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Ultrasound... yes? no?

Okay, before you grab the ultrasound machine.. before you squirt the gel... before you reach for that ultrasound head... ask yourself why?

Why are you choosing to use ultrasound for someone with adhesive capsulitis of the shoulder?

a)  The deep heating properties of ultrasound will increase the extensibility of the joint capsule.
b)  You learned in your graduate or post-graduate program about modalities; ultrasound to the axillary fossa was deemed an acceptable intervention in your classroom scenarios.
c)  Everyone else uses it.
d)  You need to maintain your productivity units.
e)  You just want to sit down, have a break and chat with your patient as you move the magic wand.
f)  You really don't care about your patient and want to really jinx the likelihood of a favorable outcome.

You could have many potential reasons for using ultrasound. 

You have two excellent reasons not to choose ultrasound.  The hard cold facts seem to indicate ultrasound reduces the odds of improvement in function.  The cold hard facts seem to indicate ultrasound reduces the odds of improvement in pain.

Outcome evidence suggests joint mobilization and exercise as interventions of choice for shoulder adhesive capsulitis to increase the likelihood of favorable outcomes in physical function and bodily pain.  Interesting work done by  Dianne Jewell, Daniel Riddle, and Leroy Thacker. 

For some, it might be time to break tradition.

~Selena

Assessing Chronic Back Pain

Pain... pain is definitely not a simple subject.  We see people in pain every day and need the knowledge to effectively address the complaint of pain.  I'm willing to bet the majority of patients seen in the outpatient setting have a complaint of low back pain.  Most of us here realize that drugs and surgery are inadequate in resolving back pain complaints.  Drugs and surgery are not without risks and side effects and failure rates (in the case of surgery).  Surgical risks and surgical failure rates aren't a secret; mentioning "unneccesary surgery" in a new study creates a positive spin on drugs.

Joachim Scholz has obviously spent some time studying pain.  It appears to me that Scholz has recognized the ineffectiveness of treatments directed toward pain due to the failure of the provider (and maybe even drug manufacturer) to consider pain mechanisms.  Scholz and colleagues recently published (April 9, 2009) a Standardized Evaluation of Pain (StEP) for the low back.  It's great to see work outside our field being done on classifying patients with low back pain according to pain characteristics.  It's great to see the type of pain being considered as an important factor for those with low back pain.

The downside is they are barking up the wrong tree.  I say this because of the funding for the study:  

"This study was supported by an unrestricted grant initially awarded by Pharmacia through The Academic Medicine and Managed Care Forum, with supplementary support from Pfizer. Some of the study authors have disclosed various financial relationships with Pfizer, GlaxoSmithKline, Pharmacia, Elan, Allergan, Progenics, Alpharma, Janssen, Merck, Novartis, OrthoMcNeil, Union Chimique Belge, Bristol-Myers Squibb, Eli Lilly, Roche, Abbott, Endo, Hydra Biosciences, Taisho, Solace Pharmaceuticals, Ferrumax Pharmaceuticals, and PLoS Medicine. The General Hospital Corporation owns the copyright on StEP."

Maybe one day it will be common knowledge that a drug isn't the best option for chronic back pain.

~Selena

Comparative Effectiveness Revisited

Comparative effectiveness can reach into so many different areas than just surgeries or medications. We are all probably familiar with the 1998 Cherkin study comparing physical therapy, chiropractic manipulation and a booklet for low back pain treatment options.

After coming back from the Combined Sections Meeting, I caught up on a lot of reading/skimming of various materials.  Eric already mentioned the lack of wireless, so I won't say any more. 

I read something that obviously hit a nerve with me because I need to share my thoughts.

"Foot orthoses were similarly effective as physical therapy for patellofemoral syndrome, but combining the 2 interventions was no more effective than either alone."

I had to review the source of this statement.  Thomas McPoil was one of the authors.  I was interested in what was defined as "physical therapy."   

"Physiotherapy consisted of a combined therapy approach that has proved efficacious in patellofemoral pain syndrome and included patellar mobilisation, patellar taping, a progressive programme of vasti muscle retraining exercises with electromyographic biofeedback, hamstring and anterior hip stretches, hip external rotator retraining, and a home exercise programme."

At first glance it appeared reasonable... but... doesn't research seem to indicate that the better a patient is classified, the better the outcomes?  It appeared that everything but the kitchen sink was thrown at these patients without any thought into individualization.  In the November 2008 Journal of Orthopaedic and Sports Physical Therapy, Carina Lowry, Joshua Cleland and Kelly Dyke described multimodal management of 5 patients with patellofemoral pain syndrome.  Interestingly, each patient did not receive orthotics nor did each patient have patellofemoral taping nor did each patient perform the same stretches.  Manual intervention to the hip and lumbar spine was also provided depending on the evaluative findings of each patient.  This particular case series brought regional interdependence into the treatment equation.

I thought maybe the lack of classifying each patient was a design problem.  So... what could I find on classifying patellofemoral pain syndrome? In 2005 Witvrouw et al. classified non-operative patellofemoral pain syndrome in Knee Surgery, Sports Traumatology, Arthroscopy. They seemed to ignore regional interdependence, in particular the hip and the lumbar spine. The article had one very, very small mention of dynamic activities such as single leg squats, and ascending/descending stairs.  The dynamic activities weren't even included in their figure diagramming their proposed classification scheme.  For sure, the work of Powers et al. wasn't included.  It appears to me that the only recent published classification system that I could find, wasn't adequate in really subgrouping patients into a treatment based classification system.

What struck a nerve with me was that the article was highlighted as "Medscape Best Evidence."  Best evidence?  How can that be without a real control?  Sure, the study took on a multimodal approach, but there was little thought as to whether every piece of the approach was really needed with each patient.  I'd be more interested in the findings if the design included a real control and instead had the physical therapy aspect more in line with what Lowry, Cleland and Dyke described. 

So, now there are physicians and possibly third party payors that are believing that a pre-fabricated foot orthosis (with or without some alterations) is just as good as receiving physical therapy services for patellofemoral pain syndrome.  Physical therapy services will be viewed as a costly alternative that provides the same results as a prefabricated orthosis.  Nice....

So, how do we position ourselves to address these types of situations?

photo by pomoyle via Flickr

~Selena

Chronic Back Pain and Treatment by a Physical Therapist

There were a few choice words that I didn't let slip out of my mouth after reading this...  I have to know WHAT is going on in the real world?

Physical therapists are not following guidelines!  Why?  Is there a reason?  Is this just a geographical variation in treatment practice and not representative of our profession as a whole?

This is not good. How are we ever going to be the musculoskeletal practitioners of choice? 

If you are somewhat uncertain about your clinical decisions in treating the spine OR if you need to have a dose of evidence to support your decisions, might I suggest this session.  I'm completely confident that John Childs, Deydre Teyhen and Michael Walker can enlighten you and invigorate you to rise above what this particular study is claiming!

~Selena 

ACL Surgery is Not all It's Cracked Up to be

No kidding, according to this study, done in Lund, Sweden (which I imagine is a good place to do an ACL study since there is no significant economic gain by the doc to do one).

“Reconstruction does not lead to greater improvement than rehabilitative training after knee ligament injury”

Music to a PT’s ears.

PT: The Best First Choice in treatment of ACL injuries.

Perhaps we can get the Swedes to reproduce this study on spines?

larry@physicaltherapist.com

One step forward...

JW had me reeling after his post yesterday describing the irrational and irresponsible decision by BC/BS of Minnesota to stop paying for manual therapy codes.  Decisions like this are a real kick in the teeth to the physical therapy profession.  Our hands are our tools, and just as you wouldn't expect a carpenter to work without a hammer or a surgeon to work without a knife, it is complete nonsense to expect a profession grounded in hands-on techniques to work without their hands.  Our ability to defense bad calls like this is only as strong as the evidence supporting our interventions.

Thankfully, this bad news was significantly tempered by a much more optimistic release in the form of a study published in Spine (which JW briefly mentioned as well).  Walker et al published, "The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain: A Randomized Clinical Trial." [via PubMed]

I have given this paper a thorough review on NPA Think Tank, so if you have some time, head over and check out my post there.  For those on the fly, here is the take home:

Manual physical therapy and exercise was compared to a minimal intervention approach.  Subjects included those with mechanical neck pain with or without upper extremity symptoms.  Both thrust and non-thrust joint mobilizations were used over a 6 session treatment period.

● "Manual physical therapy and exercise was significantly more effective in reducing neck pain and disability, and increasing patient-perceived improvements during short- and long-term follow-ups."

This is a solid study which will garner some serious attention.  Each time a report like this comes out, the entire profession takes a giant step foward, and will hopefully be more effective in stomping out terrible decisions like that made by BC/BS of Minnesota.  JW is right, this study helps make an impairment-based manual physical therapy and exercise approach to mechanical neck pain a "slam dunk!"

ERIC

Photo courtesy of FreeBirD via Flickr

One Reason Physical Therapists Are Not Considered

Who is conservatively managing patients with a new complaint of back pain combined with pain radiating down a lower extremity?  How does a primary care physician interpret "conservative" management?   I read with interest a summary:  American Family Physician.  Does conservative management primarily include 6 weeks of "stay active" advice with a "wait and see" philosophy?  Would seeing a physical therapist also be sound advice?

Selena

Physical Therapy Within a Week after ACL Injury

I reread a comment by Paul Neuman regarding ACL injuries a couple of times. 

"... patients with ACL injuries should begin rehabilitation with a physical therapist who specializes in knees within a week of their injury."

15 years after an ACL rupture, those that chose physical therapy over ACL reconstruction had less pain, less tibiofemoral osteoarthrtis, less patellofemoral osteoarthritis and overall better function.  Physical therapists initiated services very early after onset of injury with a high focus on neuromuscular re-education.

It seems that the research by Neuman and colleagues is favoring physical therapists over orthopaedic surgeons.  Piecing together the results seems to indicate that choosing a physical therapist might be a better option than ACL reconstruction; ACL reconstruction should be reserved for those that exhibit a positive pivot shift 3 months after injury.

Isn't this yet another example of the value of physical therapists?  Wouldn't physical therapists also be more cost-effective than surgery?

Selena

Physical Therapy and Readiness

Should professionals give up before they begin?

Should professionals only begin when patients are ready?

When looking at the final outcomes of care provided by a physical therapist, is this factor a variable that should be included as a risk-adjusted variable?

Okay, the Patient Activation Measure really hasn't been utilized by physical therapists... but some spine surgeons must apparently believe physical therapy is a relevant post-operative necessity after spinal surgery. 

Also, interesting work presented by Linda Gerber, PhD that utilizes the Patient Activation Measure with patients with chronic conditions.

Shouldn't we be promoting self-efficacy and shouldn't we be providing patient focused care?  Maybe the information on slides 61-64 would be helpful to keep in the back of our minds.

Selena

Do Physical Therapist Assistants Add Quality?

When a physical therapist utilizes a physical therapist assistant is the physical therapist assistant really an extender of the physical therapist?  Probably not.  Then again, the response to the question does depend on quite a few factors.  Was a physical therapist assistant involved more than 50% of the treatment time?  Does the location of practice where services are provided have state regulations that require onsite supervision?  Does the location of practice have state regulations that dictate PT/PTA ratio?

In 2006 Linda Resnik, Zhanlian Feng and Dennis Hart addressed whether physical therapist state practice acts had an effect on services.  Specifically, what predicted high physical therapist assistant utilization?  Were the number of visits per episode of care affected by service delivery?  Was the patient's reported level of function at discharge affected by service delivery?

Focus on Therapeutic Outcomes Inc. (FOTO) provided data.  The data from 2000 and 2001 included 395 clinics from 38 states utilizing FOTO.  High utilization of a PTA occurred 7.7% of the time within a final sample of 63,900 patients.  High utilization was defined as services provided by a PTA more than 50% of the time.  60% of the patients within this data were treated in a hospital outpatient setting.

State practice acts did not have an association with high PTA utilization.  A high ratio of PTA to PT on staff was associated with high PTA utilization.

High PTA utilization was associated with 2.0 more visits per episode of care.  State practice acts that required onsite supervision of the PTA were associated with 3.1 more visits per episode of care.  If there was a state practice act that regulated PT/PTA ratio, this was associated with 1.1 fewer visits per episode of care.

High PTA utilization was associated with lower discharge scores.  State practice acts with unspecified PTA supervision was associated with lower discharge scores.  (In FOTO, greater the discharge score the better the functional level.)

My gut reaction is that physical therapist assistants might not be valuable in service delivery if the goal is efficient and effective care.  Although the evidence is devaluing services provided by physical therapist assistants, the actual process of how a physical therapist assistant is introduced into the service delivery model hasn't been analyzed.  Is there a competency issue with physical therapist assistants (education/training), is there a process issue (how and when a PTA is utilized) or is there a combination of both factors that create a less valuable product?

Even though we are a small slice of the pie in health care dollars, as various stakeholders are analyzing costs and determining the value of our services, what effect will a high utilization of PTAs (>50% of treatment time) have on our future?

Selena