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Physical Therapy in Thin Slices…..When Less is More

One of Larry’s contrarian truths of physical therapy is that the last visit is the most important, not the first. It seems many PTs view it just the opposite as is evidence by conducting what usually amounts to a data collection safari on the initial visit. Hey, what are we looking for anyway?!

Cook County Hospital, 1996: Chicago's principal public hospital is in crisis, with a major contributing problem of indigent patients presenting to the ED with chest pain. The problem is that many of these people aren’t having a cardiac related issue at all (only 10% presenting actually do) yet all were being admitted the CCU for observation at the expense of $2000.00 a day. There was no rational, standardized way of making the decision of who goes to the CCU vs the observational unit. Enter Lee Goldman who collected data and developed what amounts to a clinical prediction rule (CPR) to determine which patients had urgent (relevant) risk factors predictive of major cardiac complications (and therefore needed to be admitted). Based on the ECG and 3 simple findings (unstable angina, fluid in lungs, and SBP <100mmHg) there was a whopping 70% improvement in identifying these patients (95% probability). Was this readily received? No way, after all how could a guide consisting of a few key indicators perform better than a trained physician?

Marketing - LBP/CPR Briefing

Here is a briefing I just finished for the physicians at my hospital (abbreviated DHCN in the briefing). It goes over the CPR and it's use in primary care, as well as how/why to refer to PT. Keep in mind, I work in a hospital-based outpatient clinic in the US Army, so some of this material may not be suited for your individual situation. Of course, none of the material is classified or anything like that. There are some references to the "DOD/VA LBP CPG" which is the Department of Defense/Veteran's Affairs Low Back Pain Clinical Practice Guideline, for primary care. Please feel free to use, modify, take credit for, and generally twist this presentation to meet your individual needs. Heck, even slap your own name on it, I don't care. It does have a reference list for it's main points as well. I hope this is a helpful addition to your list of pre-packaged briefings and information for physicians and referral sources. Please leave a comment if you've a suggestion as well. Thanks.

Jason.

This was updated 2DEC05 with the most recent version of the briefing.

Download lbp_and_pt_primary_care_2005.ppt

Medication for mechanical neck disorders (MND) & low back pain (LBP): tried, found wanting, but under the radar

David’s comments remind me that physical therapy interventions and management are targets that come under scrutiny with regularity. Rightfully so, because as John has pointed out repeatedly, practice patterns vary widely among PTs, which means that many folks are practicing sub-optimally; everyone can’t be right. On the other hand, you see attempts to address the problem (described by David below) by prescribing a course of action that is inadequately informed at best, and at worst is strictly motivated by financial concerns. 

The problem is that instead of looking at what interventions are effective when employed in the care of patients with musculoskeletal disorders, it is just much easier to lump it under the all heading of “physical therapy”, and make impressive and often pompous statements about what “works” and what doesn’t. That is a separate topic altogether that can be addressed later. 

The reality is that individual suffering, disability, and costs due to musculoskeletal disorders (in particular LBP)continue to rise, and at the end of the day when all is said and done the clinician still has to manage the individual patient he or she finds in front of them.

Workers Comp and Guidelines- " Is this reall the best evidence"

Our Texas Comp system is under constant change at the present time.  Many so-called experts are putting on seminars that are making over-whelming generalization or simply inaccurate information.  Dr. Melissa Tonn of Dallas states in her presentation on new developments in the workers comp system about the “evidence” regarding various aspects of practice.  One that surprised me was the one she made from the United Kingdom Guidelines- stating” The is no firm evidence to predict which patients will respond to spinal manipulations or what kind of manipulation is the most effective”.  Have any of you heard of these guidelines?  Grossly inaccurate.   

 

Secondly, these “experts” are using consensus or population sources as “evidence” such as the ACOEM (AmericanCollege of Occupational and Environmental Medicine).  These include information from the CDC NHIS ( National Health Interview Survey).  Most of the data is from 1996 and does not tell us that is was appropriate or even optimal treatment only what the average return to work numbers are for conditions and suggested duration of therapy.  This is being used against PT’s to deny appropriate care.  There is a disclaimer in the ACOEM under each guideline that states that the guideline was never meant to be applied to an individual case yet this is happening.  By the way, these guidelines support manipulative intervention in the early stages of low back pain.  This seems contradictory to the wait and see scenario presented below.   

Lastly, the paradigm of encouraging general activity and reassurance is obligatory in patient that have low back pain; however, this does not necessarily mean that these people will recover optimally or sufficiently yet the rationale seems very simplistic: 90% of low back pain gets better without any specific therapy so odds are in your favor- just wait and see.  Is there any evidence to refute this claim of spontaneous recovery beyond Jull’s work on the multifidus.  

The other amunition of insurance carriers seems to be the Official Disability Guidelines(ODG) which are extremely restrictive on the duration of physical therapy with a common number of 9 visits.  Has anyone ever seen a rotator cuff repair need more than 9 sessions?  Sure you have unless you practice on the insurance side of things.

PA assessment of the lumbar spine

What is the validity of PA mobility of the lumbar spine in determining appropriate interventions? I have attached a recently published article by our colleagues Julie, Julie and John. This is a sub analysis from John’s validation study. Patients exhibiting hypomobility who received the manip exhibited a NNT of 2.1 as compared to stabilization. And those who exhibited hypermobility exhibited an NNT of 1.6 when receiving a stab program as compared to manip.

Josh
Download fritz_hypomobility_manip_archives.pdf

Intangibles of Successful Practice

Larry sent this news article around to a group of us yesterday. It's a great reminder about the intangible aspects of practice that, if left ignored, can overwhelm and interfere with even the best evidence-based practice. Does your front desk staff 'WOW' the individuals seeking care in your practice? Or do you fear for the patient sitting in your waiting room expecting to be treated with courtesy and prompt service? Don't forget the person sitting in front of you could be your mother.

John

Connect and Optimal

I read with interest APTA's testimony on CMS' pay for performance initiative:

APTA Links Performance-Based Pay to Fixing Medicare Problems
APTA urged a congressional committee this week to repeal the therapy cap and fix payment problems that interfere with quality care incentives before adopting any pay-for-performance system for Medicare. In written testimony submitted to the House Ways and Means Health Subcommittee, the Association endorsed Chair Nancy Johnson's (R-CT) Medicare Value-Based Purchasing for Physicians Services Act (HR 3617) but urged the subcommittee to specifically include physical therapists and other non-physician professionals in developing any system. To effectively implement pay-for-performance, APTA argued that Congress must repeal the Medicare therapy cap and replace the "sustainable growth rate" in the current Part B physician fee schedule, as well as standardize the physical therapy benefit in all outpatient settings and use APTA Connect and Optimal, the Association's electronic patient medical record and assessment tools, in moving to a value-based payment system.

I cannot agree enough with the repeal on the cap-it impacts those seniors that tend to have greater needs that we can address in rehab but I am particularly confused over the marketing of the Connect and Optimal as a tool to move to value-based payment system.  Are any of you using it?

The other major point to permanently repeal the cap that makes the most sense is that the cap is not really lifted-it would only be in place for all NON HOSPITAL delivery systems (exempt for hospitals).  How would part B medicare patients in a nursing home get to a hospital?  Why would you want cost shifted to the highest cost delivery system (sorry for those that work in a hospital but it is the highest cost deliverer-statistically speaking) AND it would appear to violate some type of anti-trust in this regard as well.  If reimbursement for medicare continues to go lower (both in nominal and real terms and coupled with higer costs), it would make it a complete loss for hospitals to have so many patients shifted.  Thoughts?  Let's all continue to be advocates to our representatives for the repeal.

Larry