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  • 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.

    Foundation Announces 2017 Scholarship, Grant Opportunities

    The Foundation for Physical Therapy (Foundation) now is accepting applications for the 2017 Florence P. Kendall Doctoral Scholarships and the 2017 Research Grants. The grant opportunities include 2 new offerings: one that focuses on the development of new interventions and another, made possible by APTA, that targets research addressing cost-effectiveness and patient safety.

    The Kendall Post-Professional Doctoral Scholarships assist physical therapists and physical therapist assistants with outstanding potential who are in their first year of postprofessional doctoral degree studies. The $5,000 awards are given to meet tuition expenses or academic fees associated with a doctoral program. Application deadline is August 3, 2017, at noon ET.

    Grant opportunities include:

    • Magistro Family Foundation Research Grant: $80,000 for a research project investigating physical therapist interventions. A letter of intent is required; applicants will be invited to submit full applications based on content. Letter of intent is due June 1, 2017, at noon ET; full application is due August 3, 2017, at noon.
    • Foundation Research Grant: $40,000 for an investigator-initiated research project by an emerging investigator. Full application due August 3, 2017, at noon ET.
    • Snyder Research Grant (new for 2017): $40,000 available for clinical research projects that investigate services delivered by physical therapists, and the development of new interventions that offer reasonable assurance that they will be clinically relevant and therapeutically effective. Full application is due August 3, 2017, at noon ET.
    • Health Services Research Grant (new for 2017): a single $50,000 grant awarded to support research that examines how patients obtain physical therapy-related health care, how much that care costs, and outcomes, with an emphasis on the most-effective ways to organize, manage, finance, and deliver high-quality physical therapy-related care while potentially reducing medical errors and improving safety for patients. Full application is due August 3, 2017, at noon ET.

    Questions? Email the Foundation, or call 800/875-1378.

    Note: Eligibility guidelines for several of the grants have changed from previous years (and in some instances, expanded), so please review the criteria. Before starting your funding application, be sure to carefully read all instructions and funding mechanism deadlines. Also, it's a good idea to start the submission process early to allow for potential questions to be answered.

    JAMA: Spinal Manipulation Can Improve Acute LBP

    In brief:

    • Systematic review and meta-analysis studied 26 randomized clinical trials (1,711 individuals) involving the use of spinal manipulative therapy (SMT) for acute low back pain experienced for up to 6 weeks
    • Researchers found moderate but statistically significant decreases in pain and increases in function within 6 weeks after the intervention among individuals treated with SMT
    • Pain decrease was roughly equivalent to pain reduction associated with use of NSAIDs
    • Function improvement was more variable—1- to 2.5-point improvement on a 24-point scale
    • Lack of detail on SMT interventions used in the study, high heterogeneity of results, lack of large numbers of SMT studies make it difficult to identify what aspect of SMT is most strongly associated with improvements

    In a systematic review of 26 randomized clinical trials involving 1,711 individuals with acute low back pain (LBP), researchers have concluded that spinal manipulative therapy (SMT) produces moderate decreases in pain and increases in function for this group. Authors note that variability in individual study results—and the relatively small volume of SMT research available—make it difficult to pinpoint exactly what it is about SMT that makes it useful for the condition; still, the findings represent a positive endorsement of an intervention used by many physical therapists (PTs).

    The study, published in the Journal of the American Medical Association (abstract only available for free), reviewed studies of the use of SMT on adults with acute LBP lasting for 6 weeks or fewer, and that reported outcomes within 6 weeks of treatment. The SMT approaches varied between thrust and nonthrust techniques, and those that were used alone or in conjunction with a package of therapies. The interventions were administered by a range of clinicians, with 13 studies involving PTs, 7 studies involving chiropractors, 5 studies involving medical doctors, and 3 studies involving osteopathic physicians. Of the 26 studies, 4 compared SMT with a sham manipulative intervention.

    Researchers found that studies pointed to what they termed a "modest" yet statistically significant drop in pain among participants who received SMT—about a 10-point drop on a 100-point pain scale, a decrease they described as roughly equivalent to improvements associated with nonsteroidal anti-inflammatory drugs (NSAIDs). When it came to function, authors concluded that SMT resulted in an improvement of between 1 and 2.5 points on the 24-point scale used in the Roland-Morris Low Back Pain and Disability Questionnaire (RMDQ).

    Authors noted several limitations to their review. First, of the studies included, more provided low-quality evidence that high-quality evidence (though better results for SMT were associated with the high-quality studies). Second, the studies tended to be foggy on the details of the SMT intervention, making it impossible to make precise conclusions related to application in practice. Third, researchers noted a high degree of heterogeneity in the results that couldn't be explained—partly because there haven't been enough studies like the ones reviewed. And fourth, no real consensus has been reached on what constitutes a minimum clinically important difference when it comes to outcome measures.

    Nevertheless, says Bill Boissonnault, PT, DHSc, FAPTA, executive vice president of professional affairs at APTA, the study adds important support for clinicians who use SMT in their practices.

    "The fact that the review had difficulty isolating 1 aspect of SMT that was most strongly tied to positive outcomes is consistent with something PTs have known about SMT for a long time," Boissonnault said. "SMT is an intervention whose benefits may arise from several areas—the actual manipulation, of course, but also the therapeutic elements of 'hands-on' work and the ways SMT is related to sense of trust between the patient and the PT."

    Boissonnault thinks that the study has an added upside. "The facts that so many studies involved physical therapists providing the SMT care, and that PTs authored several of the cited studies illustrate the important role PTs have had related to the evolution of SMT as an intervention," he said.

    In an editorial accompanying the study, author Richard Deyo, MD, MPH, describes the findings as "generally consistent" with recent clinical guidelines from the American College of Physicians, which shifted its recommendations to nonpharmacologic approaches as first-line treatment for acute, subacute, and chronic LBP.

    "The guidelines concluded that most patients with acute [LBP] improve with time, regardless of treatment," Deyo writes. "Thus, therapy is often directed simply at symptom relief while natural healing occurs. None of the trials in the study … suggested that SMT was less effective than conventional 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.

    Researchers Report Another Success in Using Electrical Stimulation to Restore Voluntary Movement in a Patient With Paralysis

    In brief:

    • Researchers replicated a study from 2014 that used electrical stimulation to enable patients with spinal cord injury and paralysis to make voluntary leg motions
    • Current study focused on a patient with clinically motor-complete spinal cord injury who had sustained the injury 3 years prior to the study
    • Before implanting the epidural electrical stimulation device, the patient underwent 22 weeks of motor training sessions with a physical therapist
    • After device implantation (and postrecovery) the patient achieved success after 2 weeks, including the ability to stand independently and make "steplike" motions while standing

    Researchers from the Mayo Clinic announced that they have successfully replicated an earlier study that used spinal cord electrical stimulation to help an individual intentionally move his paralyzed legs. The latest success, reported in Mayo Clinic Proceedings, was achieved in less than 2 weeks after beginning the stimulation program, and included 22 weeks of extensive physical therapy beforehand. Authors of the study include Meegan Van Straaten, PT, and Megan Gill, DPT.

    The initial goal of the research was to replicate a study published in 2014 that succeeded in using epidural electrical stimulation (EES) to enable 4 individuals with varying degrees of paralysis to voluntarily move their legs. However, authors of the latest project write that they wanted to go even further and find out if EES could enable voluntary control over "rhythmic, steplike activities," and could achieve that goal in a relative short time. The answer? Yes.

    The study subject was a 26-year-old man who had sustained a traumatic spinal cord injury at the 6th thoracic vertebrae 3 years earlier. While he was diagnosed with sensory and motor complete (as defined by the American Spinal Injury Association impairment scale) SCI prior to the study, during the motor training phase of the project researchers identified a portion of neural tissue that remained intact across the injured site, a condition they termed "discomplete" SCI. Even so, the patient was unable to experience sensation and could not voluntarily move his legs prior to the EES program..

    The EES device itself was surgically implanted in the patient's abdomen and connected to a 16-contact electrode array on the epidural surface of the spinal cord just below the injury site. The patient underwent 3 weeks of postsurgical recovery before the EES tests and training began.

    Before that phase of the study, however, the patient was engaged in motor training sessions performed by a physical therapist (PT) at a rate of 3 90-minute sessions a week for 22 weeks. The sessions were designed to prepare his muscles for the movements he would attempt during the EES phase. They consisted of lower extremity stretching (15 minutes), locomotor training on a treadmill with body support and assistance at the legs and pelvis (45 minutes), and balance and strengthening exercises while sitting and standing (30 minutes).

    Once motor training and surgery recovery were complete, researchers began working with the patient to achieve volitional movement. After 8 sessions of 5-7 hours each, conducted over 2 weeks, the patient was able to move his legs while lying on his side, make "steplike" motions while lying on his side and while standing with support, and engage in full weight-bearing independent standing using his arms for support on bars. "For the first time, all of these functions, which were absent before EES, were enabled in the presence of the first 2 weeks … in the same participant," authors write.

    "The results of this case report, combined with previous reports … suggest that subfunctional neural connections are likely present in some cases of clinically motor complete … SCI, and these neural connections can be identified and used for enabling volitional control of motor function via EES," authors write, adding that combined with earlier studies, results "provide further evidence that spinal cord neuromodulation strategies combined with intense motor rehabilitation can facilitate functional recovery even when initiated years after the occurrence of a motor complete spinal injury."

    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.

    2-Year Study: Informal Exercise Could Play a Role in Slowing QoL, Mobility Losses Associated with PD

    In brief:

    • Researchers tracked individuals with PD over a 2-year period to look for correlation between self-reported informal exercise hours per week, and changes to health-related quality-of-life and TUG test scores.
    • Participants who reported at least 2.5 hours of exercise a week showed slower losses in HRQL and TUG than participants who reported no weekly exercise.
    • On average, for every 30 minutes of weekly exercise, annual HRQL rates slowed by 0.16, TUG score losses slowed by 0.04 seconds.
    • Losses were slowed at an even higher rate among participants with advanced PD who exercised 2.5 hours per week or more.
    • Authors say findings point to the need for providers to track and facilitate informal exercise patterns of PD patients, particularly for patients with more advanced PD.

    Plenty of research supports the idea that formal, supervised exercise interventions can slow and even improve mobility and health-related quality-of-life (HRQL) among individuals with Parkinson disease (PD), but a new study asserts that informal home-based exercise can also produce positive effects that are long-lasting, especially when individuals get in at least 2.5 hours a week—and particularly for those with more advanced stages of the disease.

    The study, published in the March 28 issue of the Journal of Parkinson's Disease (abstract only available for free), analyzed data from 3,408 individuals participating in the National Parkinson Foundation Quality Improvement Initiative (NPF-QII), a 3-country program that tracks functional mobility, HRQL, and lifestyle data among individuals with PD through a series of annual visits. Researchers looked at data spanning a 2-year period, hoping to see if there was any correlation between participants who reported at least 2.5 hours of exercise weekly and scores on HRQL and mobility measures over time. HQRL was measured by way of the Parkinson Disease Questionnaire; mobility was measured through the timed up-and-go test (TUG).

    A correlation emerged. While participants who reported at least 2.5 hours/week of exercise still recorded losses in HRQL and mobility over the 2-year study period, those losses were smaller than those recorded by participants who reported no exercise. For the nonexercise group, HRQL worsened by an average of 1.37 points over 2 years, and by 0.47 seconds in the TUG test; among those who exercised, researchers found that for every 30 minutes of activity, annual losses slowed by 0.16 on the HQRL and by 0.04 seconds on the TUG.

    Positive effects in HRQL were even more significant among participants with advanced PD who exercised at least 2.5 hours/week. On average, that group slowed losses to 0.41 over 2 years, compared with exercisers with mild PD, who showed a rate that was 0.14 points slower than the nonexercise group. Functional mobility improvements were the same for all PD stages.

    Researchers even found improvements among participants who began exercising after their first visit; however, they were unable to see significant change among participants who waited until after their second visit, about 1 year later, to begin exercise. Authors speculate that the reason improvement wasn't noted with the later adopters is that "informal, independent exercise habits may require a longer time to accrue than short-term, supervised, research-based exercise participation."

    Authors of the study claim that this is the first time researchers have looked at the effects of self-reported informal home (as opposed to supervised and/or clinic-based) exercise over an extended period of time.

    The current study has several limitations, according to the authors: participants in the study represented only 42% of the total NPF-QII patient population and tended to be younger and more likely to be in the early stages of PD; the data do not include type or intensity of exercise performed and were self-reported; and the findings cannot be assumed to establish any causal relationship between exercise and improvements in HRQL and mobility.

    Still, they assert, the findings do shed light on the need for clinicians to "encourage, facilitate, and monitor long-term exercise participation" among their patients with PD, and particularly among those in more advanced stages.

    "While the incremental difference was small this finding has significant clinical and research implications for the development of strategies to make exercise and physical activity more accessible to people with more severe disability," authors write. "Novel methods to encourage physical activity and exercise in people with advanced PD … could provide a great benefit to the PD community."

    APTA offers several resources on the role physical therapy can play in the treatment of PD, including MoveForwardPT.com's PT's Guide to Parkinson Disease designed for sharing with patients, and evidence-based practice research that can be accessed through PTNow. The association has also produced a 4-module education series in partnership with the Parkinson Disease Foundation (module 1, module 2, module 3, module 4).

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

    CDC: TBI Due to Falls Climbing at a Disproportionate Rate Among Older Adults

    In brief:

    • CDC analysis of ED visits, hospitalizations, and deaths related to TBI, 2007–2013 reveals positive and negative trends.
    • Overall rate of visits, hospitalizations, and deaths rose from 1.9 million to 2.7 million; death rates attributable to TBI from motor vehicle accidents have dropped.
    • Most of the increase was due to ED visits; hospitalizations remained unchanged; deaths rose slightly.
    • Researchers noted significant and disproportionate increases in ED visits, hospitalizations, and deaths from TBIs attributable to falls, particularly among adults 75 and older—even while other age groups and categories were decreasing.
    • Authors cite need for more widespread falls-prevention efforts.

    According to the US Centers of Disease Control and Prevention (CDC), better public awareness of the symptoms of and the need to treat traumatic brain injury (TBI) may partly explain why the rates of emergency department (ED) visits rose between 2007 and 2013, but that understanding doesn't account for what researchers describe as a "substantial" jump in TBI-related ED visits, hospitalizations, and deaths among adults over 75. For that older population, falls-related TBIs are growing at a disproportionate rate, even adjusting for age, and point to a need for stepped-up falls-prevention efforts.

    The CDC report issued on March 17 uses Healthcare Cost and Utilization Project databases to analyze TBI-related ED visits, hospitalizations, and deaths from 2003 to 2013, and it contains a mixture of good and bad news. Among the bright spots: the age-adjusted rate of TBI-related deaths attributed to motor vehicle accidents dropped from 5 per 100,000 population to 3.4 per 100,000 between 2007 and 2013, with the overall number of hospitalizations for TBI-related injuries related to car accidents also dropping from 23.5 per 100,000 hospitalizations to 18.8 per 100,000 during the same time period. Less encouraging: TBI-related deaths attributable to falls have increased among adults 75 and older, from 39.7 per 100,000 population to 50.3 per 100,000. Similarly, TBI-related hospitalizations attributable to falls also increased for this group, from 257.3 per 100,000 to 354.8 per 100,000 by 2013.

    According to the CDC, while the combined number of TBI-related ED visits, hospitalizations, and deaths did rise from 1.9 million in 2007 to an estimated 2.8 million in 2013, the rise was due mostly to ED visits, which accounted for 2.5 million events, compared with 282,000 hospitalizations in 2013—about the same as 2007—and 56,000 TBI related deaths, representing a slight increase from 55,920 in 2007.

    However, researchers explain, the overall figures don't tell the whole story.

    Authors believe the uptick in ED visits among youth may be attributable in part to increased awareness among the public (resulting in a higher number of individuals seeking care) and increased awareness and use of assessment tools among health care providers (resulting in more TBI diagnoses). More problematic, according to the researchers, is the fact that falls are becoming an increasingly prevalent cause for not only ED visits, but hospitalizations, and deaths—and are growing at a disproportionate rate for older adults.

    What kind of growth? In 2013, falls accounted for 57.3% of the increase in ED visits, representing a 50% increase in incidence from 2007. Though TBI-related hospitalizations didn't increase by much between 2007 and 2013, the number of hospitalizations related to falls did, from 33.9 per 100,000 (age adjusted) to 42.2. The same was true for TBI-related death rates attributable to falls, which increased from 3.8 to 4.5 per 100,000 between 2007 and 2013.

    Researchers note that those increases in falls-related TBIs were experienced disproportionately, depending on age. And the change can't be explained by increases in life expectancy from 2007 to 2013, during which time average lifespan rose from 78.1 years to 78.8 years. "The reason or reasons for this increase [in falls-related TBI injury] is unknown," authors write.

    "Although increases among youth were found for TBI-related ED visits, there were significant increases in the number of ED visits, hospitalizations, and deaths attributable to TBIs resulting from older adult falls," authors write. "This across-the-board increase over a relatively short time suggests the need to address preventing and reducing the number of older adult falls resulting in TBI."

    Among the interventions that can make a difference, researchers advocate for increased use of "empirically validated [falls] prevention measures" that include physical exercise programs, Tai chi, Vitamin D supplementation, surgeries such as cataract procedures and pacemakers when appropriate, and strategies to reduce home health hazards. Also recommended: the CDC's Stopping Elderly Accidents, Deaths, and Injuries (STEADI) program that "incorporates empirically supported clinical guidelines and scientifically tested interventions to help … address patient falls risk."

    APTA remains a strong advocate for greater attention to TBIs as well as community-based falls-prevention programs. Last week, representatives from the association again participated in the Brain Injury Awareness Fair on Capitol Hill, and APTA continues to work to support the physical therapist's role in concussion management. More resources can be found at APTA's Traumatic Brain Injury webpage, and in a clinical summary on concussion.

    On the falls front, APTA offers a variety of resources on falls prevention, including a clinical summary on falls risk in community-dwelling older adults, a practice guideline on the assessment and prevention of fallstests and measures related to falls, a Physical Therapy-published clinical guidance statement from the Academy of Geriatric Physical Therapy, an online community for PTs and physical therapist assistants interested in falls prevention, and a balance and falls webpage.

      Rep Bill Pascrell 350x324  

    On left, Rep Bill Pascrell Jr (NJ), chair of the congressional brain injury caucus, meets with APTA Senior Congressional Affairs Specialist Michael Hurlbut during the recent Brain Injury Awareness event on Capitol Hill.

    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: 10-Year Pattern of HS Soccer Injuries Shows Need for New Look at Injury Prevention Programs

    In brief:

    • Study tracked detailed information on injury rates among high school soccer players over a 10-year period (2005 – 2014).
    • Concussion rates are on the rise for both boys and girls; may be due to better recognition of symptoms.
    • Boys experienced decline in nonconcussion injuries; girls' rates remained steady.
    • Girls experienced significantly higher rate of knee ligament sprains that result in surgery.
    • Authors say that data points to need for tailored preventive approaches in training, with specific attention paid to reducing incidence of knee ligament sprains among girls.

    In what authors say is the largest-scale study to date, an analysis of high-school soccer injuries from 2005 to 2014 reveals similarly increasing rates of concussion among boys and girls but differences in nonconcussion injuries, with boys' rates dropping while girls' rates hold fairly steady. Researchers believe the data they've collected may help coaches and trainers create more targeted injury prevention programs.

    Overall, injury rates during the study period were recorded at 2.06 per 1,000 "athletic exposures" (AEs)—defined as "a single athlete participating in a single practice or competition." That works out to 6,154 injuries in the study group (55.4% sustained by girls and 44.6% by boys), which researchers say corresponds to an estimated 3.38 million injuries nationally for the 10-year study period. Data were drawn from the National High School Sports-Related Injury Surveillance System, High School Reporting Online (RIO), based on a nationally representative sample of 100 schools in the US. The study appears in the British Journal of Sports Medicine.

    Over time, a rise in concussions was reported in both boys and girls. Boys' rates rose from about 0.25 to 0.45 per 1,000 AEs, and girls' incidence climbed from .4 to around .7 during the same time, resulting in an overall rate of 0.36 per 1,000 AEs for the study period. Similar to other studies of youth sports concussion, authors believe part of the reason for the recorded increase is better recognition of concussion symptoms among coaches and trainers.

    As for nonconcussion injuries, the trends among boys and girls started to part ways, with a drop for boys from about 2.3 to 1.3 per 1,000 AEs vs a relatively steady rate for girls, at close to 1.9 per 1,000 AEs.

    Other findings from the study:

    • The 3 most common injuries among boys and girls were grade II-III ligament sprains (29.7%), followed by concussions (17.9%) and muscle strains (16.1%). Most injuries resulted in activity time loss of less than 1 week, but 6.7% resulted in more than 3 weeks' wait before return-to-play, and 5.8% resulted in a season-ending medical disqualification.
    • Of the injuries resulting in a loss of play for 3 weeks or more, the 3 most common injuries for boys were concussions (17.8%), knee sprains (15.5%), and ankle sprains (8.9%). Among girls, knee sprains topped the list (26%), followed by concussions (22%), and ankle sprains (13.2%).
    • Girls sustained a higher proportion of ligament sprains than boys, with a 34.4% rate compared with 23.9% in boys. Boys were more likely to sustain fractures, at 8.9% vs 6% for girls.
    • Injuries were much more prevalent during competition than during practice and tended to result in a higher proportion of injury resulting in 3 or more weeks without play (24.3% vs 15.3%).
    • In the competition setting, the rate of ligament sprains that required surgery was much higher in girls (0.28 per 1,000 AEs) than boys (0.09 per 1,000 AEs).
    • Most injuries (37.6%) were sustained by midfielders, followed by forwards (28.9%), defenders (23.6%), and goalies (9.4%). The most common area of the field for injuries to occur was between the goal box lines, with 34.6% occurring while players were on their offensive side of the field and 21.5% occurring while on the defensive side.

    While some of the findings were more-or-less in line with other research—particularly related to concussion rates—authors believe that the larger scale and more extensive detail offered in the current study should give coaches and trainers better insight into the prevention needs of their players.

    Based on these data, "a re-evaluation of injury prevention programs, especially in girls, should be performed with the goal of more effectively reducing non-concussion soccer injury rates," authors write, adding that the study revealed a "need for targeted preventive programs for girls' knee ligament sprains to reduce the need for surgical intervention, as well as further research into potential reasons for this observed difference between sexes."

    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.

    Get the latest perspectives on youth sports issues at the upcoming NEXT Conference and Exposition, June 21-24: "One Size Doesn’t Fill All: Safe/Inclusive Youth and Adaptive Sports," and "Back in the Game: Treating Young Athletes With Low Back Pain." Also worth checking out: APTA Learning Center courses on postconcussion return-to-play and repetitive stress injury in youth athletes. More insight is available through PTNow's clinical summary on concussion.

    NIH Provides More Insight on Major Reboot of Rehab Research Plan

    A revised National Institutes of Health (NIH) rehabilitation research plan made headlines when it was unveiled last fall, and now several journals, including Physical Therapy (PTJ), are helping to shed even more light on where it came from and where it's going.

    This month, the American Journal of Physical Medicine and Rehabilitation published 2 articles on the NIH plan, which creates a roadmap for more cohesive, targeted research on restoring function. The articles—one a recap of a conference discussion on how research areas should be prioritized, and the other a summary of the overall research action plan—help to provide context for that core document. In April, PTJ will publish the same articles, accompanied by an editorial from Editor in Chief Alan Jette, PT, PhD, FAPTA, who was a member of the blue ribbon panel that created the initial recommendations for the plan.

    Jette wasn't the only APTA member who played a critical role in the plan's development: former PTJ Editor in Chief and current member of the Foundation for Physical Therapy's Scientific Advisory Council Rebecca Craik, PT, PhD, FAPTA, chaired the blue ribbon panel, and Anthony DeLitto, PT, PhD, FAPTA, was also a member of the group. APTA was a strong supporter of the plan and increased overall funding for rehabilitation research, both of which became a reality with the December 2016 signing of the 21st Century Cures Act by then-President Barack Obama.

    According to the action plan, over the next 5 years NIH will support research in 6 main areas: rehabilitation across the lifespan, rehabilitation in the context of community and family, technology use and development, research design and methodology, translational science, and building research capacity and infrastructure. The research, currently supported by 17 institutes and centers across NIH, will be coordinated by the NIH National Center for Medical Rehabilitation Research.

    "Although a great deal has already been accomplished, there is more to do," NIH states in its action plan. "NIH looks forward to working with all the stakeholder communities involved in rehabilitation research to track progress on these newly established priorities and advance the science of rehabilitation in partnership with them."

    Researchers Identify Factors That May Keep Some Patients From Making Optimal Gains in Cardiac Rehab

    In brief:

    • Researchers studied 541 patients who underwent CR after a cardiac procedure (either percutaneous coronary intervention or coronary artery bypass graft).
    • Pre- and post-CR gains in 6MWT were compared with a range of demographic and health data to look for predictors of individuals who did not experience optimal exercise capacity (EC) gains from CR.
    • Findings: baseline 6MWT results, age, PCI, LDL-C levels, gender, use of statins, systolic at-rest BP, BMI, and triglyceride levels all identified as predictors of suboptimal EC post-CR.
    • Lower LDL-C and use of statins were associated with lower EC; higher LDL-C and no use of statins also were associated with suboptimal EC.
    • Researcher say predictors could help clinicians customize CR interventions for maximum effectiveness.

    Authors of a new study say they've found a set of predictors that could help providers identify which cardiac rehabilitation (CR) patients are at risk of making lower gains in exercise capacity (EC) from the intervention.

    Researchers analyzed before-and-after results from the 6-minute walk test (6MWT) among 541 patients enrolled in the Mayo Clinic Florida's CR program, tracking distance as well as heart rate and blood pressure before and after each test. Next they compared post-CR 6MWT results with a range of health and demographic data including type of initial cardiac procedure, age, sex, body mass index (BMI), total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (LDL), triglycerides, and use of lipid-lowering drugs (LLD) at baseline. Results were published in the American Journal of Cardiology (abstract only available for free).

    When they looked at who didn't achieve optimal EC after CR, researchers found a constellation of factors that they believe may be predictive of an individual's likelihood of making substandard gains. In all, 9 major predictors were identified (listed here in descending order of effect): baseline distance on 6MWT, age, percutaneous coronary intervention (or PCI, as opposed to coronary artery bypass graft, or CABG), LDL-C level, gender, the interaction of LDL-C while on LLDs, systolic BP at rest, BMI, and triglyceride levels.

    The CR protocol used in the program was built around 30 minutes of aerobic exercise within a prescribed heart rate range and 30 minutes of upper and lower body resistance exercise 3 times a week for 4 to 12 weeks. Patients were also given home exercise instructions that involved 30 to 60 minutes of exercise on non-rehabilitation days, and were provided with instruction on cardiovascular risks and nutrition.

    According to authors, some of the predictors—particularly age and gender—were already associated with lower post-CR EC gains among women and more elderly individuals. Other predictors, however, were more surprising. Among them:

    LDL-C levels and use of LLDs. Researchers found that the use of LLD and a lower LDL-C level while on the drugs was associated with lower post-CR exercise performance, while among participants without LLDs, higher LDL-C levels were associated with lower EC. Authors cite the need for more research on the effects of statins on a patient's ability to exercise, but they add that "if patients are showing signals of statin-related myopathy that limit their exercise performance, the clinician needs to have an open discussion with the patient about the benefit and risk involved in regards to EC and take the patient's preference into account."

    PCI vs CABG. Patients who received PCI—a nonsurgical procedure often involving angioplasty and stents—recorded less dramatic EC gains than those who received CABG, with the PCI improving their median 6MWT by 23.3 meters less than the CABG group. "This is probably due to the fact that patients are more deconditioned after CABG than after PCI and have more room to improve their functional capacity … but the possible effect of a more complete revascularization after CABG cannot be ruled out," authors write.

    BMI. While patients with higher BMI had lower EC improvements, authors noted that other studies have identified the so-called "obesity paradox"—a negative correlation between BMI and total cardiovascular mortality rates after a cardiac event—which makes BMI a bit less useful as a predictor of anything other than EC gain. Instead, authors advise paying careful attention to waist-to-hip ratio, beyond BMI, which they write "identifies more accurately those patients in CR who are in need of special attention with their preventive efforts."

    Researchers say that the case for the overall effectiveness of CR remains solid and was clearly supported by their own study, in which 92% of patients showed an increase in 6MWT results after CR. Rather than question CR itself, authors believe that their study points to the need for providers to weigh factors that might get in the way of success and then adjust interventions to suit, writing that "personalized treatment plans for such patients appear warranted in these groups to promote greater improvements in functional capacity and the related benefits."

    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.