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  • 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.

    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.

    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.

    Revised Pediatric Concussion Guidelines Address Assessment, Return-to-Play, More

    The revised recommendations on pediatric sports-related concussions (SRC) from the American Academy of Pediatrics (AAP) aim to strike a careful balance: while the report emphasizes that "each concussion is unique," it also lays out several broad recommendations on SRC management that touch on assessing recovery, factoring in the circumstances around individual injuries, and understanding the ways state law can impact return-to-play decisions, among other areas.

    The revision—the first in 8 years—comes at a time when SRC reporting is on the rise, with both state legislatures and national media paying increased attention to the effects of repeated mild traumatic brain injury (mTBI) on the human brain. Authors of the AAP report write that while the brighter spotlight is welcome, "underreporting by athletes with SRC remains a large concern," and the general increase in the number of children and adolescents participating in youth sports likely will result in more SRCs, which are currently estimated to happen at the rate of 1.1 million to 1.9 million annually. The report was published inPediatrics.

    In terms of which sports pose the greatest SRC risk, things aren't much different from 2010: boys' tackle football still poses the most threat of SRC, with a rate of 0.54 to 0.95 concussions per 1,000 "athletic exposures" (AEs)—games and practices. Next highest was girls' soccer with a 0.30 to 0.73 AE rate, followed by boys' lacrosse and boys' ice hockey. Authors also point to recent research that indicates SRC rates are even higher among athletes 12 and younger, with an overall contact sport concussion rate that was 2.4 times higher than their 13-and-older counterparts.

    In addition to epidemiology, the report covers signs and symptoms, assessment on the field, imaging, neurocognitive testing, acute management, return-to-play decisions, prolonged symptoms, and prevention. The analysis served as the foundation for 9 conclusions and 6 recommendations.

    The conclusions:

    • SRC is "common" in youth and high school sports, and warrants further research.
    • Each concussion is unique, with "a spectrum of severity types and symptoms.
    • Evidence-based guidelines indicate that "conventional neuroimaging" may be used unnecessarily, as most imaging is normal after an SRC.
    • Providers should be familiar with a range of tools to evaluate the athlete after an SRC.
    • Symptoms of the SRC should resolve within 4 weeks postinjury for most athletes.
    • An initial reduction in physical and cognitive activity after SRC can be beneficial, but prolonged restrictions "can have negative effects on recovery and symptoms."
    • The long-term effects of concussion—both single and multiple events—have not been definitively determined.
    • No medications can treat or prevent SRCs.
    • Ceasing participation in sport because of SRC "is an individualized decision that may benefit from consultation with a physician who has experience in recommendations for retirement after SRC."

    The recommendations:

    • Neurocognitive testing should not be the only tool used to make a return-to-play decision.
    • Providers should assume that an athlete who remains unconscious after a head injury also has suffered a cervical spine injury.
    • If an athlete has prolonged symptoms after an SRC, providers should conduct an evaluation for coexisting problems, and make referrals as appropriate.
    • All athletes with a suspected SRC should be removed from play immediately and not allowed to return "until they have returned to their baseline level of symptoms and functioning and completed a full stepwise return-to-sport progression without a return of concussion symptoms." A return to a full academic workload should always precede a return to play.
    • Complete prevention of concussion may be impossible, but cervical strengthening, better equipment design, and sports rule changes may help.
    • Providers need to have a thorough understanding of their states' return-to-play laws and regulations.

    Physical therapists have a critical role in concussion prevention and management. APTA offers multiple resources on concussion, which include a Traumatic Brain Injury webpage and a clinical summary on concussion available for free to members on PTNow. The association also offers a patient-focused Physical Therapist's Guide to Concussion on APTA's MoveForwardPT.com consumer website.

    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.

    PTJ: Physical Therapy Outcomes Registry as a Potential Leader in 'Systems Science'

    "What are the risk-adjusted outcomes for individuals with a specific classification/movement diagnosis?" "Are patient outcomes better if the treatment provided matches the patient's classification/movement diagnosis?"

    Those are the kinds of questions that can be answered through systems science, which emphasizes collecting and analyzing clinical data using a common language, say authors of a "Point of View" article in the November issue of PTJ(Physical Therapy). They believe it's a scientific approach that could make APTA's Physical Therapy Outcomes Registry (Registry) a crucial tool in reducing unwarranted variation in practice.

    In the article, Karen Chesbrough, MPH, director of the Physical Therapy Outcomes Registry; Matt Elrod, PT, DPT, MEd, APTA practice department lead specialist; and James J. Irrgang, PT, ATC, PhD, FAPTA, chair of the Registry's Scientific Advisory Panel, explain the how the 4 pillars of systems science—measurement, innovation, replication, and a continuous cycle of quality improvement—continue to inform the Registry's development and refinement.

    But, authors say, a team approach involving all stakeholders is crucial to improving quality of care, outcomes, documentation, and payment, as well as research. This involves adopting a common data-sharing language across electronic health records (EHRs) and "standardizing a core set of data elements." This electronically migrated EHR data, they write, "would provide opportunities for health services research that is more robust and rich than what is currently possible with existing databases."

    Authors believe that the potential for the physical therapy profession to amass sufficient data to create a robust system is strong. By way of comparison, they describe how the American Academy of Ophthalmology's Intelligent Research in Sight Clinical Data (IRIS) registry accumulated more than 148 million patient visits from just over 13,000 ophthalmologists in just 3 years, making it the country's largest specialty society registry. "Imagine the possibilities of health systems science in rehabilitation with that same number of physical therapists, which would be less than 15% of current APTA membership, contributing data to the Physical Therapy Outcomes Registry," they write.

    While they say that it's "still too early to draw any generalizable conclusions across the profession," authors describe how data from the Registry already being are used to identify gaps in the documentation—gaps that can make a difference in patient outcomes and payment. In addition, they write, "practices and organizations are also starting to portray their workforce through Registry data and to use that information for promotional purposes."

    More teamwork and implementation of systems science principles will help the Registry grow stronger in the future, but even now, authors write, "data representing physical therapist practice, with the assistance of informaticians, has become actionable in practice."

    Study: Number of Pills Prescribed Is a Stronger Predictor of Opioid Consumption Than Pain Severity Postsurgery

    According to psychologists, humans have a tendency to make decisions based on an overreliance on a single value, to such a degree that other values are minimized or ignored entirely. It's called the "anchoring and adjustment heuristic," and it's not uncommon: we tend to eat more food than normal (the adjustment) if we're presented with larger quantities of it (the anchor); we tend to think we're getting a good deal on something we're shopping for (the adjustment) if the price is lower than the one we've fixed in our minds, which is often the first price we saw (the anchor).

    Now researchers are wondering if this behavior phenomenon plays an even more insidious role when it comes to opioid use—namely, a tendency for patients to take more opioids if they're prescribed larger quantities of pills. That's what authors of a new study discovered after conducting patient surveys that revealed postsurgical opioid consumption rose by an additional 5 pills for every 10 prescribed. In fact, they claim, the relationship between opioids consumed and opioid quantities prescribed is stronger than the link between the level of pain experienced by patients postsurgery and their opioid consumption.

    The results, published in JAMA Surgery (abstract only available for free), are based on surveys of 2,392 patients in Michigan who were prescribed opioids after undergoing 1 of 12 targeted surgeries including cholecystectomy, appendectomy, femoral hernia repair, incisional hernia repair, colectomy (laparoscopic and open), ileostomy and colostomy takedown, small-bowel resection, thyroidectomy, and hysterectomy (vaginal and abdominal). Researchers conducted phone interviews with patients during a window between 30 days and 120 days postsurgery, asking them how many opioid pills they had consumed and gathering self-reports on pain using a 4-item scale. They then analyzed patients' answers in relation to various demographic variables, surgeries received, and oral morphine equivalents (OMEs) prescribed.

    Here's what they found:

    • The strongest predictor of opioid consumption was the amount of opioids prescribed to the patient. Researchers estimate that for each additional OME prescribed, patients used an additional 0.53 OMEs. Put in terms of pill equivalents, that's equal to using 5.3 more pills for every 10 additional pills prescribed. "A patient prescribed 100 pills could therefore be expected to use roughly 40 more pills than a patient prescribed 20 pills," authors write.
    • While pain severity also was linked to increased consumption, the relationship wasn't a strong as the tie to quantity of pills prescribed: compared with patients reporting no pain postsurgery, those reporting moderate pain used an additional 9 pills, and those reporting severe pain reported using an additional 16 pills, on average.
    • Tobacco use and obesity were related to increased opioid consumption; outpatient surgery was associated with decreased consumption, as was older age.
    • Overall, 24% of patients reported taking no opioids after surgery. The highest rate of nonuse was among patients who underwent thyroidectomy (48% nonuse rate) and lowest was for the group receiving abdominal hysterectomy (20% nonuse rate).
    • Consumption of the entire opioid prescription was reported by 22% of patients interviewed.
    • In all surgeries studied, the quantity of opioids prescribed was "significantly greater" than the quantity of opioids consumed, with an average of 30 5/325 mg of hydrocodone/acetaminophen pill-equivalents prescribed compared with an average of 9 pills taken. Consumption ranged from 3% of opioids prescribed following thyroidectomy to 67% of opioids prescribed after ileostomy/colostomy takedown.
    • Mean age of the respondents was 55, with 57% women; 77% underwent elective surgery as opposed to urgent or emergent surgery. Three surgical procedures made up more than half of the total surgeries analyzed: hernia repair (28%), cholecystectomy (25%), and appendectomy (9%).

    Researchers acknowledge that there may be a link between postsurgical consumption and preoperative opioid use—data they weren't able to gather—but they believe the key to their findings my lie with the anchoring and adjustment heuristic.

    "In this case, a larger amount of opioids may serve as a mental anchor by which patients estimate their analgesic needs," authors write. "The amount of opioids a surgeon prescribes to a patient may influence that patient's opioid consumption after surgery."

    Also concerning, according to the authors, is that the complete opioid prescription is seldom consumed—at least as part of recovery postsurgery. What's worse, "most patient who received opioids after surgery do not dispose of leftover medication," they write, adding that "it is well established that most individuals who misuse prescription opioids obtain the medication from a friend or relative as opposed to 'doctor shopping' or illicit sources."

    While the researchers think their findings may help in better customizing prescriptions based on individual patient variables, they believe there's an even more obvious first step that needs to be taken immediately: stop prescribing so many opioids, period.

    "Overprescribing occurred for all procedures included in this study, from relatively minor to major operations," authors write. "These data highlight the importance of significantly changing the way opioids are prescribed following surgery to decrease excess medication as a source for diversion and abuse."

    findings reported in the JAMA article echo the conclusions of a recently updated report from the Plan Against Pain, which asserts a link between opioid prescriptions postsurgery and later opioid dependence. APTA's #ChoosePT opioid awareness campaign is a selected partner of the plan.

    In addition to its flagship #ChoosePT opioid awareness campaign, APTA also hosted a Facebook Live panel discussion and satellite media tour to highlight the effectiveness of nonopioid approaches to pain management. In addition, APTA produced a white paper on reducing opioid use and contributed to the National Quality Partners Playbook on Opioid Stewardship.

    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.

    European Psychiatrists Recommend Physical Activity in the Treatment of Severe Mental Illness

    Could the effect of physical activity (PA) on the brain extend beyond a general sense of well-being? The European Psychiatric Association (EPA) thinks so and has issued guidance that recommends supervised PA as potentially effective treatment for individuals with severe mental illnesses (SMIs) such as schizophrenia and major depression. The recommendations are supported by the International Organization of Physical Therapists in Mental Health.

    The recommendations, appearing in European Psychiatry (abstract only available for free), are based on a review of 20 meta-analyses and systematic reviews gathered through January 2018. Researchers began with a pool of more than 2,000 studies but narrowed their review to studies of randomized controlled trials that specifically addressed exercise interventions for individuals with schizophrenia, major depressive disorder (MDD), and bipolar disorder (BP).

    Authors of the recently released guidelines were interested in the role of PA among the population of individuals with SMI not only in relation to its ability to lessen symptoms, but also as an intervention that could extend lifespans in that population. According to the researchers, individuals with SMI face an increased risk of early mortality by as much as 10 to 20 years, with physical disorders accounting for as much as 70% of those early deaths.

    The type of PA analyzed was focused on aerobic exercise, high-intensity exercise, resistance exercise, and mixes of aerobic and high-intensity exercise. Researchers excluded mind-body PA such as yoga and tai-chi, "since these activities are presumed to exert beneficial effects on mental health through additional factors distinct from the [PA] itself."

    In the end, authors found good evidence to support PA as a treatment for both schizophrenia and MDD, particularly when supervised by an exercise professional such as a physical therapist. For MDD, authors recommend 45- to 60-minute sessions of supervised aerobic training or aerobic and resistance training at moderate intensity 2-3 times per week. Research on optimal PA frequency, duration, and intensity for individuals with schizophrenia was harder to find, but authors make a general recommendation for 150 minutes per week of aerobic exercise to improve symptoms, cognition, and quality of life. Authors were unable to find sufficient research to reach a conclusion on the effects of PA among individuals with BP.

    Additionally, the researchers issued a recommendation, based on "some evidence," that PA should be used to improve the physical health of individuals with SMI—a recommendation that was limited by what authors describe as the "paucity of studies that have targeted this important topic." The set of guidelines also includes a recommendation, "based on expert opinion," that individuals with SMI should be routinely screened for PA habits in both primary and secondary care.

    Authors also include a set of 6 recommendations to address what they believe are the current gaps in research around PA and SMI. Recommended areas for research are investigation into the effects of PA in the early stages of SMI, the development of "pragmatic, scalable methods" for PA in the SMI population, establishment of optimal dose-response relationship between PA and SMI, exploration of interventions to reduce sedentary behaviors, identification of the underlying neurobiological mechanisms at work, and an analysis of the long-term cost-effectiveness of PA as a treatment for SMI.

    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.

    Survey Finds 'Considerable Variation' in Postsurgery ACL Rehab

    Authors of a new study say that while guidelines exist for rehabilitation after anterior cruciate ligament (ACL) reconstruction, there remains "a large degree of variation in rehabilitation progression" among physical therapists (PTs), particularly when it comes to timing of the progression, strength assessment, and use of patient-reported outcome measures

    Those conclusions, published in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free) were based on results of an online survey of 1, 074 members of APTA’s Academy of Orthopaedic Physical Therapy, American Academy of Sports Physical Therapy, and Private Practice Section. Authors believe that this is the first time PTs' private practice patterns in this area have been studied.

    As for the respondent pool, the majority of PTs treated patients in a private practice or hospital-based outpatient facility. Just over half (52.5%) held American Board of Physical Therapy Specialties certifications in either orthopaedic or sports physical therapy, and 92.5% were APTA members. Authors of the study also classified respondents by the volume of post anterior cruciate ligament repair (ACLR) patients they treated annually, with 32.3% falling into the "low volume" category of 1 to 5 per year, 28.8% grouped into a "medium volume" category of 6 to 10 patients per year, and 37.9% categorized as "high volume," with 11 or more post-ACLR patients per year. Researchers also tracked respondents by years in practice.

    Here's what they found:

    • Overall 56% of respondents reported the duration of supervised physical therapy at 5 or fewer months.
    • Regarding the length of time PTs would wait before recommending a patient initiate sports activity, 58% said 3-4 months for jogging, 50% said 4-5 months for modified sports activity, and 40% said 9-12 months for unrestricted sports participation. Given that most respondents reported treatment periods of 5 months or less, the number of PTs who don't recommend unrestricted participation until after 9 months postsurgery "imply that there may be a long gap between the discontinuation of supervised rehabilitation and return to activity," authors write.
    • Over 80% of respondents used strength and functional measures to assess patients during rehabilitation. Most PTs used manual muscle testing (MMT) to assess strength before progressing patients to jogging (80.6%) or modified sports (74.3%). Of those, 56% relied solely on MMT as a mode of assessment—a potential concern, according to authors, because MMT "may lack the sensitivity to detect residual strength deficits that may be present at this phase of recovery, leading to poorly informed decision making." The tendency to rely solely on MMT was more prevalent among low-volume providers and uncertified PTs.
    • Before progressing patients to jogging or modified sports, most respondents assessed knee strength, function and balance, knee range of motion, and degree of knee effusion. However, there was significant variation among PTs regarding limb strength criteria for functional advancement. Authors speculate this may be due to a lack of clear evidence.
    • Only 45.3% of respondents reported using patient-reported outcome measures to quantify functional deficits. The most common measure was the Lower Extremity Functional Scale, used by 39.2% of respondents, with fewer than 10% of respondents reporting use of measures related to fear or athletic confidence. Authors describe the lower usage rates of patient-reported outcomes as "regrettable," writing that "it has become clear that physical recovery alone is not sufficient to ensure successful return to sports, and many authors have emphasized the importance of assess¬ing psychological readiness and fear of reinjury." The lack of attention to patient-reported fear and readiness "[neglects] the holistic framework highlighted within the biopsychosocial approach to patient management," they add.

    According to authors, across the survey areas reviewed, 1 consistent element emerged: PTs who treated a large volume of post-ACLR patients, more recent graduates, and those with specialty certifications were more likely to report practice patterns "that were more consistent with current best evidence."

    Authors caution that the results should be understood within the limitations of the study itself. Among those limitations: the survey instrument was not validated before dissemination, there were no questions that addressed the possible influence of payment systems on treatment patterns, and the respondents were overwhelmingly APTA members—a fact that authors believe may hide even greater variability among the entire PT population.

    Overall, however, authors call the results "surprising," and note that "one of the most noticeable findings was the degree of variability in clinical testing and decision making, particularly within the later phases of rehabilitation, during the transition back to sports activity." The variation, they write, points to the possibility that at least when it comes to on-the-ground PT practice, "there is no consensus about the ideal postoperative rehabilitation program."

    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.

    JAMA Study Supports Physical Therapy as First-Line Approach to Meniscal Tears

    A new study has turned the debate over physical therapy-versus-surgery for meniscal tears on its head—and even from that angle, the results again point to the validity of physical therapy as first-line option for treatment.

    In an article published in JAMA (abstract only available for free), researchers from the Netherlands analyzed outcomes for adults aged 45-70 with nonobstructive meniscal tears, not by trying to find out whether physical therapy is better than surgery but by evaluating whether physical therapy is "noninferior" to surgery. The logic behind the approach is fairly simple: given that arthroscopic partial meniscectomy (APM) is 1 of the most frequently performed orthopedic surgeries, given that it comes with a hefty price tag ($4 billion annually in 2006), and given that it's, well, surgery, it would make sense that physical therapy would simply need to be no worse than surgery to qualify for consideration as a first-line treatment.

    The study assigned 321 participants with nonobstructive meniscal tears to 1 of 2 groups: one that underwent APM, and another that participated in 16 30-minute sessions of physical therapy over 8 weeks that included "cardiovascular, coordination/balance, and closed kinetic chain strength exercises." Individuals who experienced locking of the knee, instability caused by an anterior or posterior cruciate ligament rupture, or severe osteoarthritis were not included in the study. Additionally, patients who had received prior knee surgery or whose BMI was higher than 35 were excluded.

    To gauge improvement, researchers monitored outcomes from the International Knee Documentation Committee Subjective Knee Form (IKDC) a self-assessment measure that uses a 0-100 scale to rate knee function, symptoms, and ability to engage in physical activities. Assessments were taken at baseline, 3 months, 6 months, 12 months, and 24 months after randomization. As for the participants, both groups were similar, with a mean age of 58, 56% women, and comparable baseline knee function and pain during weight-bearing. Here's what researchers found:

    • Overall, the physical therapy group IKDC scores demonstrated noninferiority—defined by authors as average IKDC scores no more than 8 points apart—compared with the APM group. During the 24-month study period, knee function improved from 44.8 points to 71.5 points for the APM group, and from 46.5 points to 67.7 points for the physical therapy group.
    • While the score differences between physical therapy and APM showed physical therapy as noninferior at 3 months and 6 months, the gap widened at 12 months and 24 months. But those differences weren't enough to move physical therapy from an overall "noninferior" rating.
    • Participants who were obese tended to report higher improvement scores related to pain during weight-bearing than did their physical therapy counterparts. Other factors—location of the tear, education level of the participant, osteoarthritis severity, mechanical complaints, sex, and age—did not seem to significantly affect treatment outcomes.

    "The results of this trial support the recommendations from the current guidelines that [physical therapy] may be considered an appropriate alternative to APMs as first-line therapy for patients with meniscal tears," authors write, adding that their study echoes the consensus that "APM should not be the first treatment in middle-aged and older patients with meniscal tears."

    Authors of an accompanying editorial cast the results as yet another affirmation of physical therapy's effectiveness as a treatment for meniscal tears but wonder why "the orthopedic community [has been] slow to reduce APM."

    The editorial authors speculate on several possible explanations, including "community norms" around the expected treatment, surgeons simply doing what they've always done, and the power of a volume-based health care environment that incentivizes more procedures. Change may only come, they write, when payers take a more informed approach to what is and isn't authorized—but even that change may be slow to happen until everyone can agree on treatment guidelines.

    "To change clinical practice, it may be necessary to establish a consortium of all groups involved in the management of this knee condition—orthopedic surgeons, physiatrists, physical therapists, professional organizations, and insurance companies—to develop evidence-based treatment guidelines that each group can support," editorial authors write. "The guidelines should be focused on the best interests of the patients, rather than the clinicians, therapists, and other groups or entities who may gain from the different treatments."

    [Editor's note: check out APTA's PTNow online resource for a clinical practice guideline on meniscal and articular cartilage lesions, updated earlier this year.]

    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.

    Physical Activity May Decrease Mortality Risk in Frail Older Adults, Say Researchers

    While previous research has found that physical exercise decreases fall risk and improves mobility, researchers at the Universidad Autónoma de Madrid (UAM) in Spain wondered whether physical activity could reduce frailty-associated mortality risk. In their study, published in the Journal of the American Geriatrics Society, authors found that physical activity decreased mortality rates for healthy, prefrail, and frail adults over age 60.

    Authors used data from a nationally representative sample of 3,896 community-dwelling individuals to explore any “separate and joint associations between physical activity and frailty” and all-cause and cardiovascular disease (CVD) mortality rates.

    At baseline, in 2000–2001, researchers interviewed participants at home about their “leisure-time” physical activity: inactive, occasional, several times a month, or several times a week. They administered both the Fatigue, Resistance, Ambulation, Illness, and weight Loss (FRAIL) scale and 3 items from the 36-item Short-Form Health Survey (SF-36) to measure frailty, fatigue, resistance, ambulation, and weight loss. Participants also were asked whether they had been diagnosed with pneumonia, asthma or chronic bronchitis, hypertension, coronary heart disease, stroke, osteoarthritis or rheumatism, diabetes mellitus, depression under drug treatment, hip fracture, Parkinson disease, or cancer.

    Based on their answers, participants were categorized as “robust,” “prefrail,” or “more frail.”

    In 2014, authors determined that 1,801 total deaths had occurred, including 672 from cardiovascular disease.

    After adjusting for sex, age, education, alcohol use, smoking, BMI, waist circumference, and mental status, researchers found:

    • Prefrail individuals were 26% more likely as robust individuals to die of any cause, with frail individuals more than twice as likely to die of any cause compared with robust individuals.
    • Prefrail individuals were 40% more likely and frail individuals 2.32 times as likely as robust participants to die of CVD.
    • Fatigue, low resistance, limitations in ambulation, and weight loss were significantly correlated with higher all-cause and CVD mortality rates.
    • Being physically active decreased all-cause mortality by 18% in robust, 28% in prefrail, and 39% in frail individuals.
    • Participants who were frail and inactive were 2.45 as likely as robust, physically active individuals to die of any cause.
    • Risk of all-cause and CVD mortality in frail, physically active individuals was similar to that of prefrail, inactive participants.
    • Prefrail, active individuals had all-cause and CVD mortality similar to robust, inactive participants.

    This study, authors write, is the first to examine the effects of physical activity on mortality risk in frail and prefrail older adults. Authors speculate that physical activity contributes to longevity by helping to reduce chronic disease and falls and increase balance, strength, agility, and gait speed. This, they conclude, highlights the importance of future research on “the effectiveness of mobility programs to reduce mortality in frail older adults.”

    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.