On Preventative Physical Therapy

I have encountered a few discussions recently regarding the implementation of an annual physical therapy exam. The original source of this thought likely traces back to the legendary Shirley Sahrmann who has talked at length about this concept. The foundation of the argument appears to stem from the belief that preventative medicine is cost effective (which it is) and that physical therapy improves outcomes at a reduced cost (which it does for a lot of reasons and disorders). While both of these aspects are fairly valid, combining them to suggest that everyone would benefit from seeing a physical therapist (or any provider) annually and that this exam would reduce healthcare costs is a bit of a stretch.

First, we also need to acknowledge that the term “preventative” medicine is a slightly inaccurate. No disease or injury can truly be “prevented”; despite optimal care and an ideal patient, there will always be some risk. For movement based disorders physical therapy services can absolutely reduce risk and improve performance in many domains. We should also continue to screen for systemic disease. However labeling what we offer as prevention may create unreasonable patient expectations and unrealistic beliefs in a providers utility. Both of which can influence outcomes. But for now, until we devise a better word we’ll go with “prevention”

For most healthy individuals, receiving an annual physical therapy examination would be meaningless and it would come at cost. If an individual moves well and is disease free there are few benefits to them receiving examinations by a PT (or any provider) annually. This is similar to the issue encountered with the overly-capricious use of diagnostic imaging. If the pre-test probability is low then the test/image isn’t going to be useful and may result in false positives (See Bayes’ Theorem of conditional probability). Which leads to more testing, clinical visits and further costs. This issue occurs with imaging and tests that actually possess strong statistical power, which many of our movement based exams lack. Thus the false positive rate for an annual physical therapy exam may potentially be even worse!

We also must consider the bio-psychosocial ramifications associated with these potential false positives. One of the issues with over-utilization of imaging is that provides a tangible “proof” to patients that they are “broken” and often remain attached to those results. It can be quite difficult to break that cycle once it starts. Another example of this are those who visit a chiropractor monthly ad infinitum for tune-ups. What is actually being improved and is manipulation necessary even if the technique results in cavitation? Most (rightfully) would consider the notion of regular chiropractic visits to be unreasonable. Seeing a physical therapist annually despite being asymptomatic would be as well.

Even the utility of annual medical exams/physicals have even been investigated recently. With the majority of the evidence suggesting that they may actually increase costs without reducing much risk. This further analysis of risk reduction is also likely why the ACSM has recently adapted their recommendations and removed ETT/medical exams for many patients even those with risk factors. The old ACSM guidelines created bottlenecks in access to care, and delayed the initiation of exercise which affected outcomes. With the provider gap that currently exists in this country, the delivery of care needs to be as efficient and effective as possible. Annual visits to a physical therapist could also potentially impair access to care for those most in need of rehab services.

When deciding on policy change it must always be asked, does the intervention reduce risk and associated healthcare costs more than the cost of providing it? While I agree that access to physical therapy services needs improvement this annual model needs to be further analyzed. I suggest that maybe a “regular” physical therapy exam combined with other providers should be implemented. The frequency of this exam could then be modified based a number of health-related factors (congenital diseases, family history) and adapted to any novel changes (weight changes, acute injury etc). From our end we also need to start tracking outcomes data more consistently to help improve the effectiveness and efficiency of our care (which I have been working on improving with my software “Outcome Manager” set to release in the coming months) and develop more accurate tests and measures.

Again, as always the truth defies simplicity.

On Crossfit

crossfit-fuengirola-slide03

 

I wish more PT/physios would realize the potential in owning a box or gym and operating a clinic contained within. Instead of commenting on the issues with training and programming that Crossfit or any other training model has, we should be looking at ways address them while incorporating them into practice models. I’m more of an academic at this point in my career (and likely going forward) but it would seem that having a more fit and motivated patient population would be ideal. Having multiple revenue streams, a greater potential for direct access and collaboration with fitness professionals to ensure a smooth transition post rehab are all decent perks; not only for clinicians but patients too. These are all items that are frequently mentioned as lacking in most clinical models and barriers to outcomes. Why more of us haven’t explored this business model is beyond me and appears to defy logic.

The primary point I am getting at is that owning a gym, box, Pilates studio, fitness centers etc should not be the exception rather the norm. As would owning your own clinic vs working for one of the large PT chains. We complain about revenues and reimbursement, yet we as a profession choose to work in situations where our earnings are limited with sometimes ridiculous work demands and paltry compensation. What other profession practices in this manner?  Of course there is significant capital required to operate your own business with increased risk, especially early in one’s career. But this sort of model is ideally developed over time and possibly in partnership with a few like-minded clinicians (not necessarily PTs) to divide the risk. At the end of the day one will never earn as much as they can working for somebody else. Until we as a profession realize this, from a practice standpoint we will continue to remain significantly impaired in our ability to move forward.

CSCS for the DPT Student: You’ve got questions, we’ve got answers.

MK strength & conditioning

Well, I hope we have answers to your questions about the CSCS.  I just want to thank everyone who answered the survey I posted out on social media to help with material for this blog post.  A number of my colleagues and I have noticed a trend in the interest for the CSCS credential from the NCSA.  I wrote a blog post a while back and you can read that here. There you can learn basic background information on what the CSCS is (unfortunately, some of the links are outdated because the NSCA updated their study materials).  With the recent spike in interest, I’ve decided to update my blog post with a group of fellow PT students who are also CSCS Certified to try and help answer your questions about the CSCS.

An amazing 65+ of you answered the survey so unfortunately I can’t answer everyone’s specific questions.  I had…

View original post 5,291 more words

Updates

Proud to announce my partnership as a contributor with New Grad Physical Therapy! Their team offers a great resource for PTs of all levels of experience (not just entry level) on a variety of topics and practice settings. Looking forward to working with them more in the future!

PTReviewer: As for this site I am still continuing to update and add more content, The official “re-launch” should take place around mid-August.

On Evidence based medicine

We as therapists and humans in general try to compartmentalize concepts in a manner that drastically oversimplifies physiological, biomechanical and psychosocial processes of human movement. Evidence based practice is NOT shifting from one indoctrination to another whilst abandoning the prior practice patterns and research.. Too often are we, physical therapists, guilty of subscribing to the newest trend in research and abandoning what existed prior. There are too many examples of this: McKenzie based extension exercises for patients with low back pain, everyone with back pain has a weak TrA, every runner needs to start running bare foot and shoes are suddenly the worst thing ever, all patients with tendinopathy need to do eccentrics, patients who fall within a CPR for SMT need to be manipulated and suddenly everyone has a weak diaphragm. Patients improved prior to these studies and body systems are rather complex. That’s not stating that we should not adapt our behaviors and practice patterns, as research continues to develop more effective treatments. As a clinical researcher, DPT educator and PhD student, I fully support the idea of evolving your practice with time and staying current. I do not condone jumping ship, once a new idea presents itself

Science is a constantly evolving process that builds on the work of previous studies and changes gradually; most often due to the development a novel method of visualizing and measuring phenomena. There are few absolutes in life, one that best reflects this particular problem we face is that “The Truth Defies Simplicity”. Evidence based practice is not defined as abstaining from treatments that aren’t supported by the most recent meta-analysis. It is also not giving the same treatment for every person because research supports it. For example, when a patient demonstrates signs of Achilles tendinopathy it doesn’t mean you should automatically use eccentrics 3×15 x 5 times per day per Alfredson. Some patients won’t tolerate it or be appropriate and there are other interventions that can be used to reduce pain and improve function. Blanket statements for treatment decisions such as those can’t possibly be valid and therefore interventions cannot be the same for every patient. If we are to believe that exercise is medicine, which it is, then we must conceptualize it as such and be dose specific.

Movement disorders are multimodal with varying degrees of deficits relative to each person. My mentor from my cardiopulmonary residency at the VA in Madison, WI, Jim Carlson, offered a great quote to me, which my students may be familiar with as a I use it often, “treat what you see in front of you.” This simple quote offers a lot in terms of practice patterns and decision making. Identify what limits a patient’s ability to function and interact with their environment; then address those issues. Identifying dysfunction also coincides with another great quote I remember by CI from my first clinical, Emily Kelley, “focus on function not the diagnosis”. The diagnosis often doesn’t matter as much as we give it credit for and often even correct imaging or diagnostic tests don’t reflect a patient’s ability to move and function. For example a patient may have positive findings on an MRI for a herniated disk but be asymptomatic and a patient with heart failure may have an ejection fraction of 27% but may move better than a patient with an ejection fraction of 45%. Diagnoses are useful as a starting point but can also cause clinicians to be too myopic with decision making. This segways into, another quote from a mentor of mine here at UIC, Aaron Kiel, our residency director, “have a reason for doing what you choose as an intervention”. That quote right there so succinctly defines EBM at its core. Don’t just go through the motions and solely base decision making on the regurgitation of results from a meta-analysis or clinical practice guideline. Though often the patient will improve over time, that’s not EBM, that’s being a technician. That type of practice is wasteful not only to you but to the patient. In a climate where reimbursement and coverage is increasingly becoming more based on outcomes and efficiency, one cannot afford to continue practice in this manner. Evidence is meant to enhance decision making and critical thinking, not replace it. Clinical practice is called such, as a clinician one should be constantly reflecting, refining and appraising their skills over time. It is easy to become complacent with perpetuating the same practice patterns; and within the current landscape of healthcare that is still reimbursable. Being a good clinician, scientist or any skilled worker is difficult and requires all those things mentioned prior. It is up to the individual to decide on how they choose to act and doing the right thing may be more difficult, however the fruits of that labor are much more enjoyable.

Have a Happy Sunday.

Updates

Well it’s official, I’ll be teaching continuing-ed for Medical Minds In Motion, LLC starting this fall! Excited to get more physical therapists and rehab professionals talking about the relationship between the cardiopulmonary physiology and orthopedic conditions. ‪#‎ubiquitous‬ ‪#‎stoked‬ ‪#‎easydecision ‬‪#‎useyourDPT‬ Check out the link attached for some of their current offerings!

http://medicalmindsinmotion.com/

Now back to updates for the site, research, finishing residency and starting this PhD!

Updates

Due to many unexpected yet amazing developments this past few months I have not been as active as planned this year. However during that time, I think I have finally found my niche as a provider and researcher which is combining Cardiovascular and Pulmonary Physiology to orthopedic populations and vice versa. These areas are viewed as dichotomous to each other yet in reality they should definitely be integrated. Especially considering that heart disease and pulmonary diseases are the #1 and #3 cause for mortality in the USA. Additionally other providers frequently ask me questions regarding this and I feel that is due to the lack of a large enough voice talking about these issues.  Therefore the direction of this blog will be to focus attention on those areas, as well as provide therapists and rehab professionals content related to areas I find interesting and and those which there aren’t many resources. This will include resources for lab values, medications, cardiopulmonary diagnostics, early mobility guidelines, considerations for OP ortho providers as well as other topics. There are too many good blogs that cover ortho, manual therapy  and sports; here are a few of the best ones

 http://snyderphysicaltherapy.com/ http://www.mikereinold.com/  http://chrisjohnsonpt.com/  http://scotmorrison.com/

But there just aren’t any good ones that cover cardiopulmonary areas and acute care. Let’s change that.

Have a good week.

-Rich

On Physical Therapy residency programs

The topic of physical therapy residencies came up on a DPT student facebook page and I decided to share a brief article I wrote for the Wisconsin Physical Therapy Association’s student corner. Enjoy and comment.

Residency education in any section whether it be orthopedics, cardiopulmonary, sports, neuro, etc offers a competitive edge to clinicians, particularly entry level DPTs. Fast tracking to specialization, direct mentoring, opportunities for research, teaching responsibilities are not typically offered in most places of employment (especially to new grads) and rarely if ever provided in combination. Additionally in certain areas of practice (pediatrics, cardiopulmonary, women’s health and clinical electrophysiology) it is rather difficult to obtain the necessary hours needed to sit for board specialization. For those sections residency training is almost necessary to practice.

That being said if you are unsure after graduating as to what sort of clinician you aspire to become or what area you want to practice in, I would caution against pursuing a residency. As with a residency you are in effect “building on” clinical skills and knowledge more so than “building up”. The extent of that will vary from program to program and amongst sections but in general I feel that is the case; and as sparse as the spots are nationally, they very well should be. Residency training is not mandatory and neither is specialization, although that hopefully may change. So as with anything in life if you are uncertain, avoid making a rash decision and wait. Along those lines if you do decide after graduating and passing the NPTE that you do not wish to pursue a residency immediately, I would strongly recommend limiting that waiting period to 3 years post graduation. By that time you should have your own identity as a clinician, earned at least your first promotion and possibly been a clinical instructor. Instead I would then consider sitting for whichever board specialization you desire as an independent.

In choosing a residency I feel that the best programs are affiliated with a DPT program or a university. Private clinics lack the opportunities for research, teaching and collaboration with other providers that all university based programs offer. Again the importance of this varies between residents but I feel that a program should offer more than just mentoring. A residency should offer pathways to different aspects of the field and develop a therapist into a leader in their section not solely a “clinical expert”. Again this is my opinion alone, talk to other residents in order to gain as many perspectives as possible which will help you make the best choice for YOU. Ultimately it’s your professional life, goals and aspirations.

The Oxygen Delivery Problem

For those working in acute or cardiopulmonary sections of physical therapy you may have considered this:

“If a patient has a low oxygen saturation and they respond to supplemental oxygen why don’t we just put them on a non rebreather mask non-stop? It would surely provide them with enough oxygen that they would never desaturate”.

A non-rebreather mask (NRB)

A non-rebreather mask (NRB)

For starters a non rebreather mask (NRB) is an oxygen delivery device that provides patients with a fraction of inspired oxygen (FiO2) of 100% and is used on patients in critical conditions such as ARDS . Normally the air we inspire is a mixture of gases, mainly nitrogen (78%), and the FiO2 is 21%. The amount of both gases in this mixture is important physiologically for a number of reasons. Due to the increased affinity of hemoglobin for oxygen at the alveolar level due to the Haldane effect (also see Bohr effect transport of O2 to working tissue) oxygen is preferentially absorbed over other gases and nitrogen remains in the lungs which help maintain the inflation of the alveolar sacs. If one were to increase the percentage of inspired O2, over a period of time there would be less nitrogen available to maintain the patency of alveoli. Due to the physiological principles described above this would eventually result in alveolar collapse or the technical term “absorption atelectasis

Secondly, increased blood levels of O2 can suppress the ventillatory drive, especially in patients with Chronic Obstructive Pulmonary Disease (COPD) who demonstrate CO2 retention(1-2). CO2 retention, defined as increased blood gas values of CO2, can occur in patients with severe COPD (1). The mechanisms for this physiological process are still not completely understood. Carbon dioxide values, in a normal functioning system, regulates the drive to breath, via central and peripheral chemoreceptors (3). In patients with CO2 retention this mechanism is altered and their body responds to circulating levels of oxygen; lower levels of O2 facilitates breathing and higher amounts suppress (1-3). Therefore increasing the amount of delivered oxygen to a patient with this condition could possibly result in apnea.

Hyperoxia (higher than normal levels of oxygen) has also been shown have other systemic effects on the body (4-7). In the peripheral vasculature, hyperoxia causes vasoconstriction. The amounts of vasoconstriction and blood flow reduction varies in body area as the coronary arteries and brachial arteries demonstrate markedly reduced blood flow when exposed to hyperoxic states, the reduction in the cerebral arteries appears to be less (5-7). In addition to the vasoactive effects, hyperoxia can also lead to an increase in reactive oxygen species which can lead to oxidative stress and damage tissue (7).

Rarely does one chemical, tissue or system act completely in isolation. Your body is not a petri dish and we do not operate in a vacuum. The effects from something seemingly innocuous to one organ system may result in deleterious effects to another. Just because the reaction in a cell to a given amount of substance is beneficial is does not always mean that more of that chemical is always good. Human physiology is a story, with many subplots and characters with an exer-expanding number of volumes as we learn more about the body.

1 Kim S et al, Oxygen Therapy in Chronic Obstructive Pulmonary Disease Proc Am Thorac Soc. May 1, 2008; 5(4): 513–518. source 

2 Gorini M et al, Breathing pattern and carbon dioxide retention in severe chronic obstructive pulmonary disease Thorax 1996;51:677-683 source 

3 Jones and Barlett Learning LLC 2014, Regulation of Ventilation pgs 4-14, source 

4 Dean J et al, Hyperoxia, reactive oxygen species, and hyperventilation: oxygen sensitivity of brain stem neurons, J Appl Physiol 96:784-791, 2004 source 

5 Farguhar H et al, Systematic review of studies of the effect of hyperoxia on coronary blood flow, Am Heart J. 2009 Sep;158(3):371-7 source 

6 Xu F et al, Effect of hypoxia and hyperoxia on cerebral blood flow, blood oxygenation, and oxidative metabolism. J Cereb Blood Flow Metab. 2012 Oct;32(10):1909-18. source 

7 Rossi P and Boussuges A, Hyperoxia-induced arterial compliance decrease in healthy man, Clin Physiol Funct Imaging. 2005 Jan;25(1):10-5 source.