• News New Blog Banner

  • Study: Knee OA Treatment That Doesn't Follow Guidelines Comes at a Price

    In brief:

    • Current orthopedic surgeon guidelines recommend use of physical therapy, tramadol, and NSAIDs for nonsurgical treatment of knee OA, and against use of injections and opioids other than tramadol.
    • Analysis of claims utilization data found that the top 3 interventions were corticosteroid injections (46.0%), hyaluronic acid injections (18.0%), and opioids other than tramadol (15.5%), none of which are recommended in the guidelines.
    • Physical therapy was prescribed for only 13.6% patients.
    • Adhering to AAOS treatment guidelines for knee OA could decrease cost of care by 45%.

    If health care providers treated patients with knee osteoarthritis (OA) according to established guidelines that include physical therapy, researchers say costs of treatment could drop by as much as 45%. Yet too many physicians are prescribing interventions that are not supported by evidence and may even carry extra risk.

    An award-winning study published in The Journal of Arthroplasty (abstract only available for free) queried the Humana claims database to determine the prevalence of 8 nonsurgical treatment modalities—hyaluronic acid (HA) injections, corticosteroid (CS) injections, physical therapy, knee brace, wedge insole, opioids, NSAIDs, and tramadol—used to treat 86,081 patients with knee OA. The patients were receiving conservative treatment in the year prior to total knee arthroplasty (TKA).

    Of all 8 modalities, only physical therapy, NSAIDs, and tramadol are strongly recommended by the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for nonsurgical management of knee OA. However, authors found the 3 most frequent interventions to be CS injections (46.0%), HA injections (18.0%), and opioids (15.5%). Physical therapy was utilized by only 13.6% of patients.

    More than half of the total cost of knee OA treatment was for noninpatient care, with 29.2% accounted for by HA injections, which AAOS classifies as “Cannot recommend – strong.” The per-patient cost for physical therapy was half that of HA injections. Researchers found that the AAOS-recommended interventions represented only 12.2% of the cost of noninpatient care: physical therapy at 10.9%, NSAIDs at 1.2%, and tramadol at 0.1%.

    The study shines a bright light on the “high prevalence of low-value interventions in the management of knee OA symptoms in the year prior to TKA,” say authors, who also express concern about risk of infection associated with injections. Preoperative use of opioids, they note, has a higher risk for complications and “a more painful recovery” after TKA.

    While experts acknowledge they have no data on the interventions’ effectiveness, “given that all patients in this study underwent TKA within a year or less … it seems likely that the treatments were not overly successful in alleviating symptoms.”

    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.

    Analysis of Hospital System's LE Joint Replacement Bundling Programs Reveals Significant Drop in Expenditures

    In brief:

    • Analysis of Medicare payments related to 3,942 LE joint replacements in a 5-hospital network participating in voluntary bundling programs between 2008 and 2015.
    • During study period, average expenditures on replacements without complications dropped by 20.8%; expenditures on replacements with complications dropped by 13.8%.
    • Treatment population, severity of illness, and outcomes remained stable during study period; volume rose steadily.
    • Just over half (50.2%) of the savings were related to reduced in-hospital costs—predominantly due to a 30% reduction in the cost of implants. The remaining 48.8% of savings were related to a decreased use of IRFs and SNFs.
    • Use of home health care (including physical therapy in that setting) increased by 9% during study period.

    It may be too soon to judge the cost-effectiveness of Center for Medicare and Medicaid Services' (CMS) mandatory hip and knee replacement bundling programs, but if the experience of 1 hospital system that participated in earlier voluntary programs is any indication, facilities have reason to expect overall Medicare expenditures to drop, say authors of a new study. Their analysis of nearly 4,000 patients who participated in bundling programs between 2008 and 2015 revealed an average 20.8% reduction in expenditures for joint replacements without complications, with the bulk of those savings due to reduced implant prices and the decreased use of institutional postacute care.

    The study, published in JAMA Internal Medicine (abstract only available for free), tracked Medicare claims related to lower extremity joint replacement among patients in the Baptist Health System (BHS), a 5-hospital network in San Antonio, Texas. During the study period, from 2008 to 2015, BHS participated in 2 voluntary bundling programs offered by CMS—the Acute Care Episode (ACE) demonstration, and later, the major joint replacement of the lower extremity (MJRLE) bundle offered through the Bundled Payment for Care Improvement (BCPI) program. A total of 3,942 patients (average age 72.4) participated in the programs.

    Researchers found that between 2008 and 2015, average Medicare episode payments for joint replacements without complications decreased from $26,785 to $21,208—a 20.8% drop during a time period in which nationwide payments rose by 5%. Among the 204 cases with complications, expenditures were reduced by 13.8% on average, from $38,537 to $33,216. Authors of the study say that patient age, proportion of male patients, and severity of illness did not change significantly during that time; however, volume did rise steadily, from 192 to 246 episodes per quarter.

    Authors cite 2 major factors contributing to the savings: first, BHS was able to find less expensive implants that brought the price down by nearly 30% during the study period, (a change that accounted for 80.5% of all in-hospital savings). Second, BHS reduced spending on inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) by 54% and 24.3%, respectively. In the end, the savings associated with internal hospital cost reductions represented 51.2% of overall savings, and decreased use of IRFs and SNFs represented the remaining 48.8%.

    According to the authors, the overall BHS results may be related to the amount of experience the system has with bundling, which allowed it to build "data infrastructure and an orthopedic working group to track hospital and [postacute care] variation." Another important factor: something authors call "organizational and market characteristics" that included the "availability of home-based services such as physical therapy allowing BHS to safely reduce institutional [postacute care]." During the study period, per-episode spending on home health care rose by 9%.

    The BHS move away from institutional postacute care has not escaped notice: in 2015, National Public Radio featured the BHS bundling model, reporting that "the loss to the nursing homes and other post-discharge providers was [BHS'] gain."

    Authors of the study acknowledge the limitations associated with a focus on only 1 hospital system, but assert that their study "provides important data for hospitals implementing joint replacement bundles," particularly under the CMS Comprehensive Care for Joint Replacement (CJR) model now required in 67 metropolitan areas.

    In that sense, authors say, the BHS study could be a catalyst for large-scale changes.

    "If such approaches are successfully implemented on a broad scale with similar results, the magnitude of savings that could accrue to Medicare—and possibly private payers—would be substantial," authors write. "In turn, the success of CJR participants could accelerate the shift toward bundled payments for more conditions and procedures."

    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.

    Revised Physician Guidelines Shift to Non-Drug Approaches as First-Line Treatment for LBP

    In brief:

    • In a revision of clinical guidelines, the American College of Physicians is recommending nonpharmacologic approaches over the use of medications as first-line treatment for acute, subacute, and chronic LBP.
    • Changes are based in part on new evidence showing that acetaminophen and antidepressants were no better than placebos.
    • Guidelines recommend that physicians advise patients that pain is likely to diminish through exercise and maintenance of as many daily activities as possible.

    The latest advice on low back pain (LBP) from the American College of Physicians (ACP) makes it clear: patients with acute LBP will generally improve over time regardless of treatment, and that when treatments are necessary, nondrug approaches including exercise are preferred for all but the most stubbornly chronic manifestations of the condition. The new guidelines represent a shift from ACP's previous position, which called for the use of medication as part of first-line treatment.

    The guidelines, released on February 13, include 3 recommendations—1 each for acute (fewer than 4 weeks) or subacture (4 to 12 weeks) LBP, chronic LBP (more than 12 weeks), and chronic LBP that persists after the use of nonpharmacologic therapy. Researchers analyzed studies on the effectiveness of both pharmacologic and nonpharmacologic treatments among the 3 types of LBP. Drug-based treatments studied ran the gamut from acetaminophen to opioids, including antidepressant medications. Nonpharmocologic treatments reviewed included spinal manipulation, multidisciplinary rehabilitation, massage, "exercise and related therapies, and various physical modalities," among other approaches.

    In the end, what researchers found had less to do with breakthrough understandings of the effectiveness of exercise and maintaining daily activities—benefits of which were reestablished through a systematic review conducted as part of guideline development—and more to do with a weakening of evidence supporting the use of medications.

    "The [review that served as the basis for the previous guidelines published in 2007] concluded that acetaminophen was effective for acute low back pain," authors write. "However, [the 2017] update included a placebo-controlled RCT in patients with low back pain that showed no difference in effectiveness between acetaminophen and placebo," with the same results surfacing when it came to the use of antidepressants. On the other hand, they add, "many conclusions about nonpharmacologic interventions are similar between the 2007 review and the update."

    At the acute and subacute levels, the new guidelines strongly recommend that physicians advise patients that the pain is likely to improve over time, and discuss the use of "superficial heat, massage, acupuncture, or spinal manipulation." At the chronic level, the guidelines strongly recommend "exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (supported by moderate-quality evidence), tai chi, yoga, motor control exercise," and other approaches that include low-level laser therapy and spinal manipulation (supported by low-quality evidence). In all cases, they write, "it is important that physical therapies be administered by providers with appropriate training."

    For patients with chronic LBP that persists after nonpharmacologic approaches have been tried, the guidelines make a "weak" recommendation for considering nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, with tramadol or duloxetine as a second-line therapy. "Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and related benefits with the patients," authors add.

    The updated guidelines generated wide media coverage, including stories from CBS News, NBC News, and the New York Times, which characterized the recommendations as "bucking what many doctors do."

    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: Personal Approach Is Important to Patients With Chronic Pain, but Partial Telerehab Could Offer Acceptable Alternatives

    In brief:

    • First telemedicine study to use discrete choice experiment to examine patient preferences and priorities.
    • Survey recipients included 300 chronic pain patients on a wait list for a rehab center in The Netherlands.
    • Experiment included 15 choice tasks combining 6 telerehab treatment characteristics.
    • Patients preferred face-to-face treatment and frequent physician consultation to web-based sessions.
    • Most-preferred scenario included 75% video instruction and infrequent physician consultation, accompanied by remote monitoring and feedback technology.

    While the emergence of telemedicine holds great promise for improving access to effective, cost-efficient care, its success depends on providers designing such services “with the patients’ perspective in mind,” say experts in a study in the Journal of Medical Internet Research. The Dutch researchers found that chronic pain patients were willing to forgo face-to-face time with physicians when “remote feedback and monitoring technology is offered.”

    Authors wanted to learn about chronic pain patient preferences for telerehabilitation, including how much human contact was important to recovery and what treatment characteristics were most valued by patients. Based on qualitative interviews and a focus group, they devised a “discrete choice experiment” to learn more about treatment characteristics such as amount of preferred human contact and treatment mode and location, as well as what type of “telerehabilitation scenario they are most likely to accept as an alternative to conventional rehabilitation.”

    Researchers randomly distributed 3 different versions of a survey questionnaire, each of which included 15 scenarios in which the patient had to choose rehab program A, B, or “I choose not to be treated.” Scenarios included either clinic-based or home-based rehab, and included varying levels of human contact, physician consultation, treatment mode and location, web-based and face-to-face instruction, feedback and monitoring technology, program flexibility, and health care premium reduction.

    From the results of the 103 survey responses, authors found that all 6 of the treatment attributes were “significant determinants” in patients’ preferences. Patients preferred face-to-face treatment over web-based sessions, and would choose physician contact every session, as opposed to only some sessions. Patients also preferred the use of feedback and monitoring technology, flexible exercise times over fixed times, and exercise at a gym rather than at home.

    The scenario patients were most “willing to accept” included individualized, gym-based exercise; 75% video instruction; consulting with a physician in 1 out of 4 sessions; use of feedback and monitoring technology; fixed sessions; and no health care premium reduction. Authors note: “Remarkably, [this scenario] is the only scenario that outweighs the utility of conventional care,” indicating patients’ willingness “to accept both a reduction in consulting frequency and face-to-face consulting when remote feedback and monitoring technology is offered.”

    The least-preferred scenario: home-based care with minimal physician contact and a high degree of self-management required, with patients consistently leaning toward conventional treatment over all home-based scenarios. Authors suggest that this desire for personal contact may be attributed in part to the psychosocial nature of treatment for chronic pain, in which “patient-provider communication plays such an important role” and “empathy and emotional support are considered essential.”

    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.

    Find out how a better understanding of pain can transform practice: join a March 16 live webinar on musculoskeletal pain principles presented by 2016 Maley Lecturer Steven George, PT, PhD.

    NIH: Treatment Using Patients' Own Stem Cells Shows Promise for Knocking MS Into Remission

    Through a process that the National Institutes of Health (NIH) likens to a "resetting" of the immune system, some individuals with multiple sclerosis (MS) are experiencing long-term remission of the disease symptoms with no additional brain lesions. The technique, which depletes a patient's immune system before rebuilding it through transplants of the individual's own stem cells, has proven effective at keeping nearly 70% of participants with MS symptom-free for 5 years—all without the use of any additional medications.

    The treatment, known as high-dose immunosuppressive therapy and autologous hematopoietic cell transplant (HDIT/HCT), was applied to 24 participants with relapsing-remitting MS, the most common form of the disease. The patients ranged in age from 26 to 52 years, and all were experiencing active inflammation, severe relapses, and worsening disability despite taking medications.

    For the HDIT/HCT procedure, researchers first collected participants' blood-forming stem cells, and then subjected them to chemotherapy at high doses. Once participants' immune systems were depleted, the stem cells were reintroduced, which triggered a rebuilding of the immune system. In addition to most participants remaining in remission 5 years after the treatment, some even showed gains in mobility. The trial was sponsored by NIH's National Institute of Allergy and Infectious Diseases (NIAID). Results were published in the February 1 edition of Neurology.

    "These extended findings suggest that one-time treatment with HDIT/HCT may be substantially more effective than long-term treatment with the best available medications for people with a certain type of MS," said NIAID Director Anthony S. Fauci, MD, in an NIH press release. "These encouraging results support the development of a large, randomized trial to directly compare HDIT/HCT to standard of care for this often-debilitating disease."

    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: Cybercycling PE Program Associated With Significant Improvements in Classroom Behavior Among Children With Behavioral Health Disorders

    In brief:

    • 103 K-10 students with multiple behavioral health disorders participated in a 7-week cybercycling program as part of school PE classes
    • Intervention frequency was 2x a week for 30-40 minutes
    • Classroom monitors recorded an average 32%-51% drop in the odds of classroom behavioral problems during the 7-week program
    • On the actual days of cycling, odds of problems dropped by 71%-76%
    • Authors believe that cybercycling (and activities like it) could help enable students with complex BHD to engage in aerobic activities by minimizing transitions, noise, and other factors that can be problematic in this population

    Researchers have known for a while that there's a link between exercise and better behavior among children in school, but it's an approach that can be difficult to implement among the children who might benefit the most—those with multiple behavioral health disorders (BHD). A new study suggests that using technology-driven approaches such as "cybercycling" to encourage more intense aerobic activity may be the key to improved behavior and classroom functioning among children with multiple BHD.

    The study, conducted at a therapeutic day school affiliated with Harvard Medical School, involved 103 students from kindergarten through 10th grade, all of whom had multiple behavioral health diagnoses, including autism, attention-deficit/hyperactivity disorder, anxiety disorders, and mood disorders. Researchers implemented a 7-week cybercycling program—in this case, the "Manville Moves" program that involves stationary bicycles and virtual reality visuals—at a rate of 2 times a week for 30 to 40 minutes as part of the students' physical education (PE) classes. For the remainder of the semester, students participated in the usual PE class. The study was conducted over the course of the 2014-2015 school year, with a different student group participating each semester. Results of the study were published in Pediatrics.

    Authors of the study were particularly interested in finding an exercise intervention that would work for children with multiple BHD, who are less likely to be able to participate in physical activity due to their disorders and tend to have other chronic health conditions. While the regular PE class at the study school was designed specifically for children in this population, the focus is on "games to build socialization and team skills as well as motor skill acquisition," authors write, with only "short bouts" of aerobic exercise. The cybercycling intervention, on the other hand, aimed to build ride times from 10 minutes to 20 minutes over the 7-week course, and monitored heart rates to ensure sustained aerobic exercise.

    The cycling program resulted in significant improvements in behavior, according to trained counselors who monitored instances of poor self-regulation and disciplinary time out of the classroom setting. Overall, raters recorded an average 32%-51% drop in the odds that children would display "clinically disruptive behaviors" during the 7-week cycling program; on the actual days of cycling exercise, those odds dropped by 71%-76%, on average. Ratings were based on the Conners' Abbreviated Teacher Rating Scale (CATRS-10).

    "This study provides compelling evidence that children and adolescents with multiple, heterogeneous BHD in a school setting can successfully engage in and experience behavioral benefits from an aerobic cybercycling PE curriculum," authors write, adding that though the effects seemed to be present even on days when the students didn't cycle, "acute exercise is the primary driver of the intervention effect."

    Researchers believe that the success of the program with this student population may be related to cybercycling's "advantages" over standard PE programming, including fewer disruptive transitions, the ability to avoid peer judgments of performance, and a less "noisy and chaotic" environment. Still, they add, "a standard PE class may confer its own benefits," including motor skill acquisition and socialization.

    Authors acknowledge several limitations to their study, most notably its focus on children with substantial BHD who have been unsuccessful in public school. Further testing is needed, they suggest, to find out if the intervention can be applied more broadly in public school special education programs. Authors also point out that cybercycles are expensive and that "because the key is overcoming aerobic exercise barriers, other modalities should be explored with similar populations."

    The bottom line, researchers write, is that their study reinforces the idea that a population that could most benefit from aerobic exercise can access that exercise, and do so "within existing school programming with short durations and low frequency."

    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.

    Want to Decrease Unnecessary Spinal Surgeries? Get a Multidisciplinary Team to Do Evaluations, Researchers Say

    In brief:

    • Observational cohort study of 137 patients with lumbar spinal pathology; 100 were recommended for lumbar spinal fusion by a surgeon
    • After evaluation by a multidisciplinary team including PTs, 58 of the 100 were recommended for nonoperative treatment
    • Authors believe that collaborative evaluation can lead to better outcomes, decrease inappropriate surgical interventions, and decrease costs for patients with lumbar spine problems

    Multidisciplinary evaluation and direct communication among providers may offer patients with spine problems "more diverse nonoperative treatment options" and result in fewer unnecessary surgeries, leading to lower costs, experts say. In a pilot study e-published ahead of print in Spine (abstract only available for free), a team of providers from diverse fields recommended nonoperative treatment for 58% of patients who previously had been advised by a surgeon to undergo spinal fusion.

    Researchers were hoping to learn what effect multidisciplinary decision making could have on what they termed the "inappropriate overutilization of spine surgery" for people with spinal disorders. They put together a group of physiatrists, anesthesiologists, pain specialists, neurosurgeons, orthopedic spine surgeons, physical therapists, social workers, physician assistants, and nurse practitioners to evaluate patients who had previously been recommended for spinal fusion by a surgeon not involved in the study.

    In weekly group conferences, the clinicians assessed each patient’s level of disability, prior treatment, comorbidities, surgical and anesthesia risks, and potential for positive outcomes, as well as any imaging. Out of 137 patients, 100 had been recommended for spinal fusion. After evaluation, the group advised 58 of those patients to pursue a nonoperative plan of care. While some were advised against surgery due to obesity or smoking, the group identified physical therapy as potentially more beneficial for 22 patients and recommended others for steroid injection or vertebroplasty. "Multidisciplinary evaluation can alter the treatment recommendations" for this population, say authors.

    The multidisciplinary decision making had other positive effects as well. Four patients who had been misdiagnosed with lumbar radiculopathy were referred to joint specialists for degenerative hip arthritis. And 16 of the 58 patients who did undergo surgery had a different type of operation due to consultation with the team. None of the operative patients had complications or readmissions at 90 days. While researchers do not yet know long-term outcomes for the patients who received nonoperative care, they are following the cohort.

    "As clinicians, we bring our own biases into the treatment plan for patients … that drive us towards particular interventions," authors note. In the case of lumbar spinal pathology, they assert, "Isolated surgical decision making may result in suboptimal treatment recommendations." Instead, they urge clinicians to collaborate to "develop the infrastructure necessary to support multidisciplinary approaches to spine care."

    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.

    Patients with TKA Who Receive Outpatient Physical Therapy Soon After Surgery Recover More Quickly Than Patients Who Receive Home Physical Therapy First

    In brief:

    • Retrospective cohort study focused on 109 TKA patients
    • One group (87) received outpatient physical therapy beginning within a week of discharge; a second group (22) received 2-3 weeks of home physical therapy before entering an outpatient physical therapy program
    • While 6MWT and KOOS outcomes were the same for both groups at completion of outpatient physical therapy, the home health group took average of 20 days longer to reach benchmarks
    • Authors believe results point to need for patient education and choice; potential cost savings of immediate outpatient physical therapy

    A new study finds that when it comes to results, patients who undergo total knee arthroplasty (TKA) and engage in home physical therapy before participating in outpatient physical therapy ultimately wind up doing just about as well as patients who proceed directly to physical therapy sessions. The time it takes them to reach those outcomes, however, is another story.

    Writing in a recent issue of Orthopedic Nursing (abstract only available for free), researchers report on the results from an analysis of 109 TKA patients who participated in a hospital's joint replacement program, and who had the option of entering into outpatient physical therapy beginning within a week after surgery (87 individuals, called the OP group) or receiving home health care for 2 to 3 weeks before moving on to outpatient physical therapy (22 individuals, labeled the HH group). Researchers reviewed medical records from 2005 to 2010 to find out if the 2 paths resulted in different outcomes and what those outcomes were after completion of outpatient physical therapy.

    Researchers found that in terms of outcomes as measured by the 6-minute walk test (6MWT) and the Knee Injury Osteoarthritis Outcome Score (KOOS), both groups ultimately achieved similar scores (adjusted for age and other variables). Patients averaged nearly 80% of age and sex-predicted distances on the 6MWT and registered KOOS subscale scores (activities of daily living, pain, symptoms, and quality-of-life) that didn't vary significantly between groups.

    When they looked at the time it took for patients to reach those outcomes, however, the researchers found that patients in the OP group reached postoperative milestones about 20 days sooner, on average, than their HH counterparts. Additionally, both groups averaged about the same number of outpatient physical therapy sessions, "pointing to the fact that home health [physical therapy] did not accelerate recovery (with the possible exception of knee flexion [range of motion])," authors write.

    The outpatient track consisted of 2 to 3 physical therapy sessions per week for 4 to 6 weeks, plus a daily exercise program focused on range of motion, stretching, low-impact cardiovascular conditioning, and lower extremity strengthening and endurance. The HH program was harder to discern through medical records, authors write, but likely included physical therapy 3 times a week for 2 to 3 weeks, "with the ultimate goal of tolerance for outpatient [physical therapy] to complete rehabilitation."

    In the end, authors write, the decision as to whether to pursue immediate outpatient physical therapy or a period of home health physical therapy may depend on individual patient circumstances; still, they assert, "the results of this study provide evidence to the importance of patient education and shared decision-making between patients and the multidisciplinary team."

    "If the patient and the clinician determine that home health is necessary, then no loss of functional gains should be expected," authors write. "However, it may take a longer time period, and perhaps expense, to achieve those gains."

    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.

    From PTJ: Study of 1 Hospital Finds Nearly 16% of Scheduled Physical Therapy Sessions Don't Happen

    In brief:

    • Study focused on a single hospital and reviewed 6,246 scheduled physical therapy sessions
    • Overall, 15.9% of scheduled sessions never occurred
    • Nontreatment was highest on Sundays (33.8%)
    • Authors caution against "quick fixes" such as prohibiting Sunday sessions; assert that PTs need to exercise clinical judgment to schedule when needed

    Researchers who tracked a hospital found that, on average, more than 15%--and as many as 1in 3--hospital physical therapy sessions never actually took place, depending on the reason for hospitalization and the day of the week treatment was scheduled. Authors of the study say that's too many, and if other facilities are facing the same issue, fixing the problem will require hospitals to address their "internal culture and weekend staffing policies" and not just look for quick fixes.

    Researchers examined all scheduled physical therapy sessions in a suburban community hospital to ascertain whether patient characteristics, as well as diagnosis and day-of-week, were associated with care not being provided. In addition, they surveyed the physical therapists (PTs), physical therapist assistants (PTAs), and physical therapy technicians to obtain demographic data and information about their jobs, such as length of employment and number of evaluations performed per week. Results were published in the January issue of Physical Therapy (PTJ), APTA's scientific journal.

    Overall, of the 6,246 scheduled physical therapy sessions for 1,252 patients, 995 (15.9%) scheduled sessions did not result in treatment. Therapists did not document a reason for nontreatment in 38.8% of those instances. Patients with musculoskeletal conditions were slightly more likely to receive treatment, with an 89.17% rate of follow-through. Patients with other conditions received scheduled treatment around 80% of the time. Among all scheduled sessions, only 1.3% of the first scheduled sessions were never accomplished, but that rate rose to nearly 20% for remaining sessions.

    When broken down by day of scheduled treatment, researchers found that some days are better bets for receiving care than others. Tuesdays, for example, were more closely associated with receiving scheduled treatment, with an 87% follow-through rate. Sundays, however, were another story: researchers found that a staggering 33.88% of sessions scheduled for a Sunday never occurred. Because a high percentage of Sunday sessions also were not associated with a particular therapist, authors speculate that the greater percentage of per diem staff on weekends may be a factor in nontreatment.

    Authors acknowledge several limitations to the study, including the fact that data was limited to a single hospital (albeit 1 with a sizable dataset). Also not explored: the possibility that the therapists "spent a considerable amount of time attempting to find and schedule therapy with a patient before success, with multiple efforts to schedule and reschedule being involved."

    In calling for further research into the issue, the authors point to earlier studies that clearly support the benefits to both patients and the hospital system of providing physical therapy during a hospital stay. Those studies make the case that patients who receive physical therapy while in the hospital have reduced length of stay, lower rates of readmission, and fewer prescribed activity restrictions. As a result, health care costs decrease as well.

    But authors caution against looking for a “simple solution,” such as simply not scheduling patients for physical therapy on Sunday, in this hospital’s case. Doing so would limit the PT’s professional judgment regarding the “frequency and intensity of treatment,” they write, noting that weekend physical therapy, as well as early physical therapy for critically ill patients, have been proven to be beneficial to patients.

    The January issue of PTJ marks the publishing debut of APTA's partnership with Oxford University Press. PTJ is now housed on a new website that is responsive across all devices.

    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.

    Pilot Study Indicates Yoga Improves Quality-of-Life for Pediatric Cancer Patients and Their Parents

    With childhood cancer mortality rates falling over the past 4 decades, some researchers say it's time to take a closer look at better ways of supporting the psychosocial and quality-of-life needs of patients and their families during treatment—including making yoga a part of the mix.

    That's the premise of a preliminary feasibility study that looked at parent and patient receptivity to the idea of including yoga as an adjunct to cancer treatment, and tracked changes to quality of life after an 8-week yoga program. Results were published in Rehabilitation Oncology, the science journal of the APTA Oncology Section.

    The research was conducted in 2 parts: first, researchers administered surveys to patients and their parents that aimed to assess willingness and barriers to participate in a yoga program that would take place during treatment visits; in the second phase of the project, patients and their parents participated in an 8-week yoga program, and were asked about quality-of-life issues at baseline and after the program's completion. To qualify for the studies, patients had to be 8-18 years old, possess a cognitive ability of at least an 8-year-old, and be undergoing cancer treatment during the study period. In addition, parents were required to be able to physically participate in yoga with their children. The first phase of the study involved 20 patients and 20 parents or guardians; the second part of the study included 12 patient-parent pairs.

    Researchers found that even though patients and parents recognized potential barriers to participating in yoga—most frequently, concerns about side-effects of cancer treatments, and potential pain and discomfort—just over half were interested in participating in a program, and 80% believed "participating in a program that would help you relax" would be helpful. Researchers used the results to help yoga instructors create interventions that would accommodate side effects such as fatigue and discomfort to help reduce those perceived barriers.

    Volunteer patient-parent dyads were then enrolled in the 8-week yoga intervention, a program held weekly by a certified yoga instructor with special training in providing instruction to the pediatric cancer population. Sessions were designed to last for an hour each; however, patient symptoms prevented sessions from going longer than 30 minutes in 30% of the sessions. Delivery methods varied by patient status, and included bed and chair-based yoga.

    Researchers found that the program resulted in significant changes among patient perceptions of quality-of-life related to emotional and social wellbeing, measured on a 100-point scale. Patients who participated in the program saw an average uptick of 11.5 points on the emotional scale, from 62.5 to 74. Average gains in the social scale jumped by just over 10 points, from 76.1 to 86.5. For parents, the biggest gains were made in the "mental health composite scale" assessment, which revealed an average increase of 8 points, from 39.1 to 47.

    Authors of the study acknowledge that their research is preliminary, and that several limitations—including lack of a control group, small sample size, and relatively low dose of intervention—make it difficult to draw definitive conclusions about effectiveness.

    Researchers also found implementation to be problematic, given their attempts to coordinate the sessions with inpatient or outpatient treatment. "We found that the patients' treatment appointments were somewhat erratic, making scheduling difficult," authors write. "We only had a few specific times available for offering the yoga, and often these times did not fit patients' schedules."

    Still, they believe, it's time for health care to more carefully consider integrating a broad range of interventions, such as yoga, to help patients and parents stay as physically and emotionally healthy as possible during cancer treatment.

    "Given advances in pediatric cancer survival rates, the importance of support for the wide range of treatment-related challenges incurred by children and their families has increased. As a result, integrative medicine has received an increasing amount of attention in hopes of promoting holistic health and wellness for this growing group of survivors," authors write, concluding that "our findings support the notion that yoga for pediatric cancer patients during active treatment is feasible and potentially helpful in improving both patients' and parents' well-being."

    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.