Don't laugh. Expect to see them aggressively marketing to large company's, schools, and even other stores. Oh, and they are owned by Walgreen's. Wonder if Walmart, Costco, and Target will be the next health and wellness company offering their version of #physicaltherapy.
thoughts?
@physicaltherapy
Bonus Bullet: Stop using a successful case(s) as a Silver-bullet cure poster child for LBP (“ripping fascia” really?!).
Rob
As a boy growing up, I still remember my granddad always telling me that there is no such thing as a free-lunch; somebody is paying
Tim and several other colleagues have discussed the current travesty occurring in the area of spine surgery in general and spinal fusion in particular (it used to be scalene-ectomy’s, 1st rib resections, and who knows what the next surgical fad will be---maybe sacroiliac joint fusion? Stay tuned for that one). Needless to say, there are many contributing factors on the provider and hardware manufacturer’s side. However, one of the factors on the patient side is the expectation of “quick-fix” and often unrealistic view of what surgical intervention offers; a one-sided trade or free-lunch of sorts: “I trade my pain for pain free function and some-one else pays the majority of the cost (or I cash in on the premiums I have been paying all these years).”
In this brief news piece (part 6: Going under the knife, part of a series entitled Aging America), Dr. Dale Avers does a great job of communicating that even for surgeries with high success/low complication rates like TJA of the lower extremity, there are still trade-offs that have to be considered when patients are considering a surgical vs non-surgical management decision. These include type of pain, incapacitation, as well as the sweat, time, and pain in order to resume even base-line, let alone improved function (not to mention risk….even low risk doesn’t mean much if you win the lottery prize in that category).
So what? We will have gone from 40 million Americans over the age of 65 in 2009 to 70 million in 2030. Needless to say, this will put enormous pressure on the health care system so that many won’t even have a surgical choice. Those that do may be even more apt to “make a quick trade”. PTs will be in a great position to not only educate and inform patient decision making for those considering surgery, but to help influence patient expectations for the many who don’t have a surgical option by helping them understand that the non-surgical option may be the best trade after all.
Rob
Ever get the feeling that the more things change the more they stay the same? The links below to two recent medical headlines remind me of the fact that despite our health care system being bro ken (and the Affordable Health Care for America Act has not and will not fix it), the following Pied-piper tune within the culture seems to only grow stronger: a. More surgery (at ever younger ages, more extensive procedures, and for increasingly “elective” reasons and b. More drugs.
In the first case, total joint replacement and resurfacing procedures have transitioned from being the last intervention option after all other means of relief have been exhausted to becoming a primary option for getting folks back to kite-boarding and basketball (make sure to view the video link on that page to hear a real expert interpret and explain things for us). In the second case, what could be better than a drug (Cymbalta) that works for not only one condition (depression in this case) but for two!! Everyone loves a two’fer, right? (in this case, make sure to read the important safety information posted at the top……does that apply when taking this for chronic MSK pain or only when I am taking it for depression?).
No question that total joint replacements and medication for selected conditions have their place, but when it comes to MSK pain should surgery and drugs be the primary interventions of choice? The answer to that rhetorical question is an obvious “NO”, but too few seem to be getting it or getting that message out. Besides common and fiscal sense, there has been a voluminous increase in the volume and quality of evidence that non-operative interventions provided by physical therapists can reduce pain, disa bility, and increase function. Oh yea, there is also evidence that these same non-operative interventions (a combination of education, manual therapies, and exercise in most cases) can also reduce depression, anxiety and fear in patients suffering from these conditions (the article by Main and George is a good place to begin with getting up to speed with what has been termed “psychologically informed practice”).
It’s been said before and I will say it again. When broken down into the simplest terms, a patient’s basic intervention choices when suffering from MSK conditions are: Drugs, Surgery or Us. We need more than evidence at this point to stop the Madness that has, in many cases, become what we know as health care. I am not sure what those “somethings” are (no silver bullet for sure), but it will involve a change in behavior of all parties involved, including the consumer.
Done for now (does anyone have a Ambien?)
Rob
The California Private Practice Special Interest Group - fired off a press release on Feb 23 in response to Assemblywoman Mary Hayashi's (D-Hayward) two bills (AB 374 and AB 783) that, if passed, would legalize POPTS in CA and also allow athletic trainers to be licensed under the CA Medical Board and therefore, bill CPT codes.
California needs your support! A group of concerned consumers have created www.stoppopts.org to help spread the message. Take a look at their CLOCK that has a current tally of wasted resources.
Please support them by clicking the Like Button on their Facebook page
Follow the cause on Twitter- www.twitter.com/stoppopts
In light of the MRI info about self referral here, and the posts by Larry and John (with great discussion) here , here and here about POPTS/conflict of interest, I am hoping the readers of the EIM Blog will rally around this cause.
Concerned PT
40 students from 20 different states kicked off their program in Louisville, Kentucky this month. Four of this cohort's students are the second or third in their practice to participate in the Executive Program. EIM's Executive Program enhances the business intelligence and savvy of owners/managers in private practice with practical applications to provide a competitive advantage in the marketplace. Click here for program details.
Ok, although both orthopaedic surgeons’ and family physicians’ knowledge of treating LBP is reported to be deficient, Orthopedic surgeons are less aware of current EBP treatment approaches than family practitioners. Therefore, you decide to see a family practitioner for your recent episode of debilitating LBP
If live in Australia (and probably the US), then according to the findings of this paper by Buchbinder and colleagues, make sure you DON’T see a family practitioner who has a special interest in LBP or you are more likely to get prescribed bed-rest and imaging right of the bat. Instead, see an FP who has a special interest in musculoskeletal medicine in general or in occupational medicine (though you still may get the same ill-advised care albeit with a lower probability). This is despite the fact that all groups thought Clinical Practice Guidelines are helpful for medical conditions in general and LBP in particular. I guess that this is probably best explained as a difference between the general “I feel you” vs actually knowing content vs actually doing comes into play.
The authors conclusions: “…we found that having a special interest in LBP was associated with back pain management beliefs that are contrary to the best available evidence”………is that an oxymoron/paradox or what!?
Well, the good (and perhaps surprising) news is that the study also found that having had CME related to LBP management resulted in more evidence-based beliefs about LBP. Belief is obviously believing is not the same as doing, but hey, you have to sometimes take what you can get. In the meantime, I guess we simply have to continue to “pound the rock” and at the same time look for better and more effective hammers so we can get that nut cracked after the 1millionth blow vs 100 millionth blow.
Anyone know of any good hammers? Simply seeing an PT who practices in an evidence-based manner directly for your LBP is arguably the best solution but I wonder, if PTs were surveyed, how much different would our results be? It would be interesting to find out but one thing we for sure know won’t happen in that scenario is that imaging and minimally or non-effective/harmful medication won’t be prescribed and everyone still wins.
Rob
The article Orthopaedists' and family practitioners' knowledge of simple acute low back pain management is both informative and a great example of why one can go terribly awry simply reading an article abstract and worse yet, only the abstract conclusion. In this case, the primary abstract conclusion was: “Both orthopaedic surgeons’ and family
physicians’ knowledge of treating LBP is deficient. Orthopedic surgeons are less aware of current treatment than family practitioners……”. This would elicit a “Tell me something I don’t already know” response from readers of this blog in many cases. However, when you read further you realize that this article doesn’t really provide an answer to that question.
The researchers determined knowledge deficiency in these two groups of doctors (253 orthopedists and 140 FPs) via responses to a questionnaire at their professional conferences (apparently in Israel). The 5 questions related to: 1. use of medication (paracetomol or standard NSAID vs COX-2 meds); 2. Effectiveness of bed rest; 3. Effectiveness of encouragement and advice; 4. Effectiveness of manipulation; and 5. Need for imaging studies. Physical therapy was also listed (whatever that means or includes) but was not analyzed due to conflicting recommendations.
Results? Back then, if a patient saw an Orthopod they were going to receive a lot more COX-2 Meds, X-rays, bed-rest and less encouragement than that would from a family practice doc. Interestingly, more than half of both Orthopods and FPs viewed manipulation as appropriate but that was graded as an inappropriate response by the researchers. Physical therapy: well, what’s that? (ok, we can’t figure it our either so let’ not count that answer.)
A few things to consider: The answers were based on a 2001 Clinical Practice Guideline, the questionnaire was administered in 2005 and this article was published in 2009 (probably not exactly the best data to give us a current understanding of how these two physician groups view and manage patients with LBP).
However, there is plenty of evidence to suggest that imaging, meds and in some cases bed-rest are still frequently used. I do wonder if their perspective on the use of manipulation for acute or chronic LBP is still moderate (51% and 57% for orthopods and FP’s, respectively) or if it has increased, given the recommendations in current US and UK clinical practice guidelines. My own guess is that things haven’t changed much (except spinal surgery, especially fusion and increasingly disc replacement may now be popular, albeit ill-supported choices). How about yours?
Perhaps our patients should see a EBP physical therapist instead.
Rob
Dear Santa,
We love new and we love quicker, better, and faster…………all of us. It makes me wonder if that isn’t part of the reason Surgeons, who can make an exceptionally good living, do things like cozy up with device manufacturers instead of simply earning denaro the “Old Fashioned Way” and reserving their incredibly sophisticated craft for those who can truly benefit.
It made me think of an article in the NY Times earlier this fall about cortisone injections shared with me by one of our EIM Orthopaedic residents. When these became available in the late 1940’s it was all the rage for treating all kinds of “itisis” and continues to be used extensively for such conditions as well as pain associated with spine problems. This is despite evidence that although cortisone injections provides some short-term pain relief, they also resulted in a much lower rate of full recovery than simply doing nothing or undergoing physical therapy. People in these same trials also had a 63 percent higher risk of relapse and an average of four injections resulted in a 57 percent worse outcome when compared to one injection (we all know you “can’t eat just one”). I know we want relief and want it now, but at what price?
Human nature is what it is, translating evidence into practice is hard and behavior change is even harder so I won’t ask for anything in that regard. What I would ask for (maybe as a stocking stuffer?) is that the same level of scrutiny given by policy makers, CMS, and other payors to physical therapist delivered intervention and services also be given to other health care providers.
I have never been very good at math but it just seems focusing their attention and scrutiny on practioners who comprise a much larger part of the health care problem (hmmm, I mean pie) and who perform highly expensive procedures that can have devastating complications and side-effects would be a much better use of time and resources (especially when the evidence for effectiveness is lacking or minimal at best) than making sure they have hog-tied/air-sealed PTs with 8 minute rules and such when they only comprise 1% of CMS expenditures. In this case, just a little equality would be a beautiful thing.
Thanks Santa, and Merry Christmas!
Rob
I figured with this title I could at least get my EIM partners to read this.
OK, I grant you that yesterday being Friday the 13th was truly a scary day! However, I think that Dr. R. Craig Christianson in the Seattle Times yesterday took it to a new level. He was suggesting that when it comes to Low Back Pain perhaps conservative care might be a potentially good thing at least for a little while and you should discuss this with your physician. He then states: "It could result in therapy for maybe a week or two, and if bad things happen, then we can always go to the operating room. It may prevent some percentage of failed back operations because of that one little intervention." WOW! I didn't know that in a week or two so many bad things can happen in conservative care. The data doesn't support that assertion but hey who needs data.
On a positive note the Seattle Times article was very good at pointing out what we have continued to expose in this blog over the last several years. That is the outrageous rise in spine surgery coupled with the unethical spinal implant industry's influence on surgical practice. The article also quotes Dr. Charles Rosen who started the Association for Ethics in Spine Surgery (I wonder if there is alternative association for Unethical Spine Surgery?). I would encourage all of our readers to join the Association for Ethics in Spine Surgery. You do not need to be a surgeon to join as an affiliate member. However you must not accept compensation, stock, stock options, or royalties from companies for using or implanting any device the company makes. Yes, I know you can't accept an additional $10K for choosing to implant a Medtronic device over a Depuy. However, you will get an association certificate that can be placed prominently in your waiting area and it is a great conversation starter. I frequently get questions like "are you a surgeon?" I can then quickly respond "No, but let me tell you a little about what is going on in the U.S. and particularly our region when it comes to spine surgery."
Tim
