Evidence Based Rehab

Labels: education, physical therapist

Anew website has been published providing information and resources on fighting chronic diseases. As we all know, the biggest impact on quality of life and health care costs are the treatment of chronic diseases. The website called "Promising Practices" comments that:

America faces an important crossroads in health care. The Partnership to Fight Chronic Disease, a diverse, national coalition of more than 100 partner organizations, is committed to raising awareness of policies and practices that save lives and reduce health costs through more effective prevention and management of chronic disease. We share common concerns about the incredible burden that chronic diseases place on families, the health care system, and the economy overall.

Though many understand the need for better ways to lower the risks of developing chronic illnesses and reduce the burden of illness on those already affected, they wonder how and where to begin. Innovators in schools, communities, workplaces, and the health care system are proving the value of addressing chronic disease in building a healthier America. Working together, we can develop innovative, common sense solutions to our current health care problems. We encourage you to use these resources to develop and support meaningful changes that will make a difference.

This appears to be a nice resource of patients and providers alike.

Jason L. Harris

Labels: education, Healthcare, Low back pain

A press release from the American Association of Oral & Maxillofacial Surgeons discusses a bill that would allow them to refer patients to physical therapy. Currently only osteopathic (DO's) and allopathic (MD's) doctors may "oversee" (read: sign the ok for) physical therapy.

Oral & Maxillofacial surgeons and other dentist make the case that they routinely treat patients that would benefit from PT, therefore having the ability to do so would be beneficial:

As Congressmen Pascrell and Cantor noted in sponsoring the bill, because a dentist or OMS cannot directly refer patients for physical therapy, they must refer patients to an allopathic or osteopathic physician to establish a therapy plan. In his statement of introduction on the floor of the House of Representatives, Pascrell stated, Such consultation has proven to be inefficient, unnecessary and cumbersome, and it ultimately delays patient treatment and the continuum of care.

I agree. But I'll take it one step further. It is just as "inefficient, unnecessary and cumbersome" for patients to have to go to their MD, DO, DDS in the first place for neuromusculoskeletal rehab. True full direct access to physical therapist - the experts in neuromusculoskeletal conservative care - would greatly decrease time to recovery and the extraneous costs of medications and excessive imaging associated with going to multiple physicians before getting to see a physical therapist.

Jason L. Harris

Labels: Direct access, EBM, education, evidence based medicine, Medicare

I wanted to share a nice resource I recently found on the internet. It is an online publication of the book "Back Care Boot Camp" which covers many educational aspects for patients on low back pain. The online (free) version appears to leave nothing out in terms of what the book offers to the patient. You can also purchase an ebook version or have a patient purchase an individual section to print. Each section costs only $1.00 and the whole ebook in $4.95.

This appears to be a very nice resource to supplement you patient education and re-emphasize important topics covered in a patients clinic visit. Check it out and let me know what you think.

Jason L. Harris

Labels: Direct access, education, LBP, Low back pain

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

While I try to stear clear of blogging on the US vs. Them, PT vs. Chiro debate (although my look at the use of the DRX9000 seems to be viewed by chiros as an assault on them), the underhanded way that profession is trying to "claim" manipulation in my state has brought this post out of me.

I want to first comment on how the Chiro profession is handling itself in Nebraska in regards to the PT profession updating our practice act (which dated back to the 1960's IIRC). Their must be respected powerful lobby was threatening to hold up this new legislation because the new act included language about the use of mobilization and manipulation (these are one in the same to the PT profession). "Oh no you don't" the Chiros exclaimed. They pulled out the old very false but effective crap about no having the training or skill to do (hmm, what was that I was learning in PT school then???) High Velocity Low Amplitude (HVLA) manual therapy. And, like PT's always do, we repented and asked the Chiros what we need to do to fix it. "We'll compromise" they offer.

So manipulation was crossed out and "Grade V mobilization" was added (again, in PT, manipulation and mobilization are one in the same). So, the bill is passed (will hold off on the commentary about Orthos objections to the use of "Physical Therapy Diagnosis"; Orthos and Chiros objections to "direct access" even though we've always had it by omission and no one has died - GASP!; and the school systems wanting to bill the government for PT despite providing care with untrained aides). Fast forward a year, and as the new practice act proceeds through it's many steps to fruition - A practice act is just a guideline, and specific rules and regulations need then to be developed from it - Chiros are back shouting "hold on!". We changed our minds, we object to "Grad V mobilization" cuz we say you can't do it. So it's back to expending money, time, energy, and sweat to again fight for what we've already attained. So, the Chiros back off with a knowing smirk of "we'll be back again".

The second item that brought me to write this was a great post by Panda Bear, MD entitled "Stealth Medicine and Other Topics" railing on Chiro's attempt at backdooring into becoming pediatric primary care providers. As Panda Bear quotes them:

“The doctor of chiropractic does not treat conditions or diseases.” Says so right in their mission statement. But then a little further down it ascribes complaints in every system to our old friend the subluxation and promises, by judicious adjustment of the pediatric spine, to allow the body to express a better state of health and well-being.

Imagine that. Promising one thing and practicing the opposite. Sounds familiar to me. Orac at Respectful Insolence and Eric at Evidence In Motion have both commented on a visited this particular post (Damn, I am slow on the uptake I guess). I'll quote Eric as a nice summary to all of this:

For those non-physical therapists reading this, it may be timely to point out that what IS in our scope of practice is all sorts of manipulative therapy. That's right, the specialization area of Orthopaedic Manual Physical Therapy is one where the physical therapist is equipped with both the tools to manipulate the spine or peripheral joints AND develop a comprehensive, integrated program of neuromuscular modalities for orthopaedic conditions.

For an excellent comprehensive look at the history of PT vs Chiro, the arguments analysed and what is most likely behind Chiro's fighting PT's over manipulation (hint: it's not really patient safety. Ok Hint #2: It starts with "M" and ends in "oney") click here.

Labels: APTA, Direct access, DRX 9000, education, manipulation

Found a brief PR article on lumbar stabilization by Physical Therapists. It is from ADVANCE magazine and the article can be found here. It appears directed at nurse practitioners, which is an important audience for us as more and more of family practice is being handled by "second tier" providers.

Maybe something that could be added to you "packet" of general information one could provide to your referral base.

Labels: Direct access, education, Low back pain, physical therapy, physicians

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.

---

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 .

Labels: alternative medicine, Chiropractic, education, Fraud, Low back pain, physical therapy

Well, I'm back from my 4,000 mile drive across the US midwest and northwest. Had a great time seeing family and visiting new towns and areas of the US. Very beautiful and often time spectacular. Today I will introduce a short series on the history of post World War I Physical Therapy History. I feel it is very interesting to see our roots and understand why some aspects of our profession are the way they are.

The vast majority of the information presented comes from an article written by Beth Linker in the Journal of Women’s History, Vol. 17 No. 3. The first passage comes from 1922:

...women leaders of the American Physiotherapy Association (APA) invited Ray Lyman Wilbur, then president of the AMA, to give the keynote address at the national physiotherapy conference. APA president Dorothea Beck enthusiastically introduced Wilbur to the stage, assuring him that it was the goal of her association to “give the medical profession a band of trained women whose ideals, personality, and technical training are all that the physicians and surgeons of the American Medical
Association can wish.”
The APA’s congenial relationship with Wilbur and the elite men of the AMA complicates the typical historical narrative of professional antagonism
between the sexes during the 1920s. Physiotherapy represents a different kind of female professionalism—one that concerned itself more with achieving autonomy from other white–collar women than it did with gaining independence from white–collar men. Other female–dominated health occupations that arose alongside physiotherapy during the war, such as occupational therapy and dietetics, drew support from medical men. But as occupations steeped in the womanly spheres of arts, crafts, and home economics, these other professions also achieved legitimacy through the backing of women’s charity networks. By contrast, physiotherapists did not seek support from women’s clubs or female associations for professional uplift; rather, physiotherapists legitimized their profession almost solely by association with the medical profession.

We see early on that the PT profession banked it's success on allowing themselves to be partially "controlled" by the AMA. We have been fighting ever since. Where professions like massage therapy, ATC, DC's fought for legitimacy from public opinion, PT's have become, possibly, forever entangled with the AMA.

This has allowed for greater legitimacy in the health care world, but an inexplicable denial of autonomy by our past "parents". With this, it may be easier to "invent" a new musculoskeletal profession and become truly autonomous then ever cut the control lines from the AMA.

Labels: APTA, education, history, physical therapy

Reading one of my favorite medical blogs - Respectful Insolence - Orac posted on a Homeopath in Arizona that had a patient die after performing liposuction on her. To make this even more interesting, the assisting physician had already had 2 patients die after lipo and his lisence had been put on probation.

This got me thinking, do people really know what homeopathy is? Or do they just blindly believe what these pseudo doctors are telling them?

Here is a great video of James Randi explaining Homeopathy and the "4 rules of homeopathy":



My favorite line when referring to a homeopathic medicine:

Has no side effects. That's true. My question is 'does it have any other effects'?

Absurdity, this is. I believe people should be able to choose how to treat their ailments. However, homeopathy is duping the desperate, fearful, and needy. Educate those who ask about the quackery that homeopathy medical treatment is.

Labels: EBM, education, Evidence, Fraud

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

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