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Upcoming Evidence in Motion Courses

Check out upcoming Evidence in Motion courses currently open for registration!

Evidence-based Examination and Selected Interventions for Patients with Knee Disorders

June 10-11, 2006 - COMING SOON!
Louisville, KY (USA)

Evidence-based Examination and Selected Interventions for Patients with Lumbopelvic Spine and Hip Disorders

Sep 9-10, 2006
Toronto, ON (Canada)

Sep 16-17, 2006
San Antonio, TX (USA)

Nov 4-5, 2006
Phoenix, AZ (USA)

TBD (Fall 2006 date announcement soon!)
New York, NY (USA)

Evidence-based Examination and Selected Interventions for Patients with Cervical Spine Disorders

May 20-21, 2006 - COMING SOON!
Concord, NH (USA)

June 3-4, 2006 - COMING SOON!
Fairhope, AL (USA)

TBD (Fall 2006 date annoucement soon!)
Green Bay, WI (USA)

Join your colleagues in evidence-based courses that integrate your clinical expertise with the most the current perspectives in physical therapy clinical examination and interventions. Extensive hands-on lab sessions are included. Participants will be awarded 15 contact hours (1.5 CEUs).

We encourage early registration to insure a seat. Visit us on the web at www.evidenceinmotion.com to get more details, learn about other 2006 course dates and locations. Register online today!

Feel free to add a comment to this post on the blog or email us at courses@evidenceinmotion.com if you have any questions or need additional information. Consider passing this post on as an email to your colleagues who might benefit from this information. Hope to see you at an Evidence in Motion course in 2006! We sincerely thank you for joining with us to translate evidence into practice.

The Evidence in Motion Team

EBP and Freakonomics

We have made previous posts about the popularity of physical therapy in the mainstream media (Sopranos).  I think you will find the recent post on the Freakonomics Blog very interesting. EIM has authored an analysis of this very topic as an example of practical use of EBP which has appeared in some community press but the reach of the very popular Freakonomics blog link is significant (please also read the consumer comments to that link).

One more piece of evidence (pardon the pun) on the growing popularity of EBP is  EIM's unofficial favorite author, Malcom Gladwell, even used the term meta-analysis in one of his recent posts and of course one of our favorite business authors and "rant" artists, Tom Peters frequently lists EBP as a "cure for health care woes" (along with some great examples of the lack of EBP in most medical procedures).

These are good signs for our profession.

Larry

Clinical Consult

I have a "theoretical" question regarding manipulation. I have a patient who is 1 year s/p lumbar fusion w/ cage placement that meets hip rotation, hypomobility and no symptom below knee criteria. Her FABQW is >>19 and her onset is >> 16 days. Would you perform a manipulation in this situation? If so, what evidence would you cite? If not, what evidence would you cite? She has had no formal therapy for her spine since her surgery 5/05.

Thanks for the input.

Andy McCormick PT, MS, OCS, CSCS
Director of Physical Therapy
Crockett Physical Therapy
Lawrenceburg, TN 38464

what does 36.7% growth mean?

I received in today's mail the new Business 2.0 magazine for May.  The title of this well read magazine is "The Next Job Boom" where you get a listing of the 10 hot jobs and the 10 hot cities.  These lists seem to come up around college graduation time in a number of magazines and I am sure that all of you have read various reports. The article spent considerable amount of time about the hot network systems and data communication analyst jobs primarily choosing to focus on the opportunities in IT.  Interestingly enough, physical therapist came in #7 with a 36.7% job growth thru 2014 according to the Bureau of Labor Statistics (BLS). 

A few observations:
-the article never mentioned anything about PT or the #9 on the list OT.
-what does 36.7% job growth thru 2014 mean?
-How is it determined?  Is attrition taken into account?

I have great respect for the BLS and have used their site from time to time (side note:  never believe any salary data unless it comes from BLS.  Salary surveys are not representative and people lie-something about the BLS and census data where you attest that under penalty of jail that you are telling the truth seams to elicit more truth tellers).  There are way too many factors that determine growth rate and you have to question the authenticity of this type of data.  Let me give you an example that I use in my presentations: How big is the industry of outpatient physical therapy ?  In the last few years, I have had this question researched by the best libraries available, relevant professional associations, and the insurance industry archives (including medicare).  As best that we can tell, it is about an 11 Billion dollar industry that is growing at less than double digits relative to total billings and more than double digits in terms of people accessing services (when the industry goes from an average of around 14 visits per patient to less than 10, the math sort of works).  To put it in perspective, we are about 1/3 as large as the diagnoses of LBP.  In those terms, I am not suprised at the growth rate (law of small numbers).

I am very optomistic about the future and growth of PT but there are some warnings that I wished the article contained:

-we expect to collect about half of what we bill
-we get our money about 70 days on average after we provide the service
-we are regulated as much as banks
-if we entertain our best clients, we are commiting coporate compliance violations and can go to jail
-medicare thru bizarre coding regulations has essentially capped the value or worth of a PT at around $70 per hour (tough for industries to grow with price caps and yes I know there are a lot of cheaters out there that violate 1 to 1 therapy and 8 minute rules and use of support staff BUT nonetheless our fees are still capped by the largest payor).  Furthermore, if economic theory is any indicator (I believe that it is) than these caps will impact the growth of our profession substantially just as they would if their was caps on IT specialties.

Despite these constraints, PT will grow greatly thru 2014 and this growth will be fueled by evidence that proves out our efficacy.  lastly, past history is suggests that people go into our profession for the right reasons-a genuine desire to help people and not because of the articles describing the "hot professions".

Thoughts?

Larry

Quote of the Week

In response to Rob's post about some of the important details of the famous UK BEAM trial, here's a quote from Albert Einstein:

"Not everything that can be counted counts, and not everything that counts can be counted."

-Jason

It's The Little Things

The UK BEAM Trial was a large, pragmatic randomized trial that involved 181 general practices and 1334 patients in the UK.  The study compared “Best Care” (ie. management by a primary care physician) only to 3 other groups that also received “Best Care” combined with other treatments (+manipulation; +exercise, and + manipulation and exercise). A pragmatic or feasibility study means the methodology used not only considered the effectiveness of the interventions, but whether they actually had an effect when applied in a real-world setting that, as we know, is full of the unexpected.

The findings of this landmark study concluded that all 3 of the groups with additional interventions were more effective than “Best Care” (an oxymoron?) alone at for reducing disability at 3 months. In ascending order with regard to effect size (more of an effect), it was exercise, manipulation, and exercise + manipulation. In addition, only the latter 2 also had a significant effect at 12 months. 

In the economic analysis paper that followed, it was concluded that adding spinal manipulation to general practice for the treatment of LBP was effective with respect to both outcomes and cost, and that given the added cost of exercise manipulation alone was probably the most cost effective approach. 

However, here is what I missed (or forgot) in my first reading of this paper: the manipulation + exercise group also had a significant improvement in back beliefs and fear avoidance beliefs. I haven’t heard this talked about much and the paper didn’t make much to do about it. Given what we know about the impact of fear avoidance beliefs on return to work and response to selected treatment as well as the significant psychological factors associated with LBP sufferers, is it possible that our interest in the positive findings resulting from manipulation and exercise (reduced disability) has us overlooking one of the most significant findings of this study? Sometimes it’s the little (or less heralded) things that mean the most.

Rob

 

Walmart wants to help Health care

From Reuters: Walmart offers to Help Cure US Health Care.  Ok, let me start with a few generally recognized facts about Walmart:

Approx 5 of the top 10 richest people in the world all have Walton after their name.

Walmart has cheap prices, negotiates based on their size (side question: isn’t that what a few of the largest health insurer’s due in our markets for our rates?)

Many families can afford things that they wouldn’t normally get because of their cheap prices

They are the largest grocery chain in the US

They have almost 10% of the entire retail market

They have revenues that exceed many countries

Ok.  Ok, fair enough.  However, do I want their input on fixing health care?  Only in a few selected areas.  Let me explain.  One of my contrarian truths of physical therapy: 

Do all things great and you will be out of business.

Walmart is the classic example (another side note:  Despite what many people think, Walmart can be beat-see the cost per square foot sales at Whole Foods and Wegman’s as one example).  They only do 2 things really well.  Their stores are not especially aesthetically pleasing, their customer service is lacking, their advertising I am not sure I can remember any, HR is terrible (the lawsuits speak for themselves and by the way, don’t you only get major medical if you are an employee?), and I am sure their accounting and financing is pretty good as judged by their lack of trouble with the SEC. 

What they are great at is IT and logistics plain and simple (don’t try and tell me they are good at low prices because that is a by product of IT, logistics, and pure size).  The fact of the matter is that if they were great at all of these other functions, they wouldn’t be able to offer low prices and they wouldn’t have the profit margins that they currently do.

There are a few lessons in this.  First, as PT’s, let’s not try to be great at everything (good and adequate is not the enemy of great), specialization makes sense, and let’s stay within our niche (animal PT’s are you listening?).

As to Walmart, yes please help fix our health care but only advise in IT and logistics.  Cheap doesn’t equate to quality, health care service is different than retail, and suppliers (health care professionals) are not fungible commodities where low prices can be extracted (it has been tried and doesn’t work).  We can really use the help but please don’t have us model health care around your health care benefits to your employees or your general business model.

Thoughts?
Larry

Clinical Consult

I am currently seeing a 72 y/o lady whom had a knee replacement done about two years ago.  She is very active with a hiking club and does a lot of gardening which she does not want to give up.(thus the reason for the surgery in the first place)  I am currently seeing her with a dx of patellar tendinopathy with the MD recommending modalities - ionto, US - phono, TFM, PRE's, and ROM.  He has already performed two cortisone injections with no prior success before sending her to therapy.  He also has taken X-rays with no concerns of problems with the knee joint.

Eval - ROM typical s/p TKA 0-120 with no discomfort, Quad 4/5 through range with isometric testing painful at 90 (inferior patellar pole), TTP of patellar tendon only at inferior pole of patella

Two weeks of therapy as per MD Orders and no success with modalites and an attempt with a Jumper knee brace and painfree quad TE's.  I was doing a lit review tonight and saw the lit review that Dr. Rabin had in relation to eccentric training with this type of condition but different patient population.  I posted the link:

http://www.ptjournal.org/PTJournal/Mar2006/Mar06_EiP.cfm#ref_13

Just wondering if anyone has had any success with this type of condition post knee replacements??

Thanks,
Jeff Lipkin, DPT

Acupressure Beats Physical Therapy in Chronic LBP

In February, we blogged about the 'acupressure beats physical therapy' study recently published in the BMJ. Earlier today, Larry emailed a few of us this news article referring to the study, which jogged my memory about a commentary I was asked to prepare in response for the Washington Post. The commentary was evidently never published, so I have included the text below to close the loop on this paper. Lots of interesting issues at play relevant for ebp.

John

Results from a recent study recently published in the British Medical Journal concluded that acupressure was more effective than physical therapy to improve pain and function in patients with chronic low back pain, the benefits from which remained 6 months later. Without knowing any further details, the most logical conclusion is that patients with chronic low back pain might want to ask their doctor about the potential benefits of acupressure for their low back pain. After all, it works better than physical therapy. Or, is it that simple?

Quote of the Week

Many of the opponents of EBM/EBP would like us to believe that everyone is completely individual, and needs a completely individualized program of recovery in order to succeed.  Research on the use of classification approaches to care, started by PT researchers some years ago, and continued today [by award-winning investigators, I might add], solidly refutes that concept. While patient values and individuality are important, we can also get better outcomes by matching a patient to a treatment through classification.

“While the individual man is an insoluble puzzle, in the aggregate he becomes a mathematical certainty.  You can, for example, never foretell what any one man will do, but you can say with precision what an average number will be up to.”

--Sir Arthur Conan Doyle, in Sherlock Holmes' "The Sign of the Four"