Evidence Based Rehab

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

Multi-Million Dollar Television Ad Buy Unveiled Today Promotes Health Care Reform as a Top Domestic Priority for the Next President and the New Congress

Washington, D.C. -- January 8, 2009 -- Six organizations representing consumers, physicians, insurers, patients and pharmaceutical research companies are banding together to launch a new multi-million dollar national television advertising buy. Their common message: In order to fix the ailing economy, the nation needs health care reform that addresses the related problems of health care costs and people losing health coverage.

The groups are the American Cancer Society Cancer Action Network (ACS CAN), the American Medical Association (AMA), Families USA, the Pharmaceutical Research and Manufacturers of America (PhRMA), Regence BlueCross BlueShield, and the Service Employees International Union (SEIU).

The ad will air at least until Feb. 5 and focuses visually on the nation’s manufacturing sector, but the organizations all agree that every sector of the economy will benefit from health care reform. The ad opens with: “At a time when American businesses are hurting, why should we worry about fixing health care? Because quality, affordable health care can save money and make businesses more competitive.”

“Cancer patients across the country—including those with insurance—often must dig deep into their savings and risk financial ruin to pay for cancer treatment and care,” said John R. Seffrin, Ph. D., Chief Executive Officer of the American Cancer Society and its advocacy affiliate, ACS CAN. “Elected officials should recognize what American families already know—that fixing the economy requires that we fix the broken health care system.”

“Healing our health care system is a key component to jumpstarting our national economy. As our new ad makes clear—quality, affordable health care is good for families and it's good for businesses,” said AMA President Nancy H. Nielsen, M.D.

“While businesses and families cope with unaffordable health care costs, many workers are losing their jobs and health coverage,” said Ron Pollack, Executive Director of Families USA. “As a result, it’s clear that America’s economic difficulties require meaningful health care reform. It’s this message that animates our ad campaign.”

“Expanding access to quality and affordable health insurance is good for patients and good for our economy,” Billy Tauzin, President and CEO of PhRMA, said today. “Improved access means we can do more to promote prevention and more to detect and treat conditions at an early stage, when we can do the most to avoid poor health outcomes and costly complications of chronic diseases, which account for seven out of every ten deaths in America.”

“Given the nation’s economic and health care crises, now is the time to bring meaningful, lasting change to our health care system,” said Mark Ganz, President and CEO of Regence. “We urge President-elect Obama and Congressional leaders to bring together stakeholders who are willing to discard outdated concepts and collaborate on practical solutions.”

“As the economy sputters, the need to fix healthcare is becoming more and more urgent. The clock is ticking,” said Andy Stern, President of SEIU, the nation's largest union of healthcare workers. “It will take all of us—individuals, corporate leaders, healthcare providers and the government—working together to solve America's healthcare crisis.”

The ad was unveiled today by all the sponsoring organizations at a news conference in Washington, D.C.

About the sponsors:

ACS CAN, the nonprofit, nonpartisan advocacy affiliate of the American Cancer Society, supports evidence-based policy and legislative solutions designed to eliminate cancer as a major health problem. ACS CAN works to encourage elected officials and candidates to make cancer a top national priority. ACS CAN gives ordinary people extraordinary power to fight cancer with the training and tools they need to make their voices heard. For more information, visit http://www.acscan.org/.

The American Medical Association helps doctors help patients by uniting physicians nationwide to work on the most important professional and public health issues. Working together, the AMA's quarter of a million physician and medical student members are playing an active role in shaping the future of medicine. For more information on the AMA, please visit http://www.ama-assn.org/.

Families USA is a national nonprofit, non-partisan organization dedicated to the achievement of high-quality, affordable health care for all Americans. Working at the national, state, and community levels, we have earned a national reputation as an effective voice for health care consumers for 25 years. For more information, visit http://www.familiesusa.org/.

With 2 million members in Canada, the United States and Puerto Rico, SEIU is the fastest-growing union in the Americas. Focused on uniting workers in healthcare, public services and property services, SEIU members are winning better wages, healthcare and more secure jobs for our communities, while uniting their strength with their counterparts around the world to help ensure that workers—not just corporations and CEOs—benefit from today's global economy.

Regence BlueCross BlueShield is a leading health insurer in the Northwest/Mountain State Region, offering health, life and dental insurance. Regence serves nearly three million members as Regence BlueCross BlueShield of Oregon, Regence BlueShield (selected counties in Washington), Regence BlueCross BlueShield of Utah and Regence BlueShield of Idaho. Each plan is a not-for-profit independent licensee of the Blue Cross and Blue Shield Association. Regence is committed to improving the health of our members and our communities, and to transforming our health care system. For more information, please visit regence.com.

The Pharmaceutical Research and Manufacturers of America (PhRMA) represents the country's leading pharmaceutical research and biotechnology companies, which are devoted to inventing medicines that allow patients to live longer, healthier, and more productive lives. PhRMA companies are leading the way in the search for new cures. PhRMA members alone invested an estimated $44.5 billion in 2007 in discovering and developing new medicines. Industry-wide research and investment reached a record $58.8 billion in 2007.

Labels: Press Release