• News New Blog Banner

  • Study: PTs, Family Physicians Similar in Knowledge of LBP Management

    The numbers were small and the participants limited to certain groups, but results of a recent survey seem to point to yet another reason to increase direct access to physical therapist (PT) services: namely, when it comes to management of low back pain (LBP), PTs know just as much—and sometimes more—than the family practice physicians (FPPs) who often are sought for primary care. Authors believe the results point to the need for further study of the potential for PTs in primary care settings, an issue that APTA is exploring.

    In a study published in the Journal of Manual & Manipulative Therapy (abstract only available for free), researchers provided results of a survey of 73 PTs and 30 FPPs regarding their knowledge of optimal management strategies for LBP as well as their attitudes toward and use of clinical practice guidelines for the condition. Authors of the study used 2 survey instruments that were developed for earlier studies: an 11-item review of LBP knowledge, attitudes, and guideline statements, and a modified 8-question survey on management interventions. APTA members Michael Ross, PT, DHS; Travis Enser, PT; Allyson Muehlemann, PT, DPT; and Ron Schenk, PT, PhD, were among authors of the study.

    Participants were asked to respond using a 5-point Likert scale that reflected their level of agreement with various statements on LBP (the 11-question review) or their belief in the importance of various approaches to LBP treatment (the 8-question survey). Answers were classified as correct or incorrect based on what authors describe as "the most recent reviews of the evidence." In the end, 73 PT members of the APTA Private Practice Section (PPS) and 30 members of the American Academy of Family Physicians (AAFP) provided useable responses.

    The bottom line: the PTs and FPPs achieved similar scores on nearly every item in the surveys. Both groups strongly rejected statements such as "patients should not return to work until they are almost pain free" and "X-rays of the lumbar spine are useful in the work-up of patients with acute LBP," and broadly supported the statements "encouragement of physical activity is important in the recovery of LBP" and "there is nothing physically wrong with many patients with chronic [LBP]." When it came to statements related to optimal management of LBP, PTs and FPPs reported equally strong levels of support for the importance of physical therapy, patient encouragement, and manual manipulation; and were equally emphatic in their disapproval of surgery.

    Not all scores were close, however. Researchers found that compared with the FPP group, PTs generally had more confidence in their ability to gauge the motivation of their patients, and tended to more consistently reject the idea that "interventions by doctors and other health care providers have very little positive impact on the natural history of acute LBP."

    Other areas of more modest disagreement included support for the statement "I would find clinical practice guidelines helpful in the management of LBP" (agreed with or strongly agreed with by 58.9% of PTs compared with 76% of FPPs) and disagreement with the idea that bed rest is important in recovery from LBP—83.3% of FPPs said bed rest was "not recommended" or "of minor importance," compared with 69.9% of PTs rating bed rest in a similar way. Authors characterized these differences as nonsignificant.

    As for the PTs' confidence in their ability to assess patient motivation, authors believe that the nature of the PT-patient relationship may be at work.

    "Assessing patient motivation levels is a time-consuming process," authors write. "The duration of a typical patient visit is longer with the [PT] than a[n] [FPP] and the [PT] typically sees patients on a serial basis for a period of time. This increased patient interaction may play a part in [PTs] having less difficulty in assessing patient motivation."

    Authors also cited the presence of what they describe as "guideline-discordant care" among notable percentages of both PTs and FPPs, including an inability to choose the drug treatment most preferable for patients with LBP (26% of PTs and 35% of FPPs answered incorrectly by choosing drugs other than acetominophin and nonsteroidal anti-inflammatories), a preference for imaging (18% of PTs and 10% of FPPs), and a belief that bed rest for patients with LBP was of "some importance" (30% of PTs and 17% of FPPs). The numbers indicate that "continued educational efforts in the management of LBP are indicated and represent an area of potential cost savings for the health care system while also improving the quality of care and patient outcomes," authors write.

    The study has its share of limitations, according to its authors: response rates were small, and the use of members of the APTA PPS and the AAFP may mean that results may not be generalizable. Additionally, authors write, respondents tended to describe themselves as having a "special interest in musculoskeletal medicine," which may affect the "representativeness of the results."

    Authors believe that, despite those issues, at the very least their study merits further research into the knowledge levels of PTs and what that could mean for patient care.

    "These results may have implications for health policy decisions regarding the utilization of [PTs] to provide care for patients with LBP without a referral," authors write, "including the potential placement of [PTs] in primary care clinics to initially manage patient with musculoskeletal conditions."

    [Editor's note: What's the latest on the role of PTs in primary care? Check out this feature article from the December-January issue of PT in Motion magazine for an in-depth look at where things stand, and what APTA is doing, and learn about the basis for the association's efforts in this paper on exploring the roles of PTs in primary care teams.]

    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.

    2019 Slate of Candidates Posted

    The 2019 Slate of Candidates for APTA national office is now posted on the APTA website. The candidate webpage, including candidate pictures, statements, and biographical information, will be posted on February 25, 2019.

    Elections for national office will be held at the 2019 House of Delegates on June 10, 2019. Please contact Justin A. Lini in APTA’s Governance and Leadership Department for additional information.

    PTJ: Physical Therapy Continuity of Care Linked to Lower Rate of Surgery, Lower Costs

    Patients with low back pain (LBP) who see a single physical therapist (PT) throughout their episode of care may be less likely to receive surgery and may have lower downstream health care costs, researchers suggest in a study published in the December issue of PTJ(Physical Therapy). "Limiting the number of physical therapy providers during an episode of care might permit cost savings," authors write. "Health care systems could find this opportunity appealing, as physical therapy provider continuity is a modifiable clinical practice pattern."

    Authors examined data from nearly 2,000 patients in Utah's statewide All Payer Claims Database (APCD) to look for associations between continuity of care for LBP patients and utilization of related services such as advanced imaging, emergency department visits, epidural steroid injections, and lumbar spine surgery in the year after the first primary care visit for LBP. APTA members John Magel, PT, PhD; Anne Thackeray, PT; and Julie Fritz, PT, PhD, FAPTA, were among the authors of the study.

    Patients were between the ages of 18 to 64 who saw a PT within 30 days of a primary care visit for LBP. Researchers excluded patients with certain nonmusculoskeletal conditions; neurological conditions, such as spinal cord injury, that could affect patient management; and "red flag" conditions such as bone deficit or cauda equina syndrome.

    Researchers found that greater provider continuity significantly decreased the likelihood of receiving subsequent lumbar spine surgery, noting that "disparate management strategies across a variety of providers might inhibit or prolong the recovery in a patient with a worsening condition and contribute to the patient eventually receiving lumbar surgical intervention." They also note that a strong therapeutic alliance is associated with improved outcomes.

    Contrary to authors' expectations, high provider continuity was not associated with decreased use of advanced imaging, steroid injections, or emergency department visits. "The timing of physical therapy for LBP might have a greater impact on these outcomes than does provider continuity," they suggest. Researchers did find a link between use of these services and the presence of comorbidities, previous lumbar surgery, and use of prescription opioids or oral steroids.

    The average cost of care in the year following the initial primary care visit was $1,826 per patient. Costs were slightly less, at $1,737, for the 90% of patients with high provider continuity but rose to $2,577 for patients with a lower level of provider continuity.

    While the study's findings do not identify any cause-and-effect relationships, "it seems reasonable that physical therapists should consider approaches to managing patients with LBP that limit provider discontinuity," authors write.

    Watch for an interview with Magel by PTJ Editor in Chief Alan Jette, PT, PhD, FAPTA, coming soon to the journal's podcast webpage. "It's intriguing that so little research has been done on continuity of care in physical therapy, considering that a lot of work has been done in this area in medicine," Jette said. "Continuity of physical therapy care is highly relevant not only for practitioners but for policymakers."

    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.

    Listen Up! APTA Podcasts Keep You Inspired, Motivated, and In-the-Know

    And just like that, the holiday season is upon us. It's a great time of year, but it can also sweep you up in a whirlwind that leaves you feeling exhausted and out of touch with your profession.

    APTA has just the answer.

    The past year has been a stellar one for APTA podcasts. We now offer more content and variety than ever before, from the emotional that reminds you of why you love what you do, to the nuts-and-bolts informational that could be crucial to your professional survival. The recordings are easy to download and listen to no matter what you're up to during the holiday season—decking the halls, say, or riding in a one-horse open sleigh, or just kicking back for a few peaceful minutes of chestnut roasting. So don the gay apparel (or your favorite workout gear), fire up that device, and get listening.

    It's easy. Check out APTA's podcasts webpage, where you can browse a complete list of podcasts. Where to start? Here are some suggestions.

    Get inspired.
    APTA's "Defining Moment" podcast series is the audio companion to PT in Motion magazine's regular feature of the same name, which highlights stories from members about those moments when they felt that special—often life-changing—connection to the physical therapy profession. The Defining Moment podcasts bring you the audio version of the magazine feature, read by the authors. Treat yourself.

    For inspiration you can share with your patients, the popular Move Forward Radio is your go-to option: an interview series that features patients, PT and PTA experts, and even the occasional celebrity (past episodes have featured NBA All-Star Grant Hill and country music's Clay Walker) discussing physical therapy's role in a wide range of issues. Like APTA's MoveForwardPT.com website, the Move Forward podcast series is designed for patients and their families as well as for clinicians. Definitely share-worthy.

    Get energized.
    The secret is out: some of the liveliest discussion in the profession is taking place at the student level, and a new APTA podcast series brings the energy to you. APTA's Student Pulse, the newsletter for students, has created a podcast series that features Pulse contributors, mostly students. With titles such as "How War Led Me to Become a Physical Therapist," "Stereotype Threat," and "The X-Ray Showed a Bird," how could you not be intrigued? A great way to re-charge your enthusiasm for the profession

    Get up to speed.
    From payment and regulation to the latest in evidence-based care, it can be hard to stay in the loop. APTA helps make it a little easier to keep pace through a variety of podcasts. Wonder what all this "value-based care" talk is about, and how it applies to you? Check out APTA's value-based care series. Feel like hearing from some of the profession's thought leaders? Download the audio from the highly regarded Maley and McMillan lectures delivered at the 2018 NEXT Conference and Exposition. Getting yourself in the mood for the upcoming 2019 Combined Sections Meeting (you are going, right?)? Browse the podcast page for audio from last year's event.

    And when it comes to research, you can listen your way right to the source: PTJ (Physical Therapy), the association's scientific journal, offers a podcast series that features PTJ authors discussing their research with Editor in Chief Alan Jette, PT, PhD, FAPTA. The conversations are lively, accessible, and packed with useful information. Don't miss out.

    Study: Early Physical Therapy for Neck Pain Associated With Lower Imaging Rates, Opioid Prescriptions, and Overall Cost

    In findings on neck pain that echo the results of similar studies on low back pain, researchers have identified an association between early consultation with a physical therapist (PT) and lower rates of opioid prescription, imaging, and injections. Those lower-use rates contributed to significant cost savings over a 1-year study period compared with patients who waited 90 days or more before seeing a PT, according to the study's authors.

    The study, published in BMC Health Services Research, looked at health care utilization over 1 year among 308 patients who presented with neck pain. The patients were divided into 3 groups: an "early" group that consulted a PT within 14 days, a "delayed" group that received a PT consultation between 15 and 90 days after initial health care provider consultation, and a "late" group that waited from between 91 and 364 days to consult with a PT. All patients were members of the University of Utah Health Plans, either through private insurance or via Medicaid, and none had a recorded health care encounter for neck pain in the 90 days preceding initial consultation. APTA members Maggie Horn, PT, DPT, PhD; and Julie Fritz, PT, PhD, FAPTA, coauthored the study.

    Horn and Fritz tracked rates of spinal injection, opioid prescription, imaging (MRIs, X-rays, and CT scans), and overall health care costs at the 1-year mark, analyzing data for each group. Demographic and comorbidity information also was collected and compared.

    Overall, of the 3,533 patients who reported a new neck pain encounter with a health care provider, only 15.1% had a consultation with a PT over the entire 1-year study period. Of the 536 patients who consulted with a PT, 308 were deemed eligible for the study. The average age of patients in the study was 48.7 years, and most (69.2%) participants were women.

    Among the findings:

    • Overall, 35% of patients in the study received spinal injections at some point; however, compared with the early group, the delayed group was 5.34 times more likely than the early group to receive an injection, while the late group was 4.36 times more likely to receive the treatment compared with the early group.
    • Opioids were prescribed to 62.7% of all patients. However, when broken down by early, delayed, and late groupings, the late group was estimated to be 2.79 times more likely to receive an opioid prescription than the early group. The delayed group had about the same odds of receiving a prescription as the early group.
    • When it came to imaging, the delayed and late groups were more than 4 times as likely to receive an MRI and nearly 3 times as likely to receive an x-ray compared with the early group. Rates of CT scans were small—only 7% of all patients—but the late group was more likely to receive the imaging. There were no significant differences between the early and delayed groups related to CT scan rates.
    • At the end of 1 year, the average adjusted total health care cost for the early group was $1,853—about $1,000 less than the cost for the delayed group ($2,917) and less than half the cost associated with the late group, which averaged $4,026.
    • The median episode-of-care (EOC) for all 3 groups was 155 days, with the early group reporting the shortest median EOC, at 49 days, compared with the late group median EOC of 319 days. The groups reported no significant differences in the median number of physical therapist visits (3) over a median 22 days.
    • Among the 3 groups there were no significant differences in the prevalence of depression, anxiety, fibromyalgia, or obesity. The late physical therapy group tended to have more participants with low back pain, chronic or generalized pain, substance abuse, and tobacco use.

    "Current trends in health care costs are becoming unsustainable for payers and patients and are not resulting in improved outcomes," authors write. "The findings from our study indicate that consulting a physical therapist early for neck pain, within 14 days of an index visit, may provide an opportunity to mitigate downstream health care utilization while containing costs."

    Authors note that the increased odds of diagnostic testing and invasive treatments they found in their neck pain study is similar to patterns other research has uncovered in the treatment of low back pain (LBP), albeit with increased comparative risk. They speculate that this could have something to do the available evidence on the treatment of neck pain as a discrete condition.

    "In our study, providers may be more likely to use diagnostic testing or more invasive treatments prior to initiating physical therapy, potentially due to the lack of preponderance of evidence for treating neck pain," authors write. "Conversely, early physical therapy consultation may shield patients from this utilization pattern."

    Authors acknowledge that their study is limited to a single group of insured patients, in a single geographic location, using a single health care system, and that results "cannot be interpreted as causal or widely generalizable." Still, they write, the association they uncovered bears further study.

    "Future studies need to further explore improving earlier access to physical therapy for patients with neck pain," authors write. "Specifically future studies need to determine the effect of early physical therapy consultation within the primary care setting or through direct access in a formal randomized controlled trial."

    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.

    PT in Motion Magazine Looks at PTs in Primary Care

    Think the idea of the physical therapist (PT) as a primary care provider is some kind of far-off, pie-in-the-sky concept? Don't tell that to Tony Bare, PT, DPT, ATC; or Rebecca Byerley, PT, DPT; or Kaiser Permanente of Northern California, for that matter. They're already doing it—and doing it successfully.

    This month in PT in Motion magazine: Associate Editor Eric Ries takes an in-depth look at PTs in the primary care space, where they assume roles that range from a "roving PT" member of a multidisciplinary primary care team (the Kaiser approach), to a clinician in private practice who is often a patient's first point of contact with the health care system. Bare and Byerley are examples of the latter, both of whom have thriving practices in very different settings.

    The article features various PTs' perspectives on what it takes to provide primary care and outlines what APTA is doing to promote the concept. Ries also covers the longstanding use of PTs as primary care providers in the military and interviews PTs for their perspectives on the barriers to adopting a similar model in the civilian world, as well as the broad cultural hurdles that will need to be overcome to make the primary care PT more common.

    "Deepening Physical Therapy's Footprint: PTs in Primary Care" is featured in the December-January Issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them one of the benefits of belonging to APTA. Also in the December-January issue: APTA’s Emerging Leaders and the Catherine Worthingham Fellows of the American Physical Therapy Association share their views on such professional issues as the role of research, networking, education, mentors, and the future of the profession. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.

    Study: Clinic Ball Pits Carry Bacterial Risks

    It's no secret that when it comes to their potential for bacterial awfulness, the children's ball pits often found in fast food restaurants are the stuff of a germaphobe's nightmares. Now it turns out that if not properly maintained, ball pits in physical therapy clinics are capable of inducing shudders too.

    In a study recently published in the American Journal of Infection Control (abstract only available for free), researchers tested 6 ball pits in inpatient and outpatient physical therapy clinics in Georgia to find out what, if anything, those pits were harboring at a microbial level. Authors hope that the study will help to spark a conversation about standards for cleaning the enclosures—standards that they say have remained "elusive" to date.

    To conduct the analysis, researchers collected 9 to 15 balls taken from different depths in each ball pit, and then swabbed the entire surface of each ball. Samples were then inoculated on agar plates and allowed to grow for 24 hours at 91.4 degrees Fahrenheit. After the incubation, samples were tested for the number of colony-forming units (CFUS) present. Here's what researchers found:

    • Researchers identified 31 bacterial species and 1 species of yeast, with 9 organisms identified as "opportunistic pathogens." These organisms included bacteria associated with endocarditis, septicemia, urinary tract infections, meningitis, respiratory distress syndrome, streptococcal shock, and skin infections. The variety of yeast found on the balls—rhodotorula mucilaginosa—has "a high affinity for plastics" and has been associated with "multiple cases of fungemia in immunocompromised individuals," authors write.
    • There was "considerable variability" among the clinics, ranging from 36% to 93% of balls tested that produced recoverable CFUs, suggesting that clinics "utilize different protocols" for maintaining their ball pits, according to authors.
    • In the worst instance, bacterial colonization was found at the rate of "thousands of cells per ball, which clearly demonstrates an increased potential for transmission of these organisms to patients and the possibility of infection in these exposed individuals," authors write.

    Lead author and APTA member Mary Ellen Oesterle, PT, EdD, says the results should give clinics pause.

    "Clinics should be concerned about these findings," Oesterle said in an interview with PT in Motion News. "I would not recommend using a ball pit in a clinic until proper cleaning has occurred—and until the clinic verifies that the cleaning procedure effectively cleans the balls."

    Oesterle wasn't necessarily surprised by the findings, both in terms of the presence of pathogens and the variability among clinics. "In my own experience doing early intervention physical therapy for over 10 years, I encountered children who I suspected had contracted infections from ball pits, so this study confirmed something that rang true," Oesterle said. "The variability isn't surprising either," she added. "Each facility has different exposures, environments, and cleaning procedures, so I would expect the results to reflect that."

    And although concerning, Oesterle believes the problem is a solvable one.

    "I don't think it would be that difficult for clinics to reduce risk significantly," Oesterle said. "There are several approaches that may work well—for example, one clinic hangs balls in a mesh bag and disinfects them that way. We would like to do a follow-up study on the best cleaning method."

    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.