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  • What's the Best Post-TKA Intervention in the Acute Care Setting? There's No Easy Answer, Say Researchers

    For patients who undergo total knee arthroplasty (TKA), this much is known: physical therapy in the acute care setting is a key component in successful rehabilitation. What's not so easy to pinpoint are the individual interventions associated with the best outcomes, according to authors of a new systematic review. Their investigation into 20 years' worth of clinical trials and other studies revealed no clear standout interventions but did find "very low" evidence for the use of cryotherapy, accelerated rehabilitation, and neurostimulation within the first 7 postoperative days (PODs).

    The study, published in the Journal of Acute Care Physical Therapy, involved extensive reviews of research published between 1996 and 2016 on various physical therapy-related interventions used in the acute care setting post-TKA. Authors were on the lookout for evidence of effectiveness of a particular approach, because, they write, "despite seemingly routine use of physical therapy and its potential importance in reducing complications after [total joint replacement] in the acute hospital setting, no approach to rehabilitation in this setting appears to be standard."

    In the end, through a review process that pared down a list of 686 research titles to 40 studies that met inclusion criteria, authors were able to come up with a definitive conclusion, albeit not the most rewarding one for those looking for guidance: existing evidence isn't strong enough to support any clear winners when it comes to post-TKA physical therapist interventions in the acute care setting.

    The studies that yielded no or weak evidence looked at approaches including additional sessions of rehabilitation, compression and manual lymph drainage, knee range-of-motion (ROM), continuous passive motion, knee ROM manual passive exercise, knee ROM-active assistive exercise, biofeedback, and acupressure, acupuncture, and traditional Chinese medicine. According to authors, evidence either was insufficient or included a significant risk of bias, or both.

    Three other interventions fared somewhat better than the rest, although none were supported by strong evidence. They were:

    Cryotherapy. Reviewers identified 2 systematic reviews supporting the use of cryotherapy to reduce early postoperative pain and improve ROM, though evidence was described as "very low" quality by authors of both reviews.

    "Early" or "enhanced" physical therapy—for example, having patients walk within hours after surgery. Authors identified "very low level" evidence supporting these approaches to improve ROM and walking ability, and to reduce length-of-stay.

    Neurostimluation. "Very low level" evidence suggested that neurostimulation may help to reduce pain—but only when electrodes were placed near the surgical site, according to authors.

    Further clouding the evidence in most (31 of the 40) studies was the fact that some form of "physical therapy" or exercise intervention was used—in both the special intervention group and the comparison group—in addition to the intervention being studied. "Possibly, the lack of evidence for the effectiveness of most of the studied interventions is due to similar management of the intervention and comparison groups, and that changes in the outcomes studied are largely affected by various forms of interventions suggested by the term 'physical therapy' or 'standard care,'" authors write. In addition, they point out, all study participants likely received medical pain management, which makes it even harder to isolate the effects of a particular intervention.

    Authors say there's a clear need for more research on interventions in the acute setting, but acknowledge that such research may be challenging "because of the difficulty controlling for all the variables that may influence outcomes that affect function."

    For now, authors say, don't count on any clear recommendations on the single best intervention to use for patients post-TKA in the acute care setting.

    "Given the state of the evidence, physical therapists will need to rely on empirical evidence and physiologically plausible rationales for selecting type, intensity, frequency, and duration of interventions," authors write. "In addition, given the likely symbiotic relationship between pain management and physical therapy interventions, peri- and postoperative medical management may have important effects on the immediate gains in patients' function after TKA that cannot be separated from the effects of interventions provided by physical therapists."

    APTA members Alisa Curry, PT, DPT; Meri Goehring, PT, PhD; and Diane Jette, PT, DSc, FAPTA, were among the coauthors of the study.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Study: Ignoring Inappropriate Patient Sexual Behavior Doesn’t Work, but Other Strategies Might

    Inappropriate patient sexual behavior (IPSB) is a problem in health care, but researchers have pinpointed some concrete strategies for responding to these incidents, according to a study in PTJ e-published ahead of print. While several of these strategies can be used by the clinician during treatment, authors say less-than-stellar incident reporting outcomes and lack of administrative support “demonstrate a clear opportunity for the profession to improve.”

    The release of this study happens to coincide with action last week by APTA’s House of Delegates to strengthen the association’s position on sexual harassment in all forms, including encouraging incidents of harassment to be reported, with permission of the affected individual, to ensure that others are not similarly harmed.

    Funded by the APTA Section on Women’s Health, the study follows up a 2017 survey of PTs, PTAs, and students that found 84% experienced IPSB—47% in the previous year. In the prior study, authors defined IPSB as a range of behaviors, "from leering and sexual remarks to deliberate touch, indecent exposure, and sexual assault." Physical therapy clinicians were more likely to experience IPSB if they were female, treating mostly male patients, or newer to the profession.

    Researchers surveyed 1,027 members of APTA specialty sections and students in PT and PTA education programs to learn how individuals who experienced IPSB responded to it, and if those responses were effective at mitigating the problem.

    Similar to the previous survey, 38% had experienced IPSB. The participants described a variety of responses, from simply ignoring the patient’s behavior to documenting and reporting it to management. Respondents who are younger (under age 40) and less experienced (students or clinicians with less than 10 years of experience) were more likely to ignore IPSB. The less experienced group also were more likely to respond by joking with patients. Respondents younger than 40 were more likely to ignore IPBS, while students and newer Not surprisingly, ignoring inappropriate sexual behavior—a strategy used by more than 70% of respondents—was not found to be a successful response.

    Respondents also identified strategies that, according to them, significantly improved the situation more than half the time. They include:

    • Distraction
    • Choosing a more public place for treatment or a different treatment method
    • Direct confrontation
    • Establishing a behavioral contract with the patient
    • Transferring care to a different clinician
    • Using a chaperone

    Authors suggest that clinicians be educated on “assertive communication and redirection strategies” but add that the changes shouldn't stop there.

    There is a “need for clear workplace policies coupled with training for managers and supervisors to support clinicians in resolving IPSB,” authors write. They encourage practices to establish policies on using behavioral contracts and warning letters, chaperones, and transfer of care in response to IPSB.

    (Editor's Note: Articles e-published ahead of print are not the final version. The final version of this article will be published in the September issue of PTJ.)

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    CDC: Concussion Rates Among High Schoolers May be Undercounted

    A new report from the US Centers for Disease Control and Prevention (CDC) says that in 2017, an estimated 15% of high school students experienced 1 or more concussions, and 6% experienced 2 or more. Authors of the study say that's a number higher than some previous estimates, probably because the CDC study includes anonymous self-reports from the students themselves, many of whom may try to hide the injury from coaches and parents.

    The data were drawn from the most recent Youth Risk Behavior Study (YRBS), which, in addition to gathering demographic variables, asked students “During the past 12 months, how many times did you have a concussion from playing a sport or being physically active?” Students were also asked to respond to the question, “During the past 12 months, on how many sports teams did you play? (Count any teams run by your school or community groups.)”

    Here's what researchers found:

    • Overall, 9.1% of high school students reported 1 concussion, 3.0% reported 2, 1.0% reported 3, and 2.0% reported 4 or more concussions related to sports or physical activity during the 12 months before the survey.
    • Male students were more likely to report 1, 2, and 4 or more concussions than were female students.
    • Students in grades 9, 10, and 11 were more likely to report a single concussion than were students in grade 12, and students in grade 9 were more likely to report a single concussion than were students in grade 10.
    • Black and Hispanic students were more likely to report 4 or more concussions than were white students.
    • Among students who played on 1, 2, and 3 or more sports teams, the prevalence of reporting having had at least 1 concussion was 16.7%, 22.9%, and 30.3%, respectively.

    According to the CDC, the study yielded higher prevalence rates than those from earlier studies based on emergency department reports and data from athletic trainers, which yielded rates of 622.5 per 100,000 and 1.8 per 100, respectively. Authors of the CDC report speculate that the numbers from both sources may be artificially low, as emergency department data lack information on concussions treated elsewhere, and athletic trainer data miss concussions sustained outside school sports—and neither include medically untreated concussions.

    The CDC report acknowledges that its higher numbers may reflect a greater awareness of concussion symptoms but says that another factor may be at play.

    "A study of high school athletes found that among athletes with concussions, 40% reported that their coach was unaware of their symptoms," the report states. "Students might not always recognize or remember that they have experienced a concussion, or they might not want to report having experienced a concussion. In this study, the opportunity to anonymously self-report a concussion, without negative consequences, such as a loss of playing time, might have aided in including concussions missed by other data sources."

    The bottom line, according to the report, is that concussions among high school students may be undercounted and that more needs to be done to educate students, parents, coaches, and school personnel to recognize and report the injury.

    "Coaches and parents can encourage athletes to follow the rules of play for their sport with an emphasis on player safety, which might reduce the incidence and severity of concussions," authors write. "It is important that any athlete with a suspected concussion be removed from practice and competition and not return to play without the clearance of a health care provider."

    Physical therapists have a critical role in concussion prevention and management. APTA offers multiple resources on concussion, which include a Traumatic Brain Injury webpage and a clinical summary on concussion available for free to members on PTNow. The association also offers a patient-focused Physical Therapist's Guide to Concussion on APTA's MoveForwardPT.com consumer website. Continuing education offerings from APTA include the prerecorded webinar "Managing Concussions With an Interprofessional Team" available through the APTA Learning Center.

    Study: Progressive Strengthening Program Shows Promise Over 'Standard of Care' Rehab for Patients Post-TKA

    In brief:

    • Reseachers studied 2 groups of adults 50 and over who underwent total knee arthroplasty (TKA): 1 group that engaged in "standard of care" rehabilitation, and 1 group that participated in a clinic's progressive strengthening program. The groups were compared with each other and with a group of adults 50 and older who had no joint pathology.
    • Function was assessed through knee flexion measures, knee extension measures, quadriceps strength measures, the timed up-and-go test (TUG), stair-climbing time (SCT), the 6-minute walk test (6MW), and patient self-reports.
    • Overall, neither the strengthening group nor the standard-of-care group achieved function equivalent to the control group, but the strengthening group more often achieved scores at or better than lower-boundary scores of the control group.
    • Authors believe a progressive strengthening approach can bring TKA patients closer to "normal clinical and functional scores" than can standard-of-care approaches focused on range of motion and exercises without weights.

    Adults 50 and older who undergo TKA may never fully achieve the same function as older adults without knee pain, but a progressive strengthening exercise program may bring them closer to those levels than would the variable approaches considered "standard-of-care," according to authors of a recent study.

    The study compared self-reported function and test performance for 3 groups: 88 adults aged 50 and older without knee or joint pain (and no TKA); 40 adults aged 50 and older who underwent TKA and participated in "standard-of-care" rehabilitation; and 165 adults aged 50 and over who underwent TKA and participated in what authors describe as an outpatient clinic program that "included progressive strengthening exercises that targeted muscle groups in the lower extremity." Results were published in Physiotherapy Theory and Practice (abstract only available for free).

    The strengthening program was conducted at a University of Delaware physical therapy clinic beginning 3 weeks after TKA, and consisted of at least 12 outpatient visits 2–3 times a week. The visits themselves focused on strengthening exercises that were progressively adjusted to maintain maximal effort for 3 sets of 10 repetitions for all exercises. The "standard of care" group participated in outpatient rehabilitation elsewhere for an average of 23 sessions that mostly focused on range of motion (ROM), stationary cycling, and "various straight-leg raising exercises without weights," according to the study's authors.

    Both TKA groups were evaluated 12 months after surgery by way of 7 measures: the Knee Outcome Survey-Activities of Daily Living (KOS-ADL) self-assessment, measures of active knee flexion, measures of active knee extension, measures of quadriceps strength, TUG, SCT, and 6MW. Researchers then compared these groups with each other, as well as with results from the 88 older adults who had no history of knee pain (control group). Authors of the study were especially interested in finding out how many participants in each TKA group achieved scores at the lowest bounds of the control group. Here's what they found:

    • The control group consistently reported higher KOS-ADL scores, greater active knee ROM, greater strength, and better performance on TUG, SCT, and 6MW than either TKA group—a result that authors say is consistent with past research showing that function post-TKA hardly ever reaches the levels of age-matched individuals without joint pathology.
    • Compared with the standard-of-care group, a higher percentage of strengthening group participants achieved scores at or above the lower-boundary control group cutoff in knee extension ROM (30% in the strengthening group versus 15% in the standard-of-care group), quadriceps strength (18% vs 5%), and SCT (34% vs 18%). No significant differences were found in KOS-ADL scores, knee flexion ROM, TUG, and 6MW.
    • Compared with the standard-of-care group, participants in the strengthening group were twice as likely to achieve performance above the lower-boundary cutoff for knee extension angle and SCT, and 4 times as likely as the standard-of-care participants to outperform the cutoff for quadriceps strength.
    • Overall, 67% of the strengthening group achieved an above-cutoff score in at least 1 of the 7 variables measured, compared with 47.5% of participants in the standard-of-care group.

    "A greater proportion of patients who participated in the progressive strengthening protocol achieved what could be considered normal clinical and functional scores," authors write. "This suggests that although clinicians cannot expect TKA to restore normative function for all individuals, participating in a progressive strengthening protocol may improve the likelihood of achieving normal age-matched outcomes for a subset of patients."

    Aside from their lack of focus on strengthening, "standard of care" approaches also may be less effective because often they are anything but "standard," according to authors.

    "The lack of consensus between therapists and surgeons on the optimal timing and amount of rehabilitation, and substantial variability in timing, amount, and exercise content of rehabilitation services, may potentially have important negative effects on postsurgical outcomes," they write. "Failure to restore function by 12 months after TKA may be deleterious, as outcome measures plateau around 12 months following TKA, and no meaningful gains have been observed with longer-term follow ups."

    Authors acknowledge several limitations of their study, including a smaller number of participants in the standard-of-care group, and the fact that both TKA groups were heavier than the control group.

    APTA members Federico Pozzi, PT, MA, PhD; Daniel K. White, PT, ScD, MSc; Lynn Snyder-Mackler, PT, ScD FAPTA; and Joseph A. Zeni, PT, PhD, were among the coauthors of the study.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    APTA Selects Rapport for Education Research Fellowship

    A physical therapist (PT) educator with more than 2 decades of education experience and more than 40 research publications has been selected as APTA's 2018 Visiting Scholar.

    Mary Jane K. Rapport, PT, DPT, PhD, FAPTA, has been selected as the recipient of the APTA Early-Investigator Research Fellowship. Rapport will spend her sabbatical year focusing on research related to physical therapy education and its impact on professional behaviors, clinical decision making, and/or clinical outcomes. Her responsibilities also will include other activities in support of research-related programs at APTA.

    Rapport is a professor at the University of Colorado School of Medicine, where she also is director of the pediatric physical therapy residency program. With a background that includes extensive publications on topics ranging from pediatric physical therapy to PT education and development of the physical therapy workforce, Rapport brings firsthand knowledge of the research landscape.

    "This is an important time for investigations into clinical education in physical therapy, and Dr Rapport will play a key role in helping APTA contribute to the body of knowledge that will guide the evolution of education programs," said Robyn Watson Ellerbe, PhD, APTA's vice president of research. "We are excited to have an investigator of such a high caliber join the APTA team."

    Study: A Few Tests (And Demographic Variables) Can Help Predict Success of Nonsurgical Treatment of ACL Injury in Athletes

    In brief:

    • Researchers in Norway and the US looked at tests and measures of 118 athletes who experienced an anterior cruciate ligament (ACL) rupture and did not have surgery within the first 6 months of the incident.
    • The same tests were administered both at baseline (as soon as possible after the injury) and then after 5 weeks of rehabilitation. Researchers then tracked the patients and administered the International Knee Documentation Committee subjective knee form (IKDC) after 2 years for all participants who did not eventually have surgery.
    • Of 97 patients reporting IKDC scores, 53% reported successful outcomes (at or above 15th percentile).
    • At both baseline and 5 weeks, the strongest indicators of later success of nonsurgical approaches were older age and being female. Higher quadriceps symmetry scores and Knee Outcome Survey – Activities of Daily Living Scale (KOS-ADLS) scores were predictive at baseline; higher IKDC scores were predictive of success after 5 weeks of rehabilitation.
    • Researchers believe their findings are an easy way to help patients and clinicians make decisions about whether to pursue surgical versus nonsurgical treatment for ACL injury.

    For athletes with ACL injuries, deciding whether to pursue surgical versus nonsurgical treatment can be a tough call. Now authors of a new study say that a few tests and outcome measures—and a few demographic factors—can help to shed light on the chances of a nonsurgical approach leading to success.

    The study, conducted in Delaware and Oslo, Norway, included 118 patients who experienced a unilateral ACL rupture and did not elect to have ACL reconstruction surgery (ACLR) by 6 months after the injury (although some did wind up undergoing surgery later on). All of the patients reported participation in a "pivoting sport"—for example, soccer, football, handball, basketball, tennis, skiing, snowboarding, baseball, or softball—for at least 50 hours a year. Researchers focused on 2-year outcomes for these patients in an effort to find out possible predictors for success in nonsurgical treatment, both at baseline and after a 5-week rehabilitation program.

    All participants first underwent rehabilitation to address effusion and range-of-motion deficits, and then were administered a battery of tests as well as the KOS-ADLS and the IKDC. Next, patients participated in a 5-week neuromuscular and strength training program that included 10 sessions of perturbation training, and were administered the same tests and measures. Researchers then tracked the patients for 2 years after baseline and readministered the IKDC. Researchers labeled a nonsurgical approach a success if, after 2 years, nonsurgical participants recorded IKDC scores at or above the 15th normative percentile.

    As for the participants, age at baseline ranged from 18 to 39, with a mean age of 28.6, and a fairly even split between males and females (49.2% and 50.8%, respectively). Demographics at the Oslo and Delaware sites didn't vary much in terms of age, sex, or preinjury activity, but patients in Delaware did report a higher average body mass than the cohort in Oslo. The study was published in the Orthopaedic Journal of Sports Medicine.

    Among the findings:

    • Of the 97 patients for whom 2-year IKDC scores were available, 52 (53%) were found to have a successful outcome; of the 45 patients classified as having an unsuccessful outcome, 33 underwent late ACLR, with 12 remaining nonsurgically treated but scoring below the target IKDC percentile.
    • Patients who scored above the target percentile at the 2-year followup averaged a 94.2 on the 100-point IKDC scale; those who scored below the target averaged a score of 73.2.
    • When comparing the results with tests and measures conducted at baseline, higher KOS-ADLS scores and quadriceps symmetry index scores (LSI) above 89% as assessed through the single-leg hop test were predictive of success after 2 years. Older age and being female also increased the chance of a successful outcome.
    • The 5-week assessments yielded somewhat different predictors of success from the baseline tests, with a higher IKDC score being a stronger indicator of future success. As with baseline assessments, older age and being female increased the odds of success at the 2-year mark, but the LSI score didn't generate any predictive power. "It is possible that when knee function improves with rehabilitation, the measures of knee function lose the variance that is required for predictive ability," authors write.

    Authors see several compelling reasons for using these tests to help make a patient arrive at a decision about whether to continue nonsurgical treatment—primary among them the fact that the models can be easily applied and yield reliable results. As an example, they calculate that a 30-year-old women who scores 90 on the KOS-ADLS and has an LSI of 90% or above early after injury has an 85% probability of a successful nonsurgical outcome 2 years after injury. By contrast the same woman scoring a 65 on the KOS-ADLS and an LSI below 90% would have only a 29% probability of success after 2 years.

    "These differences in prognoses provide a powerful argument for why clinicians should routinely assess the patient's knee function after injury," authors write.

    As for the better probabilities of success with age, authors point to a problem in ACL treatment overall—namely, that younger athletes also tend to have lower success rates for surgical treatment compared with older athletes.

    "Our results in nonsurgically treated patients, as well as previous studies on surgically treated patients, support the growing concern that our current treatment methods are not successful enough for the youngest and most active patient group," authors write. "For those who have good prognoses with nonsurgical treatment, however, our results can help clinicians and patients to have more confidence in a nonsurgical treatment choice (active rehabilitation)."

    The researchers believe their study is a solid investigation into predictive factors around ACL treatment, but they see possibility for the inclusion of more variables as predictors of success, including anatomic factors, associated injuries, laxity, and psychological components. Still, they see the current results as helpful.

    "Clinicians and patients can have more confidence in a nonsurgical treatment choice in athletes who are female, are older, and have good knee function early after ACL injury," authors write. "A simple set of measures, assessed either before or after a short period of rehabilitation, can provide 2-year prognoses and thereby aid shared treatment decision making."

    APTA members Elizabeth Wellsandt, PT, DPT, PhD; and Lynn Snyder-Mackler, PT, ScD, FAPTA, are among the coauthors of the article.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    CDC: Rates of Outpatient Rehab Poststroke Low in Several States

    Despite its proven effectiveness at helping individuals recover from stroke and its important role in preventing future events, outpatient rehabilitation poststroke is still underutilized in many states, according to a new study from the US Centers for Disease Control and Prevention (CDC). Researchers found that in the states analyzed, about 1 in 3 patients received outpatient rehab after experiencing a stroke, a rate that the CDC says is "suboptimal" at best—and rife with disparities.

    The latest findings are based on 2 studies—a 2013 survey of 20 states and the District of Columbia, and a follow-up study of 4 of those states in 2015 (Maine, Georgia, Oregon, and Iowa). Researchers found that in 2013, 31.2% of stroke survivors reported receiving outpatient rehabilitation, poststroke, with state percentages ranging from a low of 23.1% in Oregon to a high of 43.6% in Minnesota.

    The 4 states selected for comparison between 2013 and 2015 did record some improvement in rates of outpatient rehab, but none broke the 50% rate: Oregon rose from 22.7% in 2013 to 39.7% in 2015, with similar increases in the other 3 states, from 24.2% to 31.8% in Georgia, 28.4% to 31.3% in Maine, and 41.7% to 49.8% in Iowa.

    Within those lackluster results there was even more bad news for younger adults, women, Hispanics, adults with less than high school education, and non-Hispanic persons of other than black or white races, who all recorded below-average rates of outpatient rehab. Overall, men reported a 33.8% rate of outpatient rehab in 2013, compared with a 29.1% rate for women. Within race/ethnicity categories, the highest rehab rate was recorded in the black non-Hispanic group, at 39.8%. Second was the white non-Hispanic group, with a 30% rate in 2013.

    Authors of the report acknowledge that efforts to increase the number of individuals poststroke who receive assessment and referral for rehabilitation have been successful, with current rates estimated at 90%—but they also point to the reported rates of actual participation in outpatient rehabilitation as a sign of an obvious disconnect.

    "Improving coordination of care to support assessment, referral, and, ultimately, participation in rehab is needed," authors write. "The continued underutilization of outpatient stroke rehab might be related to lack of patient access to outpatient facilities, ineffective referral from health care providers, high out-of-pocket costs, lack of health insurance coverage, or lack of knowledge and awareness of benefits…"

    Researchers cite several limitations to the CDC study, including inaccuracies due to possible patient misreporting of various rehab settings, lack of information on stroke severity, and smaller reporting numbers in some states. Authors also caution that the findings should not be considered nationally representative.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Study: Seeing a PT First for LBP Lowers Overall Costs, Reduces Chances of Later Opioid Prescription

    A new study has added to the growing body of evidence that beyond its effectiveness as a treatment for the pain itself, there are additional benefits to receiving physical therapy for low back pain (LBP) as a first-line approach: doing so could save money and dramatically reduce the chance of receiving an opioid prescription down the road.

    The study, published in Health Services Research (abstract only available for free), tracked private insurance information from nearly 150,000 patients for 1 year after an initial visit for LBP. Researchers were interested in identifying any differences in the kind of health care used and how much it cost over the course of a year among patients who saw a physical therapist (PT) first, those who saw a PT at a later time after an initial visit with another provider, and those who never visited a PT during the study period. To qualify for the study, patients had to have no prior history of LBP, back surgery, or other conditions that may have caused back pain.

    The conclusion: patients with LBP who received care from a PT first experienced lower out-of-pocket, pharmacy, and outpatient costs after 1 year and reduced their likelihood of receiving an opioid prescription by 87% compared with patients who never visited a PT. The PT-first group also was associated with a 28% lower probability of having imaging services and 15% lower odds of making a visit to an emergency department. The results caught the attention of National Public Radio, theOrlando Sentinel, and other media outlets.

    The cost savings for the PT-first group weren't across the board, however; researchers found that patients who visited a PT first recorded higher provider costs during the study period, a difference authors believe may be related to "a higher frequency of visits that are common for physical therapy care." However, authors point out, those higher costs are offset by the lower outpatient and pharmacy costs among the PT-first group.

    Another wrinkle: the PT-first group was associated with a 19.3% higher probability of later hospitalization. Again, the researchers weren't particularly surprised.

    "Having inpatient hospitalization is not necessarily a bad outcome for a patient," authors write. "PTs provide care that aims to resolve LBP by addressing musculoskeletal causes first, but if this problem does not get resolved, PTs may refer patients appropriately for more specialized care." Additionally, they point out, the hospital costs themselves were not significantly different from the non-PT and later-PT groups, suggesting that "seeing a PT first did not necessarily result in additional costly complications."

    Authors point to the drop in opioid prescriptions as an especially timely finding, writing that "Opioid overdoses have reached epidemic proportions, and opioids have not been found to significantly improve health outcomes. First-line, nonpharmacological methods to treat LBP have been recommended in the literature; this study suggests that [physical therapy] may be a positive alternative."

    As for prevalence of visiting a PT first for LBP, researchers found that 8.7% of patients were PT-first, 80% of patients made no PT visits, and 11.5% visited a PT at a later time after the initial diagnosis of LBP. In addition to PTs, the most common provider types seen at the first point of care were chiropractors (49.6%), orthopedists (9.4%), and acupuncturists (7.8%). A general grouping of "other providers" were seen by 15% of the patients studied. Those visiting a PT first were more likely to be female, younger, in an open-network insurance plan, and to have fewer comorbidities.

    Researchers believe that given the results of this and other studies, it's time states and insurers take a closer look at their direct access provisions to make it easier for patients to receive the more effective, safer, and lower-cost care that a PT can offer—and then make efforts to educate their residents and beneficiaries on the availability of PT services.

    "Some patients who may benefit from seeing a PT early, however, do not have access, sometimes because of regulatory and health insurance restrictions and, often, patient awareness," authors write. "Given the findings of this study, states should consider reviewing their laws that restrict direct access to physical therapy services and insurers should assess their policies."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Advanced Cancer Patients Can Benefit From Structured Exercise, Say Researchers

    Incorporating structured exercise into supportive care can help improve the lives of patients with advanced cancer, say researchers in an article e-published ahead of print in the Archives of Physical Medicine and Rehabilitation (abstract only available for free). In an analysis of previous studies, authors found that both aerobic exercise and resistance training improved many cancer side effects.

    Authors evaluated 25 studies, for a total of 1,188 participants, that measured the efficacy of exercise interventions on physical function, quality of life, fatigue, body composition, psychosocial function, sleep quality, pain, and survival. All studies used more than 1 session of structured exercise as the primary intervention and specified the "frequency, intensity, time, or type" of exercise. More than 80% of participants in each study had been diagnosed with "advanced cancer that is unlikely to be cured." Some studies used control groups, and some did not.

    Their findings include:

    Physical function. In 83% of studies, participants who exercised experienced significant improvements in physical function, including exercise capacity, aerobic capacity, and muscle strength.

    Quality of life. In 55% of studies, exercise resulted in significant improvement in at least 1 measure of quality of life.

    Fatigue. Half of the studies reported that exercise improved at least 1 measure of fatigue.

    Psychosocial function. At least 1 measure of psychosocial or cognitive function was reported as having improved with exercise in 56% of studies.

    Body composition. In 56% of studies, exercise improved at least 1 measure of body composition, including lean body mass and body fat percentage, though not BMI, fat mass, or body mass.

    Sleep quality. In all 4 studies including this area, participants who exercised reported significant improvements compared with control groups.

    Pain.Of the studies measuring pain, 2 found significant improvements after exercise interventions.

    Survival. No studies examining survival rates found a significant improvement as a result of exercise.

    Because "decline in physical function has been reported as one of the most debilitating symptoms associated with advanced cancer," authors write, "interventions targeting improvements in this domain are of utmost importance."

    While authors note that exercise "appears to be an effective adjunct therapy in the advanced cancer context," they recommend that future studies use standardized protocols to report consistent outcomes measure assessment—one limitation they observed. Authors also suggest that future research should "compare different frequencies, intensities, durations, and types of exercise" to "determine the optimal exercise dose to enhance outcomes for specific cancer diagnoses."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    CDC: Falls-Related Deaths in the US Rose 31% in 10 Years

    Among US residents age 65 and older, the rate of death from falls continues to climb steadily, having increased by 31% between 2007 and 2016, and growing at a particularly rapid rate among those aged 85 and above. The latest statistics, included in a report from the US Centers for Disease Control and Prevention (CDC), point to a need for more widespread falls screening and prevention efforts including physical therapy, authors say.

    During the 10 years tracked in the study, falls-related deaths among US residents 65 and older rose from 18,334 to 29,668—in terms of rates of death from falls, that's an increase from 47 per 100,000 to 61.6 per 100,000 in that age group. Deaths climbed by about 3% per year, according to the report.

    In addition to overall totals and rates, CDC researchers looked at data in terms of demographics and state-by-state variables. Among their findings:

    • In 2016, falls-related deaths per 100,000 were highest among white non-Hispanic US residents (68.7) and the all-ethnicity 85-and-older group (257.9).
    • While death rates increased for all age groups, the 85-and-older category recorded the most dramatic rise between 2007 and 2016, from 9,188 deaths in 2007 to 16,454 in 2016. The 65-to-74 age group recorded 2,594 falls-related deaths in 2007 and 4,479 in 2016; the 75-to-84 age group saw an increase from 6,552 deaths in 2007 to 8,735 in 2016.
    • Men had higher rates of falls-related deaths than did women—73.2 per 100,000 men compared with 54 per 100,000 per women. Researchers believe the gap may be attributable to "differences in the circumstances of a fall," with men tending to experience falls that lead to more serious injuries, such as those sustained in a fall from a ladder or as the result of alcohol consumption.
    • Rates for deaths from falls in the 65-and-older age group varied among states, ranging from 142.7 per 100,000 in Wisconsin to 24.4 per 100,000 in Alabama. Authors aren't sure of the reasons for the variance but suspect that the numbers might be related to demographic variables including differing proportions of older white adults in various states. Another possible explanation cited in the report was the impact of who completes the death certificate: According to the CDC researchers, a 2012 study showed that coroners reported 14% fewer deaths from falls than did medical examiners.

    Authors of the report theorize that the rates of falls-related deaths may be climbing in part because of an aging population and longer survival rates after common diseases including heart disease, cancer, and stroke. Whatever the contributing factors, it's a trend that needs to be addressed, they write: even if the rate were to stabilize, an estimated 43,000 US residents would die from falls in 2030, and if the rate were to climb as it did from 2007 to 2016, some 59,000 individuals may die from falls in 2030.

    "As the US population aged [65 and older] increases, health care providers can address the rising number of deaths from falls in this age group by asking about fall occurrences, assessing gait and balance, reviewing medications, and prescribing interventions such as strength and balance exercises or physical therapy," the report states.

    Better prevention efforts also may result in health care cost savings as well: an earlier report estimated that expenditures on nonfatal falls in the US reached nearly $50 billion in 2015, with medical costs associated with fatal falls coming in at an estimated $754 million.

    APTA provides extensive resources on falls prevention at its Balance and Falls webpage. Offerings include consumer-focused information, online courses, and links to other sources of information, including the CDC and the National Council on Aging. In addition, APTA's PTNow evidence-based practice resource offers a unilateral vestibular hypofunction clinical summary, a summary on falls risk in community-dwelling elders, an osteoporosis clinical summary, and tests and measures such as a fracture risk assessment, a clinical test of sensory interaction and balance, and a self-paced walk test. The association's scientific journal, PTJ (Physical Therapy) has also published a clinical guidance statement from the APTA Academy of Geriatric Physical Therapy on management of falls in community-dwelling older adults.