Evidence Based Rehab

Ihave posted several articles on the overuse of imaging in musculoskeletal care (find them here, here, here, and here). Now we have another study from the Archives of Internal Medicine making not only that statement but going as far as speculating that this is related to financial gain, improved patient satisfaction, and potential for more harm that good.

In a news release from Musculoskeletal Report, the study found:

Patients were more likely to undergo imaging tests if their primary care physician worked in large practices and if the doctor was offered patient satisfaction-based financial incentives. Practices with clinical quality-based incentives, however, were less likely to order advanced imaging tests for low back pain patients in the absence of clinical red flags.

Additionally, the article reports on the potential harm of advanced imaging stating:

...advanced imaging of the spine has a low yield of unexpected findings and an “alarmingly high” yield of irrelevant findings.

I'm sure, as physical therapists, we see the fallout from this. More and more patients are presenting in the clinic with simple low back pain (simple meaning no neurologic, systemic, or lytic component - not low in pain) with no treatment beyond narcotics and muscle relaxants and MRI in hand. Now we not only have to try to get them better after 4-6 weeks of prior ineffective treatments, we also have to convince them that all the irrelevant findings (disc bulge, DDD, foraminal stenosis in now way associated with their complaints, etc) are not the problem and will not result in death, or worse, disability.

It seems everyone knows we shouldn't be doing this. Now we just need to convince the gate keepers with their own imaging labs to not perform these unnecessary, revenue generating, insurance companies turn a blind eye to, procedures. I'm sure there will be no difficulty in that.

Jason L. Harris


Hoangmai H. Pham, Bruce E. Landon, James D. Reschovsky, Beny Wu, & Deborah Schrag (2009). Rapidity and Modality of Imaging for Acute Low Back Pain in Elderly Patients Archives of Internal Medicine, 169 (10), 972-981

Labels: evidence based medicine, Imaging, Low back pain

Acupuncture (sticking needles at specific points to a certain depth in the skin) is not an effective treatment for chronic low back pain. This may sound surprising as the media has jumped all over a new study that supposedly shows that acupuncture is more effective than "usual care". Unfortunately - as the media usually does - they've misinterpreted the results of the study. In fact the study showed that there is no difference in the effectiveness between "fake" and "real" acupuncture. Meaning, there is no effect of acupuncture.

Steven Novella over at Science-based Medicine does a masterful job of explaining this in detail. Please visit his post on this study to become enlightened by logical and scientifically based thoughts and discussion - as opposed to hype.

Jason L. Harris

Labels: acupuncture, back pain, evidence based medicine

The Insurance Journal released an article discussing how a "surprising" share of work comp case costs come from unanticipated costs or, as they term it, "Adverse Surprise Costs." The study reported on was said to find:

Adverse surprise cases were disproportionately chronic conditions with multiple surgeries. They were also disproportionately back pain cases.

That's no surprise to me, however, and should really not be a surprise to anyone dealing with chronic pain and low back injuries. While back pain is not the only musculoskeletal condition being over-treated with narcotics, expensive imaging, and surgery, it certainly is the most costly of all. In fact, most of my recent posts have centered around this subject (you can find them here, here, and here).

What is surprising is that, despite all this research showing all this imaging, surgery, and narcotic prescription make things worse often, we are still using that recipe to treat most folks with LBP. In fact, those doing it are being the ones rewarded with reimbursement for doing so.

Jason L. Harris

Labels: evidence based medicine, insurance, LBP, Low back pain, over-use

A pair of article from the April 1st issue of Spine remind us of what real reform in health care we need. While President Obama is at least attempting to get the ball rolling with changes in health care, Electronic Medical Records (EMR), expanded coverage, and "investing" in prevention and wellness aren't going to change today's problems at the root of rocketing health care costs.

One piece at the root of these rocketing costs is excessive use of imaging, surgery, and drugs. Low back pain treatment often gets the full brunt of these high cost, low efficacy procedures. Now, the new issue of Spine shines some light on the harm this approach can cause.

In the first article by Timothy Carey, MD - Practice patterns and evidence in chronic low back pain care - it was found that (surprise) there is an overuse of narcotics and imaging and little use of established beneficial treatment of exercise. The figures quoted in the article report fewer than 30% of LBP suffers had seen a physical therapist in the past year and, worse yet, only 3% had gone through a structured rehabilitation program.

The second article by Sham Maghout Juratli, MD - Mortality After Lumbar Fusion Surgery - there was a finding of alarmingly high percentage of deaths after fusion surgery related to Analgesic overdose. The author comments that:

Analgesic-related deaths are responsible for more deaths and more potential life lost among workers who underwent lumbar fusion than any other cause.

So, instead of treating LBP primarly with research-proven exercise prescription there is an overuse of narcotics and surgery that are leading to increased loss of life!

Maybe rewarding those attempting to use what research shows as effective for LBP instead of shelling out billions for imaging, drugs, and surgery might not only lead to lessening costs but decreased mortality.

Labels: evidence based medicine, Fusions, Low back pain, physical therapy

Announced today is the formation of the first wiki-based collaborative online educational resource for the global physiotherapy community. Physiopedia is an ambitious project which aims to eventually offer an evidence-based knowledge resource for physiotherapy professionals throughout the world. Through utilising collaborative wiki technology Physiopedia is a place where all physiotherapists can participate by contributing, sharing and building knowledge to develop a global understanding. For educators Physiopedia offers an opportunity to involve their students in this knowledge creation process as part of an educational program.

Individuals and educational institutions around the world are contributing to Physiopedia in various ways. Educational institutions are engaging their students to contribute content as part of their educational program, expert clinicians are contributing seed content free of copyright restrictions and individuals are contributing content out of their own personal interest and as part of their professional development.

Making high quality information for physiotherapy professionals freely available via a collaborative, open and constantly evolving website has the potential to promote the physiotherapy profession and improve patient care. Over the next few years, there will be a growing community of contributors who will create pages in different clinical areas covering anatomy, physiology, conditions, assessment and interventions. Other professional resources that will be created include evidence based practice, outcome measures and research methods. These pages will be constructed using the latest evidence and will be constantly evolving with updated information.

Today Physiopedia is calling for students, clinicians and educational institutions to contribute content. Professionals around the world who contribute to Physiopedia will have the opportunity to make a difference by promoting our profession and in improving the health of our patients. Physiopedia will also serve as an important place for professionals to create a presence on the Web and become known for their specialties.

Physiopedia’s founder is Rachael Lowe from the UK, a physiotherapist and e-learning specialist who combines these skills with the specific aim of utilising web technology for physiotherapy education. She has developed this site with the global community in mind in consultation with Eric Robertson, Assistant Professor at the Medical College of Georgia in the USA.

Educational institutions and clinicians have begun to contribute content to Physiopedia and the site will continually develop to provide a valuable promotional and educational resource to the global physiotherapy community. This free public site will officially launch later in 2009 but this preview site becomes available today at www.physio-pedia.com.

Labels: evidence based medicine, Open Access, physical therapy

Lancet recently published a systemic review looking at routine imaging for Low Back Pain (LBP) without "red flags" that would suggest serious underlying conditions (eg, myelopathy, cancer, fracture, etc). While the results aren't surprising to the majority of conservative musculoskeletal practitioners, they do need to be publicized to the general public just as much as the silly studies that show "acupuncture" being effective treatment fot LBP. The authors conclude:

Lumbar imaging for low back pain without indications of serious underlying conditions does not improve clinical outcomes," they conclude. "Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low back pain and without features suggesting a serious underlying condition

However, despite studies that show MRI's done for LBP and work related injuries tend to lead to poorer outcomes, and that much of what is foung (DDD, spondylosis, Disc herniations) are "normal" findings, the authors seem pessimistic in MD's changing their behavior.

...there is no compelling reason why more attention should be paid to low back pain than to any other prevalent condition." Other factors include patient expectations about diagnostic testing, reimbursement structures that provide incentives for imaging, and the fear of missing relevant pathology...

Throw in great marketing for spinal surgery, these imaging results are a great stepping stone to push invasive surgery for non-specific low back pain. So, get the word out - stop the excessive imaging and treat LBP initially with what we know has the greatest return for the least potential harm - Physical Therapy, education, and gentle return to activity.

Roger Chou, Rongwei Fu, John A Carrino, Richard A Deyo (2009). Imaging strategies for low-back pain: systematic review and meta-analysis The Lancet, 373 (9662), 463-472 DOI: 10.1016/S0140-6736(09)60172-0

Labels: evidence based medicine, guidelines, Low back pain, MRI

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

Reading the newest issue of Orthopaedic Physical Therapy Practice (the magazine of the Orthopaedic Section of the APTA) I found interesting the Editor's Message written by Christopher Hughes, PT, PhD, OCS. The letter titled "When All Else Fails...We Succeed!" relates that an episode of care from a Physical Therapist that does not end with hoped for gaols met, is not a waste. That, in fact, it is a valuable tool to help in the clinical decision making by MD's - especially in the arena of deciding on surgery or other invasive procedure.

I agree with this view, and have educated a number of my clients that at the very least, their episode with me will make them better prepared for surgery and increase their prognosis after surgery. I would like to speak on a subject related to this: Over Utilization.

I will give our fellow professionals the benefit of the doubt and say that the desire to achieve all goals for all clients leads to continuing treatment past maximum medical benefit. We all do this, and looking at my stats from 2008, those who were discharged w/o all goals met averaged about 2-3 more visits than those who where discharged with goals met. Some of that is related to me trying to get that last goal or two, some related to MD referring back to "just try a little more", and more is related to the client wanting to have more PT. Now, what we need to be aware of is "benefit chasing".

We all know of clinics/PTs that do this. If the client has 20 visits per year, that's how many PT sessions they'll get. Regardless if it's a knee sprain or s/p ACL reconstruction. It's this practice behavior that really hurts us, particularly in the eyes of the insurance companies.

I'm sure there are many reasons why this practice occurs. Including desire to maximize profits. What we need to do as a profession is self police and encourage appropriate utilization of our care provided. Steps we (individually) can do are:

1. Set goals with time frames, and share these with our clients. This will help hold ourselves accountable.
2. Use outcome surveys. DASH, Oswestry, Neck Disability Inex, etc. Easy to get caught up in the "I feel a little better" trap and keep treating. Use these tools to help measure actual perceived change allowing you to make better continued treatment decisions.
3. Track your outcomes. This will allow you to evaluate your tendacies in treatment and areas you can improve.
4. Question your collegues and be open to constructive critisism from your collegues regarding visits.

How do you monitor utlization? Do have anecdotes regarding over use or proper use of PT sessions? Any other suggestions on how to prevent over utilization?

Labels: evidence based medicine, outcomes, over-use, physical therapy

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

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

Just wanted to share:

"Either it is true that a medicine works or it isn't.
It cannot be false in the ordinary sense but true in some 'alternative' sense."

-Prof. Richard Dawkins, Oxford, April 2001

Great stuff. I'm a true believer that if a treatment is shown to be beneficial it's medicine. There is no "alternative" to it; as the alternative is a treatment that is not beneficial.

Jason Harris

Labels: alternative medicine, evidence based medicine

Iwas shocked to stumble upon a letter apperently written by president elect Barack Obama professing support for the chiropractic profession. Now, my intent for this blog is not to go out of my way to bash other professionals just to bash them. However, Obama's words concern me as they appear to indicate he is ignorance in regards to evidence based medicine and the problems with our healthcare system (over-utilization, excessive imaging, dogma and personal beliefs dictating treatment). From the letter posted on Chiroeco.com:

We need to knock down unreasonable barriers of access and discriminatory insurance coverage so Americans in need of quality chiropractic care can access it without difficulty. We need to expand the range of chiropractic services covered by Medicare, facilitate integration of doctors of chiropractic into the health care systems of the Department of Veterans Affairs and Department of Defense, and allow commission of doctors of chiropractic as officers in the Commissioned Corps of the U.S. Public Health Service.

I am absolutely for the right for people to choose chiropractic care for their conservative musculoskeletal care. However, I draw the line at the government using my tax dollars to pay for "subluxation" treatments and excessive imaging. The biggest problem is that an evidence based chiropractor is called a Doctor of Physical Therapy.

Secondly, Obama's comment on "integrating" chiropractic is almost laughable. The very tennant of chiropractic is it's drive to SEPERATE itself from mainstream medicine. No comment on whether this is right or wrong, just stating a fact. They push anti-vacination, subluxation theory for health, pedicatric health through manipulation, and a wide variety of nutritional supplements. Is this what we want to spend our money on?

We are all looking and hoping for health care system reform. I just hope the reforms are well researched and done with the least amount of ingnorance possible.

Jason L. Harris

Labels: Chiropractic, evidence based medicine, health care, Obama

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

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

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

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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

Wow, it has been a while and I apologize for that. My family and I have moved across the country, sold our house, started new jobs, and have been looking for a new home just in the last month. On top of that, I have been without internet access until just this past week. Well, I am back, and hope to again barage you all with disconnected rants and musings.

I'll take this time to try to give a peek as to what I plan to post on in the near future:

• Medicare Cap
• Round 2 of NATA vs APTA
• Because I'm forced to...the Wii in rehab
• Reviews on interesting Journal articles that others may like too

Expect a new post early next week. Thanks to those still subscribed.

Jason Harris

Labels: evidence based medicine, physical therapy, welcome

Degenerative Disc Disease. For many of those that get an unnecessary MRI and get this diagnosis, it's often taken as a death sentence for a back instead of what it is - a normal process related to aging. Although pain can be associated with DDD, it is more often just a radiologic finding. Something that was most likely present before onset of spinal pain and will remain unchanged once the spinal pain recedes.

June's issue of the Journal of Orthopedic & Sports Physical Therapy (JOSPT) includes and excellent commentary on what we know and don't know regarding intervertebral disc degeneration. I would like to summarize some critical points I found in the article.

• Although environmental factors play a role in the incidence and progression of DDD, the strongest predictors are genetically related. It is estimated that 74% of what causes DDD appears related to genetics.
• Smoking and heavy labor have not been supported as etiologic factors in developing DDD. In fact, competitive weight lifters w/o trauma have a lower than expected rate of DDD.
• Primary factor in DDD is reduction of the Intervertebral Disc's (IVD) nutritional capacity.
• "...age-related changes that occur in the composition of the IVD are similar to those observed in articular cartilage and are not necessarily related to pain."
• Vertebral endplate disruptions are being shown to have a strong relationship with DDD.
• Although similar in appearance, there are measurable differences in the diffusion capacity at the vertebral endplate of those IVD's with age-related disc degeneration and symptomatic degnerative discs. This may suggest that aging and degeneration are 2 separate processes.
• "High-Intensity Zones" represented by high intensity T2 signals near the outer margins of the annulus are correlated to pain production with discography (IMO, discography is often painful regardless of pathology) but also commonly found in asymptomatic individuals. This leads to poor specificity and the authors suggest it should not be used in isolation to make clinical decisions.
• The body's attempt to heal annular tears may lead to increasing the area of the disc that is innervated which is further increased by inflammatory byproducts which can lower the threshold needed to trigger pain. The result could be increased sensitivity to otherwise innocuous stimuli. This includes those from just standing and/or walking.
• Even if MRI shows a dramatic disc bulge, this finding is very often not associated with symptoms.
• When nuclear material breaks free and migrates into the vertebral foramen, ipsilateral pain and parasthesia may occur. This results from the chemical response to the nuclear material touching the dorsal root ganglion and not from "pinching" the nerve.

The authors then make some comments on clinical relevance. Here are a few that will lead to a change in the way I treat on Monday:

• Patients with later stage DDD - decreased disc height and hydrostatic nucleus lost - care should be taken during loading progressions, avoiding sustained loading at end range trunk motions.
• Symptoms often occur several hours after trauma to the degenerated disc (DD). Thus, exercise in the gym may go well but in the morning the patient may be too painful to even get out of bed.
• Studies have found favorable outcome in treating DDD with lumbar stabilization exercises.
• It was found that patients with DD who avoided early morning lumbar flexion had significantly less pain and disability then did those who performed lumbar flexibility exercises early in the morning.
• Patients with DD should be encouraged to avoid prolonged flexed compressive forces such as sitting in flexed position.
• Hip ROM limitation can have large effects on loads acting on the lumbar spine.
• The authors make it a point to illustrate the important role the psychological effect that the diagnosis of "degenerative disc disease" has on the patient. they state:
• "...it is important that clinicians carefully communicate with patients to reassure them that DD is a normal aging process; while it certainly can be associated with episodes of pain, only in rare exceptions do these symptoms represent serious disease, and they should not, therefore, prevent one from performing reasonable activities."

It's important to remember the fact DD is related to normal aging. And, thus, it's main treatment should most likely be non-invasive conservative care. And, as I always say, PT's are the experts in this area and well positioned to give the more efficacious care.

Jason L. Harris

Labels: DDD, Degenerative Disc Disease, DRX 9000, evidence based medicine, Low back pain, physical therapy