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Marketing and PT Month II

Didn't exactly get an overwhelming response to the last marketing post (with notable exceptions, thanks Andrew and Rob), so I thought I would get the ball rolling with some of my own things. Here are a couple of articles I wrote for the local paper. I stole the titles directly from APTA news releases, but wrote the text myself. Please feel free to use, edit, and put your own name on there as you find useful. I think our profession is far more in need of good marketing than of copyrighted news releases and briefings.

Download nr_1_pt_pain_relief_underlying_causes.doc

Download nr_2_pt_lx_manipulation_cpr.doc

I am working on some briefings to physicians regarding current practice issues and management of low back pain, I will post those when they are done, should be a week or two. I hope these are helpful for everyone. Thanks.

Jason.

Standardizing Care in Physical Therapy Practice

The attached article illustrates well how standardizing care processes and implementing evidence-based guidelines can improve health-related outcomes. Can you imagine the costs and disability associated with managing back pain that could be spared if we could replicate the behavior changes demonstrated in this study? The notion that practice variability reflects our 'creative talents' and the 'art' of physical therapy cannot be justified by any rational argument. It is entirely illogical to think that we can all be right. Where there is variation, someone (or many 'someones' ) is practicing in a manner that is inconsistent with best practice. We expose our patients to real risks of suboptimal outcomes every time we act in a manner that is inconsistent with current best evidence. I would also suggest we don't get any 'moral credit' for unknowingly doing so. If we make the case that our responsibility is to 'first do no harm', EBP is really a minimum standard for practice rather than some 'pie in the sky' objective that few pursue. Standardizing care in our profession will go a long ways in effecting evidence-based behavior change, ultimately accelerating our achievement of Vision 2020 well in advance of this timeline. Who wants to wait another 15 years anyways to find a profession of tomorrow that is better than today? We can have our profession of tomorrow now!

John

Download Eagle-JAmerCollCardiol-2005-GuideCareReducesMIMortality.pdf

Pain Education and Brain Activity in Patient with CLBP

Here is an interesting case report out of Australia. Moseley describes a patient with CLBP who under went fMRI scans during performance of a voluntary trunk muscle task under three conditions: 1) directly after training in the task, 2) after one week of practicing the task prior to a pain education session, and 3) immediately after a two-and-a-half hour pain physiology education session.  Review of the imaging revealed markedly decreased brain activity (specifically cortical activation) with the voluntary task following the pain education session. Moseley suggests that pain education may reduce the threat value of a voluntary muscle task in some persons with CLBP.

While the author acknowledges the need for additional research, this paper provides an opportunity for PTs to reflect on the potential effect we have as patient educators.  If indeed we are able to influence/change pain beliefs through education, what a way to empower our patients!

Download moseley_2005_aust_j_physiotherapy_widespread_brain_activity_during_abdominal_task_reduced_after_pain_education.pdf

Bryan

EBP Inertia & Running

Despite our constant calls for integrating evidence into practice and best of intentions, often our human nature remains inclined toward the path of least resistance resulting in EBP inertia.

Case in point: I discovered the joys of running (15 – 20 very slow miles a week) 3 years ago when I was 39…nothing like a runner’s high and the sense of wellness that being aerobically fit gives you. The issue is that I have is that I had an ACL reconstruction, bilateral menisectomy, and chondroplasty on my right knee when I was 18yrs old and don’t want to prematurely wear it out.  As a result of a mandatory physical I had my knee recently checked by an orthopedic surgeon. I heard from him what I had heard from various professionals (including PTs) and lay persons over the years: “By continuing to run, you are going to wear-out your knee so stick with non-weight bearing, low impact activities.” I have often wondered about this myself many times but had never checked into. Is this really the case or is this just one more example of advice that seems intuitive but really has no basis in fact?

Lumbar Stabilization CPR

Congrats goes out to our colleague Greg Hicks and company, whose dissertation work was just published in Archives of Physical Medicine and Rehabilitation. The study assessed predictors of successful outcome from lumbar stabilization exercise, providing specific insight into the clinical examination findings associated with successful outcome from this form of treatment. This is the first step in the development of a clinical prediction rule. More work needs to be done to validate these findings in a different population, but this is a big step forward. Greg, thanks for the contribution.

Download Hicks-ArchPhysMedRehab-2005-DevelopStabCPR.pdf

John

Research Funding vs. Productivity

An interesting article was recently published in JAMA that quantified funding trends from 1994 to 2004 of basic, translational, and clinical biomedical research. Adjusted for inflation, spending doubled during this period ($37.1 billion in 1994 to $94.3 billion in 2003), with industry and the National Institutes of Health providing 57% and 28% of the funding, respectively. Of particular interest was that industry sponsorship of clinical trials increased from $4.0 to $14.2 billion, while federal contributions remained unchanged. The United States spends 5.6% of its total health expenditures on biomedical research, which is more than any other country in the world. We spend less than 0.1% for health services research - figuring out how to provide the best care at the lowest cost. An article from MSNBC summarizes some of the key issues nicely.

Download Moses-JAMA-2005-AnatomyResearchFunding.pdf

John

Contrarian Truth and Best Questions to ask

Since we are going to go down the path of the best non-clinical questions to ask patients, I thought I would start this first contrarian truth:  "You cannot exceed a patient's expectations on their first visit"

Great customer service as well as a lot of motto's are around exceeding customer's expectations.  This laudable goal may be good in most retail and service industries but is totally inapplicable in most physical therapy situations.  Why is that?  Quite simply, most patients have no idea what to expect in physical therapy either because they have never accessed PT, never knew they had PT, or had PT at a different location than the one they are now seeking. 

  When it comes to freestanding outpatient centers the chances of patients having their first experience is even greater.  I often tell my co-workers (all private practice PTs) that every private practice could be eliminated tomorrow and most of the population would not know the difference because they never knew it existed in the first place.

  Although I am not a fan of patient satisfaction in PT (more on that in later posts), two studies Roush SE and Sonstroem RJ (Development of the Physical Therapy Outpatient Satisfaction Survey (PTOPS). Phys Ther. 1999;79:159-170.as well as Linder-Pelz, S. U. (1982). "Toward a theory of patient satisfaction." Soc Sci Med 16(5): 577-82) have expanded on this concept and have listed the reasons that patient's often times do not have an expectation for PT or if they do it is based on a misconception:

Physical therapy intervention is a small and relatively infrequent encounter in the health care arena

Interaction takes longer than their typical physician visit Frequency of PT visits is higher than most other medical courses of treatment

Therapy usually requires the patient’s active participation

Therapy may cause pain and may be perceived as physically threatening

So, the bottom line in PT is that if you want to exceed a patient's expectation-do it on the second visit, it is much easier!  Or, ask two of the best questions that you can on the first encounter:

Have you ever had physical therapy before (if so, tell me about it)? AND

What are your expectations regarding your physical therapy experience at this clinic? It is much easier to manage expectations than it is to exceed them.

Thoughts?

Larry

Non-clinical EBP

Over the next several weeks, I would like to thread some "non-clinical" EBP information.  For example, we know that in LBP for work comp patients that psychosocial factors are quite frequently a bigger determinant in return to work vs. clinical indicators and there are large bodies of research that support this.  Additionally, we know that drivers of patient satisfaction (something I have a strong distaste for measuring...but that's a different story) are driven by non-clinical factors (e.g. how much input did the patient have in setting their goals).  Let's start some chatter on these factors as I believe they can assist us in producing better outcomes.  Along those lines, a challenging question:  What are the most important questions to ask a patient (based on the best available evidence)?

I will be posting  some stuff from a series that I have lectured on called "Contrarian Truths of Physical Therapy".  Please provide feedback, insight, and experience.

Larry

Screening for Depression

You may be familiar with the 2-item screening question for depression, which has been shown to have high levels of sensitivity (~96%) for identifying depression in primary care. The two questions are:

1) "During the past month, have you often been bothered by feeling down, depressed or hopeless?”
2) "During the past month have you often been bothered by little interest or pleasure in doing things?”

Although highly sensitive, this screening strategy lacks specificity (~57%-67%), making the results susceptible to a high rate of false positives. Attached is a study just published in the BMJ, where the investigators extended these two questions by adding a question that asks: “Is this something with which you would like help?” There are 3 possible responses: “no,” “yes", but not today,” or “yes.”

Specificity of Manipulation - a review

Here's an interesting review of manipulation and specificty (Or lack there of) by John and Josh Cleland. When we consider the poor level of inter rater reliability with manual palpation of the lumbar spine, our inability to direct our techniques to a specific level and lack of evidence that specific treatment is superior to generalized, the complex biomechanical models that much physiotherapy is based on become questionable.

Download does_technique_matter.doc

Steve