cathy Ciolek, PT, DPT, GCS, many patients often borrow walking aids from friends and family, which can result in injuries. "We see many patients use borrowed canes, walkers, and crutches without adjusting the fit and height appropriately, which can cause discomfort and result in further injury," she said.

In addition to providing a proper fit, your physical therapist can assess your individual needs to ensure you are using the proper walking aid and that it is in proper working condition. "In some instances a cane may not be the safest option, and it would be best to use a walker. Your physical therapist can help make that decision," says Ciolek. She provides some general tips for those using a cane or walker as a walking aid:

• The walker or cane should be about the height of your wrists when your arms are at your sides.
• When using a walker, your arms should be slightly bent when holding on, but you shouldn't have to bend forward at the waist to reach it.
• Periodically check the rubber tips at the bottom of the cane or walker. Be sure to replace them if they are uneven or worn through.

As experts in restoring motion and mobility in people's lives, physical therapists work collaboratively with physicians to ensure safe recoveries from illness or injury. Ciolek recommends seeing a physical therapist for an assessment and proper fit or asking for a referral to a physical therapist from your physician. Visit www.moveforwardpt.com to find a physical therapist near you.

Labels: APTA, physical therapist, Press Release

Labels: education, physical therapist

David Straight of E-rehab has put together a website called PT's Unite to help bring about a grass-roots effort for California PT's and their push for direct access. Please consider helping in the cause. Remember, success for PT's in one state can help lead to success for you and a failure can make it harder to bring about change in your state.

Good luck to those PT's in California and thank you to David for grabbing the tourch and attempting to lead the way to change.

Jason L. Harris

Labels: Direct access, legislation, physical therapist

Richard Deyo MD, the keynote speaker at the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) National Conference in October 2008, has again published data indicting the US approach to chronic back pain dramatically increases costs without improved outcomes. Deyo and colleagues reported in the January 2009 issue of the Journal of American Board of Family Practice the following staggering statistics:

• A 629% increase in Medicare expenditures for epidural steroid injections;
• A 423% increase in expenditures for opioids for back pain;
• A 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries;
• A 220% increase in spinal fusion surgery rates.

The incidence of chronic and acute Low Back Pain, as documented by office visits, has not changed during the last 12 years. The application of these technologies is not without consequences Deyo et al noted, ‘Innovation has often outpaced clinical science, leaving uncertainty about the efficacy and safety of many common treatments. Complications and even deaths related to pain management are increasing.’ Indeed, the reoperation rates for low back pain have increased, not improved. The authors conclude that the ‘Prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain.’ They note that these approaches often are applying an acute care model to chronic pain and not acknowledging the current evidence that chronic pain requires a different approach and that there are ‘no magic bullets.’ In a “chronic care model” chronic back pain, like diabetes or asthma, ‘is a condition we can treat but rarely cure.’ Deyo et al suggest the solution that ‘chronic back pain may benefit from sustained commitment from health care providers; involvement of patients as partners in their care; education in self-care strategies; coordination of care; and involvement of community resources to promote exercise, provide social support, and facilitate a return to work.’

Tim Flynn, PT, PhD, president of the AAOMPT states, ‘The manual physical therapist is the health care provider uniquely trained to manage individuals with chronic low back pain. We utilize low risk, state-of-the-art care incorporating exercise, manual physical therapy, patient education and the application of the biopsychosocial model in managing this chronic condition. The Academy is dedicated to the application of current models for chronic pain management.’ The recent AAOMPT conference in Seattle focused on current theories and practice of chronic pain management with international experts on pain management.

Labels: AAOMPT, CPR, Direct access, evidence based medicine, health care, LBP, Low back pain, physical therapist, physical therapy

Stumbled upon a nice article written about physical therapy from a patient's perspective. Nice view as it starts out with the patient expressing his hesitation in trying treatment from a PT and his desire for a quick fix.

Oh great!" I remember thinking. "Voodoo medicine! Why can't they just give me a pill to make this go away?

Nice to see a physical therapist was able to get one of our countries finest back up and running! You can read the rest of the article by clicking HERE.

Jason L. Harris

Labels: physical therapist, physical therapy, treatment

Archives of Physical Medicine and Rehabilitation recently published a study on the benefits of physical therapy for lower extremity trauma. The abstract is as follows:

OBJECTIVE: To examine the effect of physical therapy (PT) use on a range of measures of physical impairment in a cohort of patients with lower-extremity trauma.

DESIGN: Longitudinal, observational study of patients with severe lower-extremity trauma. Patients were interviewed by a research coordinator and examined by an orthopedic surgeon and a physical therapist during initial admission and at 3, 6, 12, and 24 months postdischarge.

SETTING: Eight level I trauma centers.

PARTICIPANTS: Patients (N=382) whose legs were salvaged after limb-threatening trauma to the lower limb.

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: Unmet need for PT was assessed from 2 perspectives: an orthopedic surgeon and a physical therapist independently evaluated each patient and were asked whether the patient would benefit from PT. Patients classified by these health professionals as needing PT services over a given period and who reported receiving no PT at the end of that period were classified as having unmet need as evaluated by the orthopedic surgeon or physical therapist for that follow-up period. Multiple variable regression techniques were used to compare improvement in 5 measures of physical impairment and functional limitation between the met and unmet need groups over the periods of 3 to 6, 6 to 12, and 12 to 24 months: percentage of impairment in knee and ankle range of motion (ROM), reciprocal stair climbing pattern, gait deviations when walking, self-selected walking speed greater than 1.2 m/s (4 ft/s), and the mobility subscores of the FIM instrument.

RESULTS: Patients with unmet need for PT as assessed by a physical therapist were statistically significantly less likely to improve in all 5 of the selected domains of physical impairment and functional limitation than patients whose PT need was met. These results remained constant after adjustment for patient sociodemographic, personality, and social resources, as well as injury and treatment characteristics, reported pain intensity, and impairment level at the beginning of the study period. Patients with unmet need for PT as evaluated by an orthopedic surgeon were significantly worse off than patients with met need in only 1 of the 5 selected measures (ROM).

CONCLUSIONS: The results are consistent with a beneficial effect of PT after lower-extremity trauma. The results point to a need for improved standards for the prescription of PT services, and highlight the importance of involving a PT professional in the prescribing process.

I think the conclusion is relatively strong worded in regards to not just the importance of physical therapy intervention, but that outcomes were affected by whether the PT was involved in the decision making for rehabilitation. While it would be a stretch to generalize these conclusion to other lower extremity conditions seen in PT (elective post-op, sprains/strains, neuromuscular) it's important that MD's (the gate keepers in the health care world) begin to shift their view of PT's as less of an adjunct of THEIR treatment to micromanage, and instead begin allowing themselves to work with PT's as health care professionals that bring a different body of knowledge to help in the conservative treatment of neuromusculoskeletal conditions.

Jason L. Harris

Article Reference

Labels: Direct access, evidence based medicine, lower extremity, physical therapist

The fine folks over at NursingDegree.net have worked to post a list of their thoughts on important websites and resources for Physical Therapists.   They have entitled it: "100 Essential Sites and Resources for Physical Therapists".  Check it out and leave a note on your thoughts on what was included and maybe what you think should be included that maybe wasn't.

Jason Harris

Labels: blogs, physical therapist, physical therapy

Physical Therapists in MainE are fighting for their livelihood against the ever-growing bravado in procuring profits by denying more on more services to subscribers and cutting reimbursements to providers. AFTER PT's in MainE signed on to be providers for Anthem BC/BS, Anthem UNILATERALLY cut reimbursement to those same PT's by 20%. Although that is bad in-of-itself, strong-arming providers into reimbursement agreements that are barely at a level (and sometimes below the level) allowing for a consistent profit margin, it is not new. There are two other developments from this action that I find interesting.

The first is what happened when Anthem forced this rate cut on the PT's in MainE. Unlike our long history of passivity, the PT's stiffened up and said "no!" and now have a lawsuit against Anthem that is moving through the courts. I see this as analogous to the terrorized finally pushing the bully back. We may get our asses kicked in the end, but it's finally a step towards standing up for ourselves and our profession.

The second event related to this is the response by our professional organization the APTA. It appears from my vantage point that the APTA is keeping to itself on this issue. In my opinion, this is the perfect opportunity for the APTA to help by flexing some muscle and stand up for what we know is right. It seems we are taking the stance that we don't want to "offend" anyone so we'll just make like Switzerland and play neutral.

We need to support our fellow PT's if not for anything but to avoid becoming bullied just as they are.

Jason Harris

Labels: Anthem, BC/BS, Healthcare, Lawsuit, Maine, physical therapist

I thought I would share some resources on how to find a Physical Therapist in your area. The yellow pages is an Ok place to start. Asking a friend or you primary care provider whom they'd recommend is another option. For those that can't or don't want to use these options, there are a few tools on the internet that will help you:

• Find a Physical Therapist - A search engine provided by the American Physical Therapy Association (APTA). It lists physical therapists via a specific radius from a given zip code. You can also filter by specialty (orthopaedics, geriatrics, etc). Limited as only members of the APTA are listed - but...would you want a PT that doesn't participate in their professional organization anyways?
• Find a Orthopaedic Manual Physical Therapist - The American Academy of Orthopaedic and Manual Physical Therapists (AAOMPT) provides a tool to find physical therapists that have advanced training, via a fellowship, in orthopeadic manual therapy. While all PT's use manual therapy in some form, these PT's have demonstrated advanced skill and knowledge with it's use.

Good luck with your search!

Jason L. Harris

Labels: Direct access, how to find, physical therapist, physical therapy, search

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

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

Many of us (physical therapists) find the overbearing control of the AMA difficult and stiffleing to what we see as professional autonomy. What most of us don't know, is that it was PT's that gave MD's the power over us. Beth Linker in the Journal of Women’s History, Vol. 17 No. 3 explains:

By 1935, the APA relinquished to the medical profession what little self-regulatory control it still maintained. In 1933, it gave the AMA’s Council on Medical Education complete power to accredit physiotherapy schools. In that same year, physiotherapists turned over the task of setting up a national registry to medical men in the Congress of Physical Therapy. As part of the agreement, the Congress required that physiotherapists be called technicians and give up their private practices to work under the direct supervision of medical doctors.

Power is like money. Once you freely give either to another person, asking them to give it up is a very thorny proposition with a bleak outlook for success.

Labels: AMA, APTA, history, physical therapist

The APTA provides us with an article outlining how Physical Therapists can provide care to improve the physical status of women on bead rest during pregnancy. Standard thought makes physical activity and bed rest mutually exclusive. However, as we know, and as the article points out, Physical Therapists do more than just exercise.

The problems with that arise with bed rest are varied and many. As the article points out:

As a result of prolonged bed rest, pregnant women experience an array of symptoms, ranging from cardiovascular deconditioning, musculoskeletal discomforts, stressful postures and positions, skin breakdown, muscle weakness, as well as psychological issues such as guilt, stress, and depression.

As Physical Therapists, we can improve bed mobility, maintain flexibility, reduce the chances of potentially deadly DVT's, and educate on body mechanics and positioning.

Labels: APTA, bed rest, education, physical therapist, pregnancy