Evidence Based Rehab

I read an eye opening article by Frank Furedi, a sociologist from the University of Kent. He orates on the evolution of our society, especially western society, of illness being an infrequent negative state to a normal accepted state. In his article, Furedi laments that "wellness" is a social responsibility and possibly a state we can never acheive.

Wellness has become something you have to work on, something to aspire to and achieve. This reinforces the presupposition that not being well - or being ill - is the normal state. That is what our culture says to us now: you are not okay, you are not fine; you are potentially ill. The message seems to be that if you do not subscribe to this project of keeping well, you will revert to being ill.

The more we obsese with "wellness" the more it seems we are forever in a state of "illness". My opinion is that we should continue to counsel "wellness" but to take every opportunity to reinforce our patient's (and each others) successes. Embrace to good and accept that we can really never reach the nirvana of "wellness" that has been placed in front of us.

Labels: education, health, physical therapy

CNN posted an article today focusing on new research that shows as little as 10 minutes a day of exercise is beneficial for obese women. I think this reaffirms many of our beliefs that increasing activity in any way is helpful to the sedantary adult. The thought of a rigid 60 minute exercise session a day turns the majority of us away from becoming more active. This article can be a tool to help get more effort out of the reluctant patient.

An experience I had last year can help illustrate how PT's and research like this can help the general public. I was co-treating in a pro bono clinic with a physician. We evaluated a women with a history of IDDM and a 2 month old foot fracture. At the end of the eval the physician turned to the patient and said "you need to loose 100lbs in order to improve your health. Follow up in 3 months to check your progress". I'm sure that motivated her to go out and join a health club!

When the physician left, it was my turn to discuss with the patient some changes she could make to slowly increase her activity levels. These included simple tasks such as walking 3 laps around her home during commercials, parking 1 row further out from the store, and taking 1 flight of stairs to work and then the elevator to the last 3 flights.

I believe simple semantic change away from pushing an "exercise program" on the sedentary and obese and instead championing "increased activity" (which, down the road, should include specific cardiovascular exercise) will lead to better outcomes.

As I tell all my patients, "Doing something is better than doing nothing".

Labels: exercise, health, physical therapy

In the clinic, on the the web, and at professional meetings, I come across PT's all the time who decry Clinical Prediction Rules (CPR's) as 'cookie cutter PT'. This sentiment seems to come from a varied number of reasons. From fear of change, a feeling that their clinical practice is being dictated to them, and a lack of understanding/ignorance. So, what are clinical prediction rules?

John Childs and Josh Cleland wrote an excellent essay in the January 2006 PT Journal that inspired this blog entry. Their message is that CPR's can:

• Improve decision making in the PT practice.
• Provide PTs with diagnostic information gleaned from the H&P the can serve as an accurate predictor calling for more expansive diagnostic testing.
• Assist with subgrouping patients into more specific classifications that allow for better choices for treatment strategies.
• Assist in determining when a particular treatment may not be beneficial.

No where does this article indicate patients are treated with a set protocol with no variation or therapist input. That's how I understand "cookie cutter" to be. It does, however, indicate there are specific interventions that need to be included or specific actions that must be completed if a patient is positive for a CPR.

The end goal for CPRs is to help us change our behavior by using treatments and diagnostics most highly supported by the literature. Unfortunately, changing practice patterns is a difficult task for many of us due to comfort, fear of change, or no desire to improve ones practice.

Labels: clinical prediction rules, outcomes, physical therapy

In this Wall Street Journal article, the issue of excessive imaging and surgeries for back pain is discussed. As PT's we have all seen the patients that have had x-rays and MRI's for simple non-traumatic back pain and wondered 'Why were these done'. The article lists common missteps doctors make when treating back pain:

• Over-prescribe epidural steroids.
• Order excessive imaging
• Perform invasive surgery too soon.
• Fail to educate patients about surgery and alternatives to surgery.
• Fail to assess mental health.

Why do doctors do this? Physicians are very smart and good at what they do; but, they are human just like us. Fear of litigation, pressure to please the patient, and just not knowing a better way are all plausible answers. The problem is, there are studies that show unneeded imaging can lead to diminished outcomes, and lumbar fusion surgery offers negligible benefits at best for the majority of the back pain population for the risks involved.

The program is spearheaded by the National Committee for Quality Assurance and strives to reward physicians that follow the plan and to educate the public about their options besides surgery. They produced a list of 16 guidelines for MD's to follow with a few listed below.

RIGHT CARE FOR ACHING BACKS

A new program is urging doctors to follow 16 guidelines including:

• Help patients quit smoking
Smokers with back pain have more severe symptoms that last longer and have poorer outcomes after spinal surgery.

• Encourage patients to maintain normal activities and avoid bed rest
Bed rest can lead to problems such as joint stiffness, muscle wasting, loss of bonemineral density and pressure sores.

• Use X-rays and CT scans only when appropriate
Unnecessary for first six weeks after onset of pain unless there is indication of a more serious disorder.

• Use epidural steroid injections only when necessary
Not recommended unless symptoms include radiating pain (sciatica, herniated disc).

• Hold off on surgery
Not recommended in first six weeks of pain onset; half of patients with radiating low back pain recover spontaneously.

Conservative care and education should lead to improved outcomes and lower costs in treating back pain in this country.

Labels: Low back pain, over-use, physical therapy, surgery

A nice story from MSNBC that points out what many of us in the health professions have believed for years. We pay more for less that other countries. While the article subtly attempts to link it to lack of universal health care, I feel it's more related to consumer (that's right consumer not patient) attitudes, laws that limit efficient choice of health care providers, and our for-profit insurance structure.

As we feel we are no longer patients but consumers of health care, we demand the best, demand it now, and demand to pay very little for it (for those with insurance). Unfortunately, these three are mutually exclusive. We have to give on one to receive the other two. We tried for many years to ignore that and operate like we could get away with it. Now, we are seeing the consequences. Insurance rates rising, health costs rising, and benefits being cut back. Universal health care won't fix this problem.

Personally, another bottleneck and source of increased health care costs is our inability to access rehab services with out a physicians ok. Often times this results in at least to unnecessary office visits to a practitioner with less musculoskeletal knowledge then the PT, and delayed care.

Finally, insurance providers are out to make money. Plain and simple. And with out proper regulation, they will continue to work together (when we can't do the same to oppose them) to drive down their costs. This includes increasing premiums, deductibles and co-pays while simultaneously decreasing what they pay to practitioners and what they will actually cover.

What is the answer? We as consumers need to take responsibility for what services we demand (not, well insurance will pay for it so just do it), and also require that our insurance companies incorporate our needs into figuring their bottom line.

Labels: insurance, over-use, physical therapy