It’s coming up – soon.  Friday is the last week of clinical affiliations and then on to graduation.  It’s been a long, interesting, tiring, invigorating, troubled, amazing, blah blah blah – three years. 

I look forward to getting out and being part of the American medical system (which despite our flaws, is still pretty good). 

There has been a ton of press on the newly published article in the Journal of the American Medical Association (JAMA) discussing expenditures for back and neck pain from 1997-2005.  All the major newspapers have ran stories and thousands of blogs have discussed the topic. 

This article points out some of the major flaws in treating spine problems.  The increase in dollars spent on surgeries and drugs alone are enough to make you sick while reading the 9 pages.  For instance, narcotic analgesic use increased 423% between 1997-2004.  423%!  That’s ridiculous.  It’s no surprise that thousands to millions of individuals are addicted to drugs like oxycontin that do nothing but mask symptoms. 

Why are we (medical providers) so bad at treating some of these problems?  It’s really not all that complicated to figure out.  We have the wrong people – treating the wrong things.  Our system requires a person who hurts their back t0:

1. See their family doc who is in no way prepared or equipped to evaluate or treat musculoskeletal complaints.  You may get some drugs and an x-ray.
2. Receive referral to the Orthopedic specialist.  Wait about 2 weeks.  Receive a prescription pad full of anti-inflammatories, muscle relaxants, and maybe narcotics.  Heck, they may even throw in an MRI.  Lastly, after being told you have a “disc problem” or “arthritis” – they’ll send you to PT.
3. Finally at the PT.  It’s been between 2 and 6 weeks since onset, but hey – you finally make it.  Uh oh – now there’s the whole “lack of standardization” issue in my beloved profession.  Depending on which PT you go to – you may bet evidence-based quality treatment or status quo, highly ineffective treatment.  Roll the dice. 

It’s been two months since onset and your pain is right where it was (for the most part) and you are starting to feel like there’s nothing you can really do.  Wonder what the bill for this scenario looks like?  God forbid you go on and they recommend surgery to “decompress and stabilize your spine”.  All of this and all you have is “non-specific low back pain” regardless of what they found on all the wasted imaging and in the ICD-9 book.

When will we ever learn?  How should this work?

1. Individual hurts their back on Saturday.
2. Monday morning, they walk into the Physical Therapy clinic (direct access is legal in most states you know)
3. The Physical Therapist provides a thorough evaluation and screens for “red flags” that would require referral to another medical provider (we are trained and skilled at doing this you know).  The PT would then classify you based on clustering of signs and symptoms and treat you with matched interventions that could included directional preference exercises, stabilization exercises, manipulation, or even traction.  In a few short visits (and for a lot cheaper), you decrease your pain and disability by greater than 50% or more. 
4. You are discharged with a do-it-yourself maintenance plan.  Back to work – back to life.

Sounds good huh?  So what’s the hold up.

It’s multifactorial.  It’s easy to throw the blame around and point the finger, but let’s look in the mirror first.  Physical therapy has an identity crisis.  We have allowed who we are and what we do to be confused as a bunch of “stuff” labeled as “physical therapy”.  The totally randomness of what many PT’s are doing across the country makes it nearly impossible at times to ensure a patient/client is getting quality care.  Clinicians are ignoring the evidence and choosing to practice based on tradition and comfort.  It’s time to standardize how we treat these problems.  Then we can be recognized as what we are – THE provider of choice for musculoskeletal conditions. 

Now to finger pointing.  Physicians are guilty of the same things mentioned above.  They consistently fail to recognize they simply aren’t prepared to treat these conditions.  Useless imaging and drugs (in most cases) comprise the majority of their involvement.  Not the mention the prevalence of spinal fusions that lack evidence for their use in many many cases (look at the failure rates).   In efforts to “hold on” as the gate-keepers, they fight PT’s direct access and professional protection like they’ll be out of jobs.  Who is hurt more?

I was going to save this space for Chiropractors but have chosen not to discuss their role.  To state it simply, you can see a chiro 37 times for modalities and repeated manipulation only to pay a huge bill and get no better.  But hey, the stories are good.  Just ask about the subluxation and how it can cause everything from radiculopathy to bed-wetting.

Any way, the fact remains that medical care in this country for back and neck pain isn’t where is should be.  It’s time for everyone to wake up and realize who are the go-to-providers (FIRST LINE) for musculoskeletal conditions. 

 As Dr. Tim Flynn says, “You have drugs, you have surgery, or you have us (PT)”. 

 FYI - Where do PT’s stack up as far as managing musculoskeletal conditions?  Physical Therapists AND physical therapy students rank higher than anyone outside of physicians trained as orthopedic specialists.  Who should be the “gate-keeper” for musculoskeletal care?  The family practictioner or physical therapists?  Leave the serious and complicated cases to the specialists.  Leave the rest (the majority) up to us.

 References:

Martin et al.  Expenditures and health status among adults with back and neck problems.  JAMA.  2008; 299(6):656-64.

Childs et al.  A description of physical therapists’ knowledge in managing musculoskeletal conditions.  BMC Musculoskeletal Disorders.  2005; 6:32.

Pain is a big deal, just ask anyone who has it or treats it.  There are as many theories about pain, chronicity, and interventions as there are people who have it. 

Interestingly enough, I found myself in a platform presentation at CSM on this very topic.  I’m sure some of the information presented is old news to those who study pain, but I found it extremely interesting and clinically relevant.

Several researchers from the University of Florida continue to look at possible mechanisms for effectiveness of spinal manipulation performed by Physical Therapists.  Steven George (I must mention he is an alum of West Virginia University), Mark Bishop, Joel Bialosky, and others have focused in on a possible dorsal horn mediated mechanism. 

Without getting into the neuroanatomy and physiology too deep, this mechanism basically says that manipulation causes an inhibition of some nerve fiber input that carries pain information.  This creates a hypoalgesic response that appears to be a local phenomenon. 

 I’ll be reading more deeply into the proposed neurophysiological mechanisms and will pass along information as I gather it.  For now, here are two articles that discuss this topic – take a peek.

 George et al.  Immediate effects of spinal manipulation on thermal pain sensitivity: an experimental study.  BMC Musculoskeletal Disorders.  2006; 7:68

Bialosky et al.  The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects.  BMC Musculoskeletal Disorders.  2008; 9:19.

In a previous post I mentioned attending CSM in Nashville this past weekend.  I forgot to mention the great book I purchased from OPTP. 

Orthopedic Physical Examination Tests: An Evidence-Based Approach by Dr. Chad Cook and Dr. Eric Hegedus is a great text book and reference for students, clinicians, and educators.  This text (available on Amazon for around $50 – see link above) seeks to describe the usefulness and scientific evidence for many of the special tests we use as Physical Therapists.  It offers specificity and sensitivity data for each test and determines a usefulness score based on the quality of the studies that have supported the given test.  This will lead to high quality and more efficient exams for sure.

I also have the Orthopaedic Clinical Examination: An Evidence-Based Approach for Physical Therapists book by Dr. Josh Cleland.  Like the book by Cook and Hegedus, this book helps clinicans determine the best tests for screening by Physical Therapists.

These two books are must-have’s for all clinicians who want to offer the highest quality care through best practice.

Nashville, Tennessee was the hosting city for the APTA’s Combined Sections Meeting (CSM) this year, February 6th-9th.  If you are a Physical Therapist, Physical Therapist assistant, or Physical Therapy student – and haven’t attended one of these conferences – you are really missing out. 

 Regardless of you interests you can find something at CSM.  I attended some great sessions on examination and treatment of the wrist, manual therapy for the upper extremity, classification of neck pain, lower extremity tendinopathies, and screening the lower quarter.  Of course, each of these educational sessions were led by leaders in the profession. 

 The platform presentations are great too.  Short (15-20 minute) presentations of ongoing or in press research straight from those involved.  I found it to be very useful in learning what new research will be coming out in the literature soon.  Just a heads up – keep your eyes open for a Clinical Prediction Rule (CPR) for success with cervical traction. 

It looks like Physical Therapy students may have something to cheer about soon (at least those working with veterans, children, and adolescents)

http://www.apta.org/AM/Template.cfm?Section=Media&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=46160

I’ve recently been overwhelmed by the number of stories discussing the use of Nintendo’s newest creation for “physical therapy”.  Some clinicians have found a use for the Wii, especially in patients with neurological diagnoses such as stroke.  Unfortunately, these reports continue to blur the public’s image of our profession and what we do.

 My guess is that the benefits of using the Wii are based on re-educating motor control through movements like swinging a tennis racket, hitting a home-run, or  throwing the bowling ball.  My question is what is the carry over?  How will this translate into improved daily function and independence? 

We know that specificity of training is important.  Which is more valuable for most stroke victims – hitting a backhand or gait training?  7-10 splits or Reaching into the cabinets without losing their balance and falling? 

Don’t take me wrong, I’m not opposed to incorporating different (and fun) activities into rehabilitation.  Physical Therapy should not be packed full of repetitive protocols without incorporation of new and challenging activities.  The problem is these things (such as the Wii) should be defined as what they truly are – possible adjuncts to real Physical Therapy.  Let’s focus on interventions supported by the strongest evidence possible and avoid leaping for every fad that comes along (look up ”Blackberry Thumb”).  

 If you were the payor (insurance) wouldn’t you question why you should pay for your client to play video games?

Another article seeking to develop a clinical prediction rule (CPR) has been accepted for publication in the Journal of Orthopaedic and Sports Physical Therapy (JOSPT).  Iverson et al found five predictors of success with lumbopelvic manipulation:

1. Difference in hip internal rotation (> 14 degrees)
2. Ankle dorsiflexion with knee flexed (>16 degrees)
3. Navicular drop > 3mm
4. No stiffness with sitting > 20 minutes
5. Squatting is the most painful activity

Pre-test probability of success with manipulation was 45%. 

 If a hip internal rotation difference of greater than 14 degrees was present, the likelihood of success with manipulation increased to 80%!

 If any three of the five factors above were present, likelihood of success improved to 94%.

 Keep in mind this is a study performed on 50 subjects with detailed criteria for inclusion.  Validation studies will have to be performed, but think of this…

 If I told you that from your clinical exam, the likelihood that you would experience a 50% decrease in your knee pain if I performed a lumbopelvic manipulation was 94% – would you want that treatment?

 Practice standardization is the future of our profession – get on board. 

The folks over at EvidenceinMotion.com hit on an important topic in a January 22nd blog post.  In case you don’t know, EIM was developed by a group of Physical Therapists to promote and protect the profession of Physical Therapy.  These folks are leaders in the profession and are as passionate as any you will find.  Check out their site, the blog, and their networking site — MyPhysicalTherapySpace.com!

 A huge problem today (remember my discussions about PT’s identity crisis) is that fact that researchers and clients/patients often throw the term around incorrectly.  It’s important that everyone knows that “Physical Therapy” is not a specific treatment.  Articles like the one discussed at the EIM blog is a good example of why it’s important to appropriately say PT is a profession.

 Oh yeah — it also highlights the importance of subgrouping/classifying patients with LBP for matched interventions that lead to better outcomes. 

I’ve created a new page here at the PTDoc blog to share files and links for EBP.  I hope to make this a collection of article summaries so the visitors of this blog can have quick and easy access to current medical evidence surrounding Physical Therapy interventions. 

 Check it out.