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You're invited to an info session and Q&A about

EIM’s Orthopaedic and Sports PT Residency Programs.

 

June 27, 2010 at 7 pm CT

 

Join Rob Wainner & Teresa Schuemann  for answers on how you can jump start your career with residency training at EIM.

 

Reserve your webinar seat now at
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Questions? Contact us at info@evidenceinmotion.com

Ouch! Previous Physical Therapy Treatment Strong Predictor for Not Returning to Work

Wow... what an unbelievable finding!  Or was it?  Hats off to Glen for bringing this work to my attention.

I'm talking about "Expectations, perceptions and physiotherapy predict prolonged sick leave in subacute low back pain."  I wasn't surprised by the psychosocial factors or how beliefs most definitely play a role in return to work... nor was I surprised by how injured workers perceived their work environment had an impact.

So the story... basically, this particular study design had subjects who had been off work for the last 8-12 weeks due to back pain. About 60% of the subjects had received services from a physical therapist prior to participating in this trial.  The trial compared a brief intervention provided by a physiatrist and physical therapist to the same brief intervention with an exercise intervention (one hour of exercise three times a week for 8 weeks).  It appeared there were no statistical differences between either of the interventions with regard to return to work; the researchers also analyzed whether there was a way to predict who would NOT return to work within 3 months, 12 months and 24 months.

YIKES - receiving services from a physical therapist within the 8-12 weeks prior to participation in the trial was a prediction factor for not returning to work at 3 months or 12 months.  How can that be?

First, I have statistical questions.  I wish the researchers shared more numbers than they did.  There may not have been a statistically significant difference between the brief intervention or the brief intervention with exercise, but I would be interested in knowing how many people returned to work (and when) with each option.  I don't have a grasp of how successful the intended intervention really was.  I most definitely do not easily grasp the odds ratio.  If I comprehend correctly, subjects who received physical therapy prior to the trial had 3.3 times the risk of not returning to work at 3 months compared to those who did not receive previous physical therapy.  Subjects who received physical therapy prior to the trial had 2.1 times the risk of not returning to work at 12 months compared to those who did not receive physical therapy.  I believe I would understand relative risk with a bit more ease.  I can't visualize or grasp exactly how large of a risk it really was having prior physical therapy intervention.

Of course, the big question... what was "physical therapy?"  Lucky for us, there is a tad bit of information for us to chew on and reflect upon.  77% received hot packs, ultrasound and massage.  52% received some form of exercise.  18% received relaxation therapy.  22% received some type of home exercise program.  11% received "other."

We have a continual discussion on ultrasound.  Some physical therapists believe lack of evidence for effectiveness should not necessarily mean to eliminate ultrasound.  (A lot of physical therapists are using ultrasound, they must know what they are doing, right?)  Does this study lead to additional thoughts?  My first thought - the 60% who had these interventions during the provision of the initial physical therapy services prior to the study were obviously non-responders to those interventions.  How often is the passive type of treatment option successful?  How often is it not?  (When are we going to wake up and start truly *knowing* our outcomes?)  How are we impacting patient expectations and perceptions with the clinical choices we make?  How often am I, through my choices and my interactions with patients, a negative predictor to success?

~Selena

EIM Sports Physical Therapy Residency Program!!

EIM and Sports Medicine: The EIM Sports Physical Therapy Residency Program

EIM is excited to introduce its new Sports Physical Therapy Residency Program(SPTR)!  Dr. Teresa Schuemann has joined the EIM team as the SPTR content developer and director.  She is an experienced Program Director who has been Chair of the APTA Residency and Fellowship Credentialing Committee and now serves as one of seven members on the APTA American Board of Residency and Fellowship Education. 

“Going through a residency program was the best decision of my professional career”, states Dr. Teresa Schumann, SPTR director.  “I am thrilled to provide such and experience for other Physical Therapy clinicians.”

The SPTR is an 18-month program of post-professional clinical and didactic education for physical therapists designed to advance the physical therapist resident's preparation as a provider of client care services in sports physical therapy.  The SPTR incorporates key Orthopaedic Residency topics, such as Evidence-based Practice and Upper and Lower Extremity, with Sports specific courses, such as Emergency Response and SCS Prep.  The SPTR also requires Athletic Venue Hours in addition to Mentor Hours and Out Come Tracking. 

EIM’s SPTR is designed so that graduates will become highly skilled, autonomous practitioners who have substantially increased their ability to provide care to a full spectrum of clients with athletic injuries.  Sports Residents will gain a strong base of knowledge of evidence-based practice and preventative and rehabilitative sports therapy techniques.  Graduates will also be positioned to both achieve the Sports Certified Specialist (SCS) certification from the ABPTS and to be leaders in the sports physical therapy field.

The first cohort begins in June 2010 and the application deadline is May 1, 2010. 

Click here for additional details, SPTR FAQ’s, and the SPTR Fact Sheet.

Oh, the Confusion of Sternal Precautions

With about 7,095,000 cardiovascular surgeries performed in 2006 and the role physical therapists have after cardiac surgery, the topic of sternal precautions is relevant.

If one does searching, third party payers have sternal precautions and heart centers have sternal precautions.  Where do they come from?

There have been discussions on listserves questioning sternal precautions.

Where is the evidence?  Should there be sternal precautions or not?  What does available evidence suggest?  How strong is that evidence?

For those of you wondering the same, if you are planning on attending the American Physical Therapy Association Combined Section Meeting, a session is devoted to this topic.

Join Lawerence Cahalin, PT, Tanya Kinney LaPier, PT and Donald Shaw, PT on February 18 from 2:30 - 4:30 pm to learn more.

photo by Frank Peters via Flickr

~Selena

Growing Technology in the World of Physical Therapy

The American Physical Therapy Association Combined Section Meeting will be here before we know it.  I've been checking out the programming and figured I'd begin to share sessions that spark an interest for me.  Granted, our profession spans multiple types of settings and various types of patients.  I realize what may spark an interest may not necessarily be conducive for attending because we don't practice in that particular realm of physical therapy.

When you think about our bodies and how we learn how to do things, it makes such practical sense to basically have people with substantial movement dysfunctions be able to learn from their movement mistakes.  Personally, I have never exactly understood how people with neurological deficits really learn efficient movement patterns when we as professionals focus on protecting them from falls or adverse events.

The ZeroG dynamic body weight support system looks cool!  I remember years ago telling a patient who had a stroke that if I could string her up from the ceiling, we could have a lot of fun, a few laughs and she could really learn how to improve her balance.  What is fabulous about this session is the fact that research is being conducted on the benefit of this particular weight support system for people who have had an acute stroke.

If you are interested in finding out more about this available technology (and I'd assume some pre-published research results), Diane Nichols has a session on Thursday, February 18, from 2:30-4:30 pm.

photo snagged from CABRR site (I assume they won't mind?)

~Selena

As The Older Adult Population Grows, Are Physical Therapists Ready?

A large part of what we do as physical therapists is design programs to fit the individual needs of a patient.  I am very sure a lot of thought is put into the design of the program to be implemented to improve the function of the older adult we are treating.  I am also willing to bet that 75% or more of the time some type of strengthening exercise is included in the individualized program.  I assume this because muscle weakness is a normal part of the aging process.  The rate of strength loss occurs at about 1-5% annually after the age of 30 (Lindel, 1997).

I wonder... how much thought is put into the strengthening exercises?  How do physical therapists determine the intensity of the strengthening activity?  Do physical therapists rely on the results of manual muscle testing?  If the patient has a strength grade greater than fair, how does a physical therapist determine the workload for strengthening?  What do physical therapists think when a muscle grade of 5/5 is found during muscle testing?  Does a 5/5 muscle grade really mean the patient will perform "within functional limits?"  Did you know that the leg strength required to rise from a chair without using the upper extremities is about 40-47% of a person's body weight (Eriksrud & Bohannon, 2003)?

If you have a habit of strapping on a 2# ankle cuff weight on an older patient and then asking for however many repetitions of a knee extension movement pattern, ask yourself why?  Before you begin any strengthening activity, really try to perform a baseline assessment.  If your older patients are not performing exercises at 60% or higher of a 1 repetition maximum, ask your self why.  This is the intensity required to improve strength and function.  Sure, there are definite times when you don't want the patient even near the 60% or higher intensity level - like when they are learning the movement pattern (i.e. learning to control the movement, the speed of the movement, and the direction of the movement).  It probably doesn't take more than a couple of sessions for the control and correct movement patterns to happen.  Once the pattern is performed correctly and safely, it is time to increase the resistance of the activity.

Dale Avers, PT and Marybeth Brown, PT collaborated and wrote a White Paper on Strength Training for the Older Adult.

Are you demonstrating ageism?  Do you believe older adults are frail and will not respond to strengthening activities?  Do you fear they will injure themselves if exercising at 60% of 1 repetition maximum?

photo by KayVee.INC via Flickr

~Selena

Wait & See, Neck Collar Or Physical Therapy for Cervical Radiculopathy?

What to do for neck and arm pain that started within the last 30 days?  Drum roll... which will it be the a) just wait and see what happens, b) the semi-hard collar (Cerviflex S, Bauerfeind)  which has 6 sizes to snuggly fit necks of all sizes, or c) physical therapy?  The winner is.... the Cerviflex S semi-hard collar!

In this century of effectiveness and effectiveness studies.... What a spectacular day for people who have cervical radiculopathy - just strap on a snug fitting semi-soft neck collar and life will be fabulous within 6 weeks!

I was fearful of these types of studies because the devil is in the details and as a whole, we are lazy.  Which is more realistic?  Read an abstract and believe the conclusion OR read the full study and reflect and think?  I'm betting most will read the abstract and believe the conclusion.

I liked that the subjects seemed to be a homogeneous group.  I like the fact that the same collar was consistently used.  I don't like not knowing psychosocial factors.  I really don't like the description of what physical therapy intervention was provided.  "Physiotherapy with a focus on mobilising and stabilising the cervical spine was given twice a week for six weeks, by certified physiotherapists who participated in the study. The standardised sessions were "hands off" and consisted of graded activity exercises to strengthen the superficial and deep neck muscles."  

Current literature indicates that manual intervention and exercise are key components for a successful outcome with various types of patient complaints.  Standardized sessions that are hands off do not meet the requirements of evidence.  The design of the study capturing the interventions provided by physical therapists really wasn't up to speed on the existing evidence on how physical therapists treat patients with cervical radiculopathy. 

It's a sad, sad day when the physical therapist involved in the design of the physical therapy intervention wing of a study didn't incorporate evidence into the treatment protocol.  I really have a problem with the design of the standardized physical therapy sessions!  Where was the evidence for the protocol?

So, the big question... which payer will see the abstract... which payer will deny payment for physical therapy services because physical therapy services are not cost effective and a neck collar will "effectively" take care of the patient's cervical radiculopathy?

~Selena

A Boy Implements Evidence into Practice

Initial thoughts on active video games, such as the Wii, included, "hey, it's better than nothing."

Is it though? 

An 11-year old (Deniz Ince) noticed more pain in his finger joints and wondered if the pain was related to playing video games.  Ince's dad, a rheumatologist, must have introduced him to Yusuf Yazici, MD to assist in answering if playing video games contributed to finger joint pain in kids.

The 11-year old was listed as the lead investigator of the submitted abstract which was accepted at the American College of Rheumatology/Association of Rheumatology Health Professionals 2009 Annual Scientific Meeting.

Of the various game consoles and handheld units, the Wii was the only device associated with pain for all 7-12 year old kids regardless of how many hours it was played.

I loved Deniz Ince's thoughts on the Wii after his study was presented.  Based on the study findings, he is no longer playing video games as much as he was.

If an 11-year old boy can change his behaviors based on evidence, why do adults have so much difficulty?

photo by Ian Muttoo via Flickr

~Selena

Placebo... Nocebo... Placebo... Nocebo

Growing evidence suggests patient psychosocial factors matter.  A few variables we definitely know about - the effects of depression or the effects of fear and anxiety for someone with low back pain.  I'd extrapolate that data and assume a score indicating low confidence on the Activity-specific Balance Confidence Scale would suggest someone has a fear of falling and that fear could be limiting function.  Why do we care about these psychosocial factors?  Obviously these factors are relevant in our treatment interventions and are even becoming relevant in predicting outcomes of our interventions.

I just recently read a couple of articles about two concepts at opposite ends of a spectrum.  On one end, there is nocebo.  The concept of nocebo really isn't something that just happens in randomized controlled drug trials.  Physical therapists deal with nocebo every day.  It seems to me nocebo is the self-prophetization of patients. Think about it using diagnostic testing as a focus.  The actual action of having a diagnostic procedure is not a bad thing, really, it's just a procedure.  The result of the procedure is a report.  The report is just a factual summary of findings.  It's what happens next that creates issues.  The not knowing; the fabrication of a "story" that happens in a patient's brain; the interpretation of that "story"; the perception of how that "story" affects the patient's life... and then the behavioral choices - consciously or subconsciously that will happen because of perceptions.  The patient just does this - it just happens.  Sometimes though, medical professionals through their actions and communications can solidify the "story."  You may not know it, but as a physical therapist, you spend quite a bit of time unraveling nocebo and altering perceptions and brain "stories." 

The other end of the spectrum is placebo.  Physical therapists should harness this concept and use it to the fullest.  I'd be interested in seeing the full text of the linked study.  What we communicate and how we communicate is highly relevant and important.  The linked study definitely suggests physiological change could really occur in the spinal cord with manual intervention.  (Physical therapy research has hinted and theorized this, but this is the first study I've seen that does give some verification to what has been proposed.)  I'm willing to bet if a different study was performed with a physical therapist performing a manual intervention there would be two equally important variables.  Obviously, the manual intervention is one component, but the other component would be the prior communication setting up a patient's expectations and perceptions. 

My thoughts:  If you hang your hat only on the placebo and don't use your window of opportunity to immediately move the patient forward to a slightly higher, active level, you've lost that power of placebo.  If you aren't aware of nocebo, the amount of change and progress will be limited.

I believe the art of what we do is the nocebo-placebo teeter-totter.  Do you notice that teeter-totter?

~Selena

photo via Flickr by lilmsmrtas

Cost of Physical Inactivity is more than $24.3 Billion

$24.3 billion is an interesting amount.  It's the amount of money Governor Arnold Schwarzenegger has to cut from his budget. In 2005 it was the amount consumers spent on renting or purchasing movies.  Okay, the data suggesting the cost of physical inactivity is outdated (2001-2004).  Reality... $147 billion. 

Metabolic Syndrome was first identified in 1920.  In 2004 a group of experts met to create a consensus statement to clarify standards to identify metabolic syndrome and define treatment strategies.

An interesting twist in current research is that electronic health records can identify primary care patients at risk of future diabetes and/or coronary heart disease by alerting the primary care physician when 2 or more metabolic syndrome criteria are present.

Take one guess what can reduce the risk of metabolic syndrome by 50%.  The answer is moderate to vigorous exercise for 180 minutes per week.

Where are physical therapists in this matter?

~Selena 

photo by Greg Robbins via Flickr