Evidence Based Rehab

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 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

Ihate "health" products being pushed on us simply with anecdotal evidence and testimonials. One of the newest fads is 'Whole Body Vibration'. The claim is that exercising on this vibrating plate significantly increases your strength versus doing the exercises alone. There is very poor, and limited, evidence for this. For a good overview, please read Sal Merinello's excellent synopsis of the evidence over at The Healthy Skeptic. Below is a brand new journal article on this fad in regards to impact on older men over a 1 year period.

: J Gerontol A Biol Sci Med Sci. 2007 Jun;62(6):630-5. Links

Impact of whole-body vibration training versus fitness training on muscle strength and muscle mass in older men: a 1-year randomized controlled trial.

Bogaerts A, Delecluse C, Claessens AL, Coudyzer W, Boonen S, Verschueren SM.

Division of Musculoskeletal Rehabilitation, Katholieke Universiteit Leuven, Tervuursevest 101, Leuven, Belgium.

BACKGROUND: This randomized controlled study investigated the effects of 1-year whole-body vibration (WBV) training on isometric and explosive muscle strength and muscle mass in community-dwelling men older than 60 years. METHODS: Muscle characteristics of the WBV group (n = 31, 67.3 +/- 0.7 years) were compared with those of a fitness (FIT) group (n = 30, 67.4 +/- 0.8 years) and a control (CON) group (n = 36, 68.6 +/- 0.9 years). Isometric strength of the knee extensors was measured using an isokinetic dynamometer, explosive muscle strength was assessed using a counter movement jump, and muscle mass of the upper leg was determined by computed tomography. RESULTS: Isometric muscle strength, explosive muscle strength, and muscle mass increased significantly in the WBV group (9.8%, 10.9%, and 3.4%, respectively) and in the FIT group (13.1%, 9.8%, and 3.8%, respectively) with the training effects not significantly different between the groups. No significant changes in any parameter were found in the CON group. CONCLUSION: WBV training is as efficient as a fitness program to increase isometric and explosive knee extension strength and muscle mass of the upper leg in community-dwelling older men. These findings suggest that WBV training has potential to prevent or reverse the age-related loss in skeletal muscle mass, referred to as sarcopenia

The results show NO DIFFERENCE between groups; but, the authors make the conclusion that

"WBV training has potential to prevent or reverse the age-related loss in skeletal muscle mass..."

Huh? I guess that is true if general exercise does (which is true). But it doesn't do it any better and at a greater cost and inconvenience. Look for the manufacturers to post this on their websites as "evidence" that WBV training prevents muscle mass loss!

I say: Buyer beware!

Labels: alternative medicine, EBM, Evidence, exercise, fitness, outcomes

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