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  • From PTJ: For Patients With Nontraumatic Knee Pain, Early Rehabilitation Lowers Odds of Later Use of Opioids, Injections, Knee Surgery

    In brief:

    • Retrospective cohort study analyzed Medicare claims data for 52,504 beneficiaries with nontraumatic knee pain (NTKP) to analyze effects of early rehabilitation on later use of drugs, nonsurgical invasive procedures, and surgery
    • Patients receiving rehabilitation were divided into 3 groups: early rehabilitation (within 15 days of diagnosis), intermediate rehabilitation (16-120 days after diagnosis), and late rehabilitation (120 or more days after diagnosis); data were tracked for 1 year after diagnosis
    • Early rehabilitation patients were 33% less likely than nonrehabilitation control to engage in later use of drugs, 50% less likely to receive nonsurgical invasive procedures, and 42% less like to undergo surgery; similar differences were not found in intermediate and late-rehabilitation groups
    • Only 11% of NTKP patients received any rehabilitation at any time; of those who did receive rehabilitation, 52% were in the early group, 27% were classified in the intermediate group, and 21% received late rehabilitation
    • Authors believe results, while preliminary, support the trend toward more widespread use of early rehabilitation as a first-line treatment for NTKP

    When it comes to rehabilitation of individuals with nontraumatic knee pain (NTKP), authors of a new study concluded that it really is a case of "the sooner the better"—at least when it comes to reducing use of drugs, injection therapies, and surgeries later on.

    In a retrospective cohort study that analyzed records of 52,504 Medicare beneficiaries, researchers from the University of Pittsburgh found that patients with NTKP who received rehabilitation within the first 15 days after diagnosis were 33% less likely to use narcotic analgesics over the following year than patients who received delayed or no rehabilitation. Additionally, the early rehabilitation group was 50% less likely to move to nonsurgical invasive procedures such as corticosteroid injections, and 42% less likely to undergo later knee surgery. Results were published in Physical Therapy(PTJ) APTA's scientific journal.

    The study defined rehabilitation as "exercise or other nonpharmacological services or procedures that are recommended as early stage management options for patients with NTKP." This definition included exercise, nutritional counseling, functional training, physical agents, manipulation, and manual therapy, and was not linked to a particular service provider or setting.

    Besides the utilization patterns of early rehabilitation patients, authors of the study were also interested in overall usage of rehabilitation and whether delayed rehabilitation—defined as "intermediate rehabilitation" that occurred 16-120 days after the diagnosis or "late rehabilitation" that took place more than 6 months after the diagnosis—would make a difference in whether or not patients went on to the other interventions.

    The findings about rehabilitation prevalence were not surprising: of the 52,504 patients with NTKP, only 11% received early, intermediate, or late rehabilitation—a number consistent with other studies, authors write. Of the 5,852 patients who received rehabilitation, 52% received early rehabilitation, with 27% receiving rehabilitation 16-120 days later, and the remaining 21% having late exposure to rehabilitation.

    When it comes to later use of drugs, nonsurgical invasive procedures, and surgery, early rehabilitation seems to make all the difference compared with intermediate or late rehabilitation. Authors found that in the intermediate and late groups, the adjusted odds for receiving any of the interventions were actually higher than for patients who received no rehabilitation. While these data may seem to indicate that no rehabilitation is preferable to delayed rehabilitation, authors believe the difference may be driven by the likelihood that patients in the intermediate and later rehabilitation groups were experiencing higher levels of pain and disability for a longer time than were the early rehabilitation or control groups. Still, they explain, it's hard to say for certain, because during the years of claims data studied, data on pain and function were not included—a gap that "points to the importance of ongoing efforts to link clinical measures with health care service utilization from claims data."

    "Our findings would seem to support the recent recommendations that nonpharmacological treatment options, including those delivered by physical therapists, should be considered prior to treatment with narcotic prescription," authors write. "Developing strategies to encourage the use of rehabilitation as a first-line treatment for NTKP, as recommended by current guidelines, has the potential to positively impact a large segment of this clinical population."

    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.

    Oncology Section Introduces New Guideline on Diagnosis of Upper Quadrant Lymphedema in Patients With Cancer

    While early recognition of upper quadrant lymphedema secondary to cancer can play a crucial role in maintaining quality of life for patients, few clinical practice guidelines (CPGs) exist to help clinicians diagnose the condition. The APTA Oncology Section set out to change that with the publication of “Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association” in Physical Therapy (PTJ), APTA's science journal. An executive summary of the CPG will be published in Rehabilitation Oncology’s July issue.

    Authors Kimberly Levenhagen, PT, DPT; Claire Davies, PT, PhD; Marisa Perdomo, PT, DPT; Kathryn Ryans, PT, DPT; and Laura Gilchrist, PT, PhD, evaluated research on current diagnostic and assessment methods, including bioimpedence analysis, circumferential measurement, water displacement, perometry, and ultrasound imaging.

    In a podcast summarizing the work group’s recommendations, coauthor Claire Davies reminds clinicians, “We need to be aware that none of the diagnostic criteria are perfect in their diagnostic accuracy, especially [in] patients that fall just under or over a cut point. These [patients] have the potential to be misclassified. Also, the clinical presentation of lymphedema should influence the selection of diagnostic tool, as some measures … are more accurate in the early stage.”

    Physical therapists need to tailor the diagnostic approach to each patient. For example, Davies told PT in Motion News, “in some groups with early or subclinical lymphedema, volume measures may not be sensitive enough to diagnose and/or assess extracellular fluid. As tissue changes occur with later stage lymphedema, volume may be increased, yet measures of extracellular tissue fluid may not be as accurate due to fibrotic changes.”

    Authors of the CPG “encourage clinicians to cluster findings from their examination,” using the most appropriate tests recommended for each of the clinical presentations, to draw a conclusion on diagnosis.

    In her podcast, Davies ends “with a call for research.” Among their recommendations, authors of the CPG urge “further psychometric testing of the tools currently being used to assess and diagnose [secondary upper quadrant lymphedema].” They point out the need for research that examines diagnostic criteria at different stages of this condition. Further research should examine what “combination of history, symptoms, and other measurements” is “most accurate” for diagnosis, they state.

    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.

    News at NEXT: Foundation Receives Single $3 Million Donation, Largest Ever

    The Foundation for Physical Therapy (Foundation) recently received the largest single donation in its 38-year history—a $3 million gift that will be used to create an endowment for clinical research funding. The donation was announced at the Foundation's PT Party event held June 22 in conjunction with APTA's NEXT Conference and Exhibition.

    The remarkable donation comes from a family known for doing remarkable things for the Foundation—Stanley Paris, PT, PhD, and his wife Catherine Patla, PT, DHSc, MS. In past years, Paris has attempted to sail around the world and swim the English Channel, and he successfully bicycled across the United States, all in an effort to raise money for the organization, which is focused on strengthening physical therapy research.

    "This generous gift will transform the Foundation's ability to fund clinical research at a higher level, providing significant and ongoing support for research that forms the basis of physical therapist practice," said Foundation President, Edelle Field-Fote, PT, PhD, in a Foundation press release. "We are honored by the confidence that Dr Paris and Dr Patla have placed in us by recognizing and rewarding the exceptional work we do to support investigators in the field of physical therapy."

    "We support physical therapy research because it is critical to our profession's ongoing health." Patla said. "We want to sustain the Foundation's work for generations to come." In a video interview, Paris described the donation as a wise investment in physical therapy research. "We know that the money will be used carefully and spent effectively," Paris said.

    Paris and Field-Fote are Catherine Worthingham Fellows of the American Physical Therapy Association.

    News at NEXT: 2016-2017 VCU-Marquette Challenge Raises Over $340,000 for the Foundation

    Students from across the country were recognized June 22 during the Foundation for Physical Therapy's (Foundation) first annual PT Party, formerly known as the Foundation's Annual Gala, for their participation in the 2016-2017 VCU-Marquette Challenge—which for 2017-2018 will be called the Mercer-Marquette Challenge. Mercer University pulled ahead of its competitors this year after a second place finish in last year's competition to win the title, literally, as the challenge now takes on Mercer's name along with Marquette University as part of the contest's tradition. Mercer raised $45,220.

    Earning second place was last year's winner Virginia Commonwealth University ($37,834), and coming in third was the University of Pittsburgh ($24,449). The Foundation also recognized Marquette University students for their financial commitment to the challenge in raising over $20,000.

    The annual challenge is a grassroots fundraising effort coordinated and carried out by student physical therapists and physical therapist assistants across the country.

    This year, 146 schools nationwide participated in creative efforts to support the Foundation, raising a total of $340,986. A record number of schools returned to participate this year, yielding a 70% retention rate. Since its inception, 269 schools have contributed to the challenge, raising over $3.7 million for physical therapy research.

    The Foundation annually awards a research grant and a Promotion of Doctoral Studies Scholarship (PODS) in the name of the challenge to deserving researchers. Since 2002, the challenge has specifically funded more than 23 research grants and scholarships and also partially funded the $300,000 Clagett Family Research Grant in 2010.

    To view the complete list of participating schools visit Foundation4PT.org.

    News at NEXT: Foundation Service Awardees Recognized at NEXT

    Friends and donors of the Foundation for Physical Therapy (Foundation) recognized the achievements of several people and groups at the Foundation's inaugural awards luncheon on June 22. The event honored annual service award recipients and celebrated the efforts of students in the 2016-2017 VCU-Marquette Challenge.

    "Foundation Service Awards are presented to individuals and groups who have demonstrated their commitment to supporting the Foundation and advancing our mission to fund physical therapy research," said Foundation Board of Trustees Vice President Michael J. Mueller, PT, PhD, FAPTA, at the luncheon. "We are certain that the future of the Foundation, and more important our profession, lay bright, so long as there remains support to fund evidence-based practice."

    The 2017 service awards were presented to 4 deserving contributors.

    The 2017 Robert C. Bartlett Trustee Recognition Service Award was presented to past trustee and current honorary trustee Barbara Connolly, PT, DPT, EdD, FAPTA. This award is presented to trustees whose personal service and commitment has helped develop and sustain activities that promote the funding of physical therapy research and education programs.

    Section President William H. Staples, PT, DPT, DHSc, accepted the 2017 Premier Partner in Research Award on behalf of the Academy of Geriatric Physical Therapy. Over the years, the Foundation has presented this award to a select few who have made generous and longstanding contributions, which are critical to the success of the Foundation and its mission.

    The 2017 Charles M. Magistro Distinguished Service Award was presented to Nancy E. Byl, PT, MPH, PhD, FAPTA. This award, named for the first president and chair of the Foundation, is presented annually to individuals for outstanding service and steadfast commitment toward promoting the Foundation's goals.

    The 2017 Spirit of Philanthropy Award was presented to Patricia A. Traynor, PT. Since 2005, this award has been presented annually to donors who exhibit enthusiastic support and dedication to the growth of the Foundation and its mission.

    Later that evening, the Foundation held the Boston PT Party, a nontraditional twist on the former annual gala. During the event, further tribute was paid to the Foundation's service award recipients, and the winners of this year's VCU-Marquette Challenge were announced. Mercer University took top honors and will succeed VCU in being co-eponym of the challenge with Marquette University for 2017-2018.

    Special thanks go to this year's event sponsors: HPSO/CNA, the Boston PT Party title sponsor for the 17th consecutive year; NuStep, producer sponsor; Tri W-G, dessert sponsor; and Performance Health, awards luncheon sponsor.

    Study: Delaying ACL Surgery in Favor of Exercise Therapy May Produce Better Outcomes in Patients With 'Prognostic Factors'

    In brief:

    • Researchers analyzed Knee Injury and Osteoarthritis Scores (KOOS) of 118 young adults who experienced an ACL tear, comparing baseline with 5-year KOOS
    • Some participants received early ACL reconstruction surgery followed by exercise therapy; others received delayed surgery with a period of exercise therapy prior to the surgery; a third group received exercise therapy only
    • Researchers matched baseline and 5-year KOOS with "prognostic factors" associated with worse outcomes—cartilage and meniscus damage, osteochondral lesions, and knee extension deficits
    • Overall findings: early surgery was more often associated with worse outcomes, compared with delayed surgery or no surgery
    • In the early-surgery group, participants with meniscus damage at baseline reported worse KOOS at 5 years than did participants without meniscus damage at baseline; the delayed surgery group reported the opposite, with the meniscus-damage subgroup reporting KOOS gains over those without meniscus damage

    Researchers analyzing a study of patients with anterior cruciate ligament (ACL) tears have begun to connect the dots between early indicators of long-term outcomes and the kinds of treatments patients receive. They reached the conclusion that, for at least some, putting off ACL reconstruction surgery in favor of exercise therapy could be the way to go.

    In what authors call a "post-hoc exploratory, hypothesis-generating analysis of outcomes," researchers used data from the Knee Anterior Cruciate Ligament Nonsurgical versus Surgical Treatment (KANON) clinical trial conducted in Sweden to analyze how Knee Injury and Osteoarthritis Outcome Scores (KOOS) 5 years after injury compared with the presence of various baseline "prognostic factors" known to correlate to worse long-term outcomes. The trial focused on relatively active young adults (18-35 years) with no prior knee injuries who suffered an acute ACL rupture and began treatment within 4 weeks after injury.

    The researchers knew that the 4 prognostic factors—baseline cartilage and meniscus damage, osteochondral lesions, and knee extension deficits—increased the chances of worse outcomes at 5 years. What they wanted to find out was whether early ACL reconstruction surgery actually made those chances worse, compared with surgery delayed in favor of exercise therapy, or exercise therapy alone was responsible. Results were published in theBritish Journal of Sports Medicine (BJSM).

    A total of 118 participants were studied, with 59 receiving early (within 4-6 weeks) ACL surgery followed by exercise therapy, 30 receiving exercise therapy followed by surgery 2 to 56 months later, and 29 receiving exercise therapy only. All patients participated in the same "goal-oriented, physiotherapist supervised neuromuscular program at 9 outpatient clinics," according to authors. Functional measures were collected at baseline, 3 months, 6 months, 12 months, 24 months, and 5 years, with results adjusted for sex, age, body mass index, preinjury activity, education, and smoking.

    Among the findings:

    • For participants with baseline meniscus damage, early surgery followed by exercise therapy resulted in a KOOS that averaged 14 points worse than scores reported by participants with no baseline meniscus damage. But in what authors call a "surprising" result, when participants with baseline meniscus damage participated in exercise therapy and delayed surgery, their KOOS wound up being, on average, 14 points higher than those with no baseline meniscal injury.
    • Similar, albeit lower, effects were recorded for patients with baseline osteochondral lesions (average 5.4 points worse for the early-surgery group; average 6.2 points better for the delayed-surgery group in KOOS for pain). Participants in both categories (early vs delayed exercise) who reported baseline knee extension deficits reported small decreases for most KOOS categories.
    • Overall, participants whose ACL injury was managed with exercise therapy alone reported an estimated 10-point better KOOS at 5 years compared with the early surgery group.
    • Participants who received exercise therapy alone but later received " non-ACL surgery"—a knee surgery that was not ACL reconstructive—reported an estimated 14-point worse KOOS at 5 years compared with participants who received exercise therapy alone and no other surgeries.

    Authors of the study acknowledge that the findings related to meniscus damage were particularly unexpected, but not exactly beyond reason.

    "The mechanisms behind this surprising finding are not clear, but sustaining a second knee insult in the form of an early ACL reconstruction shortly after a previous knee trauma may increase the likelihood of experiencing persistent postoperative difficulties," authors write. They also speculate that the delayed-surgery group may have experienced more pain than their counterparts without meniscus injuries, and, as a result, "reconstructive surgery may have been more successful in relieving pain … compared with those electing to undergo surgery for a range of other reasons, including a desire to gain preinjury status, a pre-existing preference for surgery, and finding exercise therapy boring and time-consuming."

    Researchers also found that the baseline KOOS scores themselves functioned as prognostic factors for worse 5-year outcomes, with early-surgery participants who reported lower KOOS at baseline in turn reporting lower KOOS at 5-year follow-up compared with their delayed-surgery counterparts who also reported lower-baseline KOOS.

    "Low baseline KOOS scores also reflect more physical impairment and this may predispose an individual to worse postoperative outcomes," authors write. "Individuals who report worse KOOS scores prior to reconstruction may benefit from postponing surgery and commencing exercise therapy before considering surgical reconstruction."

    Authors acknowledge that the "exploratory nature" of their research included several limitations, including low sample size, lack of adjustment for multiple comparisons, and confidence intervals "suggesting uncertainty in some of the estimates." Still, they argue, this initial work is worth further exploration and, at the very least, could help to reinforce the concept that clinicians must approach treatment of ACL injuries at the individual patient level.

    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: Platelet-Rich Plasma for Tendinopathy? Researchers See Promise

    In brief:

    • Meta-analysis reviewed 18 studies (1066 participants) on the use of platelet-rich plasma (PRP) vs control (saline, anesthetic, corticosteroids, dry needling) in treatment of tendinopathy
    • Outcomes were measured by pain ratings at 12 weeks and, when possible, 6- and 12-month follow-up
    • Use of some form of PRP treatment showed better outcomes than controls, though the size of those outcomes varied depending on the kind of PRP used
    • All controls also demonstrated improved outcomes, with dry needling showing the highest standard mean difference of the 4 controls
    • Authors say more work needs to be done relative to effectiveness of specific PRP treatments on specific tendons

    Authors of a new meta-analysis from Australia say that a single injection of leukocyte-rich platelet-rich plasma (LR-PRP) can be effective in treating tendinopathy but that more work needs to be done to identify what other forms of PRP can and can't do, as well as how best to administer the treatments.

    Researchers analyzed data from 18 studies involving 1,066 adult participants with tendinopathy who received some form of PRP or another control treatment (saline, local anesthetic, cortiocosteroids, or dry needling). Studies that included patients undergoing surgery or treatment of nontendon soft tissue injuries were not included. The randomized controlled clinical trials that were assessed included trials of "any autologous blood product," with any dosage, volume, or number of injections accepted for review. The article appears in The American Journal of Sports Medicine (abstract only available for free).

    The review's conclusions were based on pain and function follow-up ratings at 12 weeks as well as 6 and 12 months. Authors found that nearly all PRP treatments produced some positive effects that exceeded controls. Effect ranged from a small standard mean difference (SMD) over control of 26.77 for autologous conditioned plasma (ACP) an overall larger difference in improvement—SMDs between 31.8 and 42.9, depending on the kit used—for LR-PRP.

    Researchers also found that all 4 treatments used as controls—saline, anesthetic, corticosteroids, and dry needling—produced some positive outcomes, with dry needling showing the highest SMD, at 25.22.

    While authors believe the results of the analysis point to the effectiveness of PRP injection, they acknowledge that a few details remain fuzzy: among them, whether some tendons are more responsive to PRP than others and the possibility that some forms of PRP are better suited to certain tendons. Earlier studies have indicated that such variability may exist, at least when it comes to the use of PRP and hamstring rehabilitation.

    The use of PRP continues to grow and is 1 component of regenerative medicine that physical therapists and physical therapist assistants can expect to see regularly in the future, according to a 2016 article in PT in Motion magazine.

    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: LBP Patients With Comorbidities at Higher Risk for 'Guideline Discordant' Care

    In brief:

    • Researchers analyzed commercial insurance claims for 513,980 adults with an initial report of back pain; matched claims history with presence of 0, 1, or 2 or more comorbidities
    • Compared with those reporting no comorbidities, patients with 1 comorbidity were 14% more likely to become a long-term user of back care (3-year period); patients with 2 or more comorbidities were 29% more likely to engage in long-term use
    • Patients with comorbidities also more likely to receive imaging, visit the ED
    • Individuals with comorbidities more likely to be prescribed opioids as an initial treatment and more likely to fill those prescriptions
    • Authors describe results as a "concerning" indication that more vulnerable patients may be at a greater risk of receiving lower-quality care

    Authors of a new study have found that for patients with low back pain (LBP), the presence of comorbidities such as diabetes, mental health issues, and hypertension raises the risk that they'll receive LBP care that uses more resources and veers off-course from LBP guidelines—including more prescriptions for opioids.

    The study, published in the Journal of Evaluation in Clinical Practice (abstract only available for free), analyzes commercial insurance claims data from 2007 to 2011 involving 513,980 adults with new visits for back pain. Researchers tracked LBP care-related claims for 3 years after the initial visit as well as procedure use and treatment patterns for the first 42 days after the visit, and matched these data with patients identified as having 0, 1, or 2 or more comorbidities based on ICD-9 codes. APTA member Sean Rundell, PT, DPT, PhD, was lead author of the study.

    The patient population studied had an average age of 45.2 years. Females made up 54% of the study group, and 44% of the population came from the southern United States. Most (80%) reported no comorbidities, with 16% (83,242) reporting 1, and 4% (21,304) reporting 2 or more. The most common comorbidities reported were endocrine, nutritional, and metabolic diseases and immunity disorders (36%), followed by diseases of the musculoskeletal system (29%), and diseases of the circulatory system (27%).

    Among the findings:

    • Compared with patients having no comorbidities, those with 1 comorbidity were 14% more likely to become a "long-term user" of back pain-related care. Patients with 2 or more comorbidities had a 29% greater likelihood of long-term use. The resource use pattern tended to include at least 1 episode of care every quarter for the 3-year study period.
    • Among the individual comorbidities studied, patients with comorbid musculoskeletal conditions were 53% more likely than those without to be high users of long-term back care resources. Individuals with mental health disorders, nervous system, and respiratory comorbidities each had more than a 30% increase in odds of long-term resource use.
    • Patients with comorbidities also were more likely than those with no comorbidities to use advanced imaging, visit the emergency department, and fill at least 1 prescription for opioids.
    • Overall, 22% of the study population filled at least 1 opioid prescription, but that average was higher among patients with comorbidities: among patients with mental health comorbidities, 27% of patients with anxiety disorders and 45% of patients with substance use diagnoses filled at least 1 opioid prescription. The same pattern was observed for patients with chronic pulmonary disease (35% prescription fill rate) and asthma (26% rate).
    • When it came to opioid prescriptions as an initial treatment, patients with depressive disorders, substance abuse disorders, and anxiety disorders were more likely to receive a prescription, as were patients with chronic respiratory conditions and asthma.

    Authors note that "guidelines discordant" care is sometimes acceptable for LBP patients with comorbidities. Still, they assert, the opioid prescription and fill numbers are "disconcerting," particularly given that some the highest fill rates were associated with patients whose use of opioids could pose a danger: individuals with substance abuse diagnoses, patients with mental health disorders that may require psychotropic medications, and patients with respiratory conditions.

    "Despite long-standing guidelines, current management of back pain continues to lack concordance with recommended practices," authors write. "[The current study's] findings are concerning because it indicates that more vulnerable patients, ie, those with a higher comorbidity burden, may be receiving lower-quality care that has a higher risk for adverse events."

    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.

    BMJ: Guideline Strongly Recommends Against Arthroscopy for 'Nearly All' Patients With Knee OA or Meniscal Tears

    In brief:

    • In countries with data available, knee arthroscopy is the most common orthopedic procedure
    • Data reviewed by an international multidisciplinary panel that included physical therapists
    • Guideline makes a "strong recommendation" against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews; authors write that "further research is unlikely to alter this recommendation"
    • Authors write that "health care administrators and funders may use the number of arthroscopies performed in patients with degenerative knee disease as an indicator of quality care"

    For patients with knee pain, the small, short-term gains in pain and function from arthroscopy are greatly outweighed by the "burden, postoperative limitations, and rare serious adverse effects" associated with the surgery, write authors of a new clinical practice guideline. Instead, authors "strongly recommend" conservative treatment over arthroscopy for "nearly all" patients with degenerative knee disease.

    The guideline, published online May 10, 2017, in BMJ, is based on a 2016 systematic review that indicated outcomes for knee arthroscopy were no better than those for exercise in people with degenerative medial meniscus tear. The multidisciplinary, international panel included physical therapists, orthopedic surgeons, a rheumatologist, a general practitioner, general internists, epidemiologists, methodologists, and patients.

    Authors defined degenerative knee disease as knee pain not caused by traumatic injury in patients over age 35, "with or without" imaging evidence of osteoarthritis, meniscal tears, mechanical symptoms, or "acute or subacute onset of symptoms."

    The panel considered 3 patient outcomes in their analysis: pain, function, and quality of life. Authors write, "Arthroscopic knee surgery does not, on average, result in an improvement in long-term pain or function." Future evidence, they say, is unlikely to change this conclusion.

    While the panelists did not explicitly recommend any particular type of conservative management of degenerative knee disease, they suggested that nonuse of knee arthroscopy could be used "as a performance measure or tied to health funding."

    Authors conclude, "Given that there is evidence of harm and no evidence of important lasting benefit in any subgroup, the panel believes that the burden of proof rests with those who suggest benefit for any other particular subgroup before arthroscopic surgery is routinely performed in any subgroup of patients."

    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: Only 10% of Physician Visits for LBP Resulted in Physical Therapy Referrals 1997–2010 While Opioid Prescriptions Climbed

    In brief:

    • Study analyzed data from 170 million visits to a primary care physician 1997–2010
    • Referrals for physical therapy occurred in 10% of the visits, a rate that was fairly constant during the study period
    • Prescriptions for opioids rose from about 15% to 45% by 2010; patients who didn't receive a physical therapy referral were more likely to receive an opioid prescription
    • Disparities in referral rates were found, with Medicare and Medicaid beneficiaries less likely to be referred to a PT
    • Authors call for more education on physical therapy as a first-line treatment for LBP

    If there is consensus among physicians that physical therapy is a preferred first-line treatment for low back pain (LBP), you wouldn't be able to tell it from the referral rates cited in a recent study. Researchers found that between 1997 and 2010 only about 10% of LBP visits resulted in a referral to a physical therapist (PT), while opioid prescription rates climbed to 45% by the study's end—and  those numbers get worse for patients whose care is paid for by Medicare, Medicaid, and even HMOs.

    The study, published in Spine (abstract only available for free), analyzed an estimated 170 million visits to a primary care physician (PCP) for LBP during a the period 1997–2010. Using statistics supplied from the National Hospital and Ambulatory Medical Center Survey as well as survey data from emergency departments, researchers were able to not only look at overall percentage of referrals for physical therapy but also to analyze those patterns in terms of demographics and payer source.

    While that time period was prior to recommendations by the US Centers for Disease Control and Prevention (CDC) and other groups for physical therapy as a first-line treatment for LBP and other types of pain, researchers believe that the efficacy of physical therapy was already well-established by the late 90s. They describe the data they uncovered as "concerning." Among the findings:

    • Over the 15 years of the study, the percentage of referrals for physical therapy changed a little, but not much, and not in ways that indicated any discernable trend—10.1% overall, with yearly fluctuations between 4.8% (2001) and 15.1% (2004).
    • Opioid prescriptions were a different story, for the most part steadily moving from about 15% of all LBP visits in 1997 to nearly 45% by 2010.
    •  Referral for physical therapy also correlated to a patient's type of insurance. Patients with preferred provider organization plans were 53% more likely to receive treatment from a PT, with patients in HMOs being 44.7% more likely to be referred for physical therapy. Medicare and Medicaid beneficiaries were 53% and 47% less likely to be referred to a PT, respectively.
    •  The patient population in the study had an average age of 50.4 years, and about half were female. About 22.3 million had Medicare, and 2 million had Medicaid. Whites made up 19.8 million of the patient population, with 12.4 Black patients and 2.3 million Hispanic patients (the study used only 3 ethnic categories).

    Researchers believe their findings reveal some "concerning" and "disconcerting" patterns—among them an increased likelihood that patients who aren't referred for physical therapy will wind up with an opioid prescription, and a connection between the kind of insurance patients have and the likelihood that they will receive a referral to a PT.

    Authors assert that while an opioid prescription may seem like the more cost-effective option in terms of upfront costs, the long-term toll—both in terms of money spent and harm to patients—far outweighs the spending associated with physical therapy. "With more evidence that [physical therapy] is an effective method of treating back pain, there needs to be a push for more insurance coverage of [physical therapy] referrals to avoid overutilization of cheaper but less effective, and potentially harmful, forms of treatments," authors write.

    Additionally, say the authors, disparities in insurance coverage need to be addressed. Given the indications that patients who don't receive a referral for physical therapy are more likely to receive an opioid prescription, the connection between referral rates and the type of insurance a patient has reveal "disconcerting economic disparities [that] need to be quantified, elucidated, and addressed," they write.

    According to the researchers, while "the ideal physical therapy referral rate [for LBP] has yet to be defined," the fact that the rate remained so steady while opioid prescription rates climbed—even as evidence of physical therapy's effectiveness continued to mount—"suggests that initiatives are needed to educate both providers and patients about the utility of physical therapy."

    APTA has added its voice to the effort to curb opioid abuse through its national #ChoosePT campaign , an initiative to promote physical therapy as a safe and effective alternative to the use of opioids in the treatment of pain. Housed at MoveForwardPT.com/ChoosePT , the #ChoosePT campaign includes national online advertising, TV and radio public service announcements, and other targeted advertising and media outreach.

    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.