• News New Blog Banner

  • 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.

    12-Year Study Tracks Impact of Television Viewing Patterns on Strength

    In brief:

    • Australian study of 1,983 participants in a 12-year health monitoring program tracked television viewing habits over time using group-based trajectory modeling
    • Tests of lower limb strength at the end of the study revealed significantly higher scores among the lowest-viewing groups; however, a high-viewing subgroup also scored well
    • Researchers believe high-viewer scores may be related to "training stimulus" associated with adiposity
    • No differences between viewing groups was noted for timed up-and-go test
    • Results point to need for early intervention, and importance of tracking viewing patterns over time, not just at a single point

    It's no secret that large amounts of sedentary behavior, such as is associated with extensive television viewing, can have a negative effect on physical function and overall health. Now researchers in Australia have amassed 12 years' worth of data that shows how extended viewing habits can impact knee extensor strength, and the results are about what you'd expect—with 1 exception.

    Researchers drew data from the Australian Diabetes, Obesity, and Lifestyle Study, a longitudinal project that began in 1999 and attempts to track its 11,000 participants over time. The most recent wave of data collection, which involves participants coming to onsite testing centers, was conducted 2011-2012. A total of 1,983 participants who had been with the program since the beginning were included in the current study, allowing researchers to follow television viewing patterns over time using group-based trajectory modeling (GBTM). Results were e-published ahead of print in Medicine & Science in Sports & Exercise (abstract only available for free).

    Using data collected over the 12-year time span, researchers grouped participants into 3 major viewing time "trajectories" consisting of 2 subgroups each: consistently low and low-increasing (0-5.75 hours/week), moderate-increasing and moderate-decreasing (6-11.6 hours/week), and consistently high and high-increasing (18-115 hours/week). No participants were added to the data pool, so the study could focus on seeing what happens as a group ages, from an average participant age of 57.6 in 1999 to 69.5 at the time of the last collection point.

    Researchers then analyzed results from 2 tests administered during the 2011-2012 sessions: the 8-foot timed up-and-go test (TUG), and the knee extensor strength test (KES).

    Data showed few differences among groups for the TUG, but researchers noted significantly higher lower-limb isometric strength among the lowest-viewing subgroups compared with the middle group. However, 1 other group also showed better results on the KES—the subset whose viewing hours were consistently high.

    The lower-limb strength associated with the high-volume viewers didn't necessarily surprise researchers, who write that high viewing time has been associated with adiposity, "which may provide a training stimulus (by carrying more weight during incidental and planned activity) and thereby maintain muscle strength." As for the lack of differences in TUG results, authors speculate that the average age of the group hadn't yet reached 70, the point where they assert reduction in gait speed begins to rapidly accelerate.

    Researchers believe the results help to demonstrate how viewing habits can change over time, "a concept that is poorly captured through traditional statistical approaches" that focus on a single snapshot of viewing. "[The current study results] suggest that historic TV time may be more predictive of physical performance than current TV time, evidenced by participants in the moderate-increasing and moderate-decreasing TV time trajectories performing similarly on both tests of physical function," authors write.

    "With the majority of adults in the moderate-increasing trajectory of TV-time, action is needed to counteract this negative trend," authors write, suggesting that that there may be "opportunities for intervention at critical life stages."

    Bottom line: those interventions shouldn't wait. "Collectively, these results suggest that excessive TV time should be addressed earlier rather than later in life," authors write.

    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.

    Number of Americans Reporting Arthritis-Related Activity Limitations on the Rise

    In brief:

    • CDC estimates arthritis prevalence in the US, based on more than 100,000 responses to National Health Interview Survey, 2013-2015
    • Total prevalence is estimated at 54.4 million Americans—about 20% of the US population, with 32 million being of working age
    • Number of Americans reporting arthritis-attributed activity limitations rose by 20% since 2002
    • Highest percentages of activity limitations were among Americans with comorbidities: heart disease, diabetes, and obesity
    • CDC recommends more widespread use of physical activity and cognitive behavioral therapy as a "proven strategy;" recommends against use of opioids

    The overall prevalence of arthritis in the US may be about the same as it was 15 year ago, but its burden on Americans is worsening at a rapid pace—and in a particularly troubling way. According to the US Centers for Disease Control and Prevention (CDC), the number of Americans with arthritis who report that the condition limits their activities has jumped by 20% since 2002. It's a trend the CDC believes can only be countered by "existing, underused, evidence-based interventions," specifically interventions that promote physical activity, which the CDC describes as "a proven strategy for managing arthritis."

    In its report released March 7, the CDC analyzed results from 3 years of National Health Interview Surveys conducted between 2013 and 2015, focusing on respondents who reported arthritis (for the CDC, that includes osteoarthritis, rheumatoid arthritis, lupus, gout, and fibromyalgia). The sample was balanced to reflect US population demographics, which allowed CDC to make overall estimates based on the results, and compared with statistics from 2002. Among the findings:

    • Just over 20% of Americans—about 54.4 million people—had doctor-diagnosed arthritis, a number that didn't change much over the 3-year study period, and is similar to statistics from 2002.
    • During that same time span, the number of Americans who reported arthritis-attributable activity limitations rose to 23.7 million, or 43.5% of adults with arthritis, up from 35.9% in 2002, and adjusted for age.
    • Activity limitations were even more prevalent among Americans with comorbidities, such as heart disease (54.5%), diabetes (54%), and obesity (49%).
    • Of those who reported arthritis, almost half (49.6%) were 65 and older; 29.3% were 45-64 years old, and 7.1% were aged 18-44.

    The percentage of individuals with an activity limitation who have arthritis and another condition such as heart disease, diabetes, or obesity are particularly worrisome, according to the CDC, because physical activity has been proven to be effective for those conditions as well. The higher level of inactivity "[suggests] that arthritis-specific barriers to physical activity (concerns about worsening pain, damaging joints, and safely exercising) might be important concerns for adults with these conditions," the CDC writes.

    When it comes to what to do about the problem, the CDC points out that while opioids are often prescribed for arthritis, "better ways to help manage arthritis often exist," and the agency suggests exercise therapy and cognitive behavioral therapy. The CDC also mentions acetaminophen and nonsteroidal anti-inflammatory drugs, but writes that "although medications can help, nonpharmaceutical measures help as well." The suggestions are consistent with the CDC guidelines for the treatment of chronic pain, which recommend nondrug approaches including physical therapy as a first-line treatment. APTA's #ChoosePT campaign incorporates the CDC recommendations in its efforts to promote physical therapy as a healthy, effective alternative to opioids for many conditions.

    "Our findings suggest that the burden of arthritis is increasing and requires more widespread use of existing, underused, evidence-based interventions," the CDC writes. "Physical activity is a proven strategy for managing arthritis, with known benefits for the management of many chronic conditions."

    What it all boils down to, according to the CDC, is a straightforward idea: do what works. And what works are nondrug approaches.

    "Given the high prevalence of arthritis and the increase in arthritis-attributable activity limitations in the United States," the reports states, "health care providers and public health practitioners can address arthritis and other chronic conditions by prioritizing proven, nonpharmaceutical interventions, such as self-management education and appropriate physical activity, as effective ways to improve health outcomes."

    APTA offers multiple resources on arthritis management through community-based programs, including an overview of evidence-based programs and a decision aid to help physical therapists (PTs) choose an appropriate program for the patient. Patients can learn more about the PT’s role in arthritis treatment at MoveForwardPT.com's webpages on osteoarthritis and rheumatoid arthritis. PTs can access tests and measures as well as clinical practice guidelines at PTNow (select the appropriate health condition in the tests and measures area; search by topic in the CPG area).

    Additionally, the US Bone and Joint Initiative (USBJI) offers a series of free public education programs aimed at helping providers increase community awareness of osteoarthritis treatment. APTA is a founding member of USBJI.

    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: Manual Therapy Works as Well, And Sometimes Better, Than Surgery for Carpal Tunnel Syndrome

    In brief:

    • Study analyzed self-reported function and symptoms, pinch-tip grip, and cervical ROM among 100 women with CTS—half received surgery; half received multimodal manual therapy
    • Physical therapy group showed significant gains over surgery group at 1 month for function, symptoms, and pinch-tip grip; no improvement in cervical ROM.
    • By 6 months, both groups were reporting similar improvements; similarly at 1 year, there were few differences
    • Connection between manual therapy and cervical ROM for patients with CTS was not confirmed; authors think it's possible a different intervention (neurodynamic) may lead to improvements in ROM in this population
    • Authors believe early gains by physical therapy group make physical therapy preferable to surgery as a way to return patients to normal activities as quickly as possible

    Authors of a new study on carpal tunnel syndrome (CTS) say that when you toss out the splints, steroid injections, lasers, and other treatments often lumped in with physical therapy as part of a "conservative" approach and focus solely on a debate about surgery vs specific multimodal physical therapy, physical therapy makes a compelling case for itself.

    How compelling? Researchers found similar improvement in self-reported function and CTS symptom severity for both surgical and physical therapy patients after 1 year, but the physical therapy group reported more significant gains in the first month. That speedier gain early on is worth noting, researchers believe, because it allows these patients to return to work and other activities sooner than their peers who underwent surgery. Results were published in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free).

    The study, conducted in Spain, focused on 100 women who had experienced CTS symptoms for at least a year including pain and paresthesia in the median nerve distribution, positive Tinel sign, and positive Phalen sign. Participants also underwent electrodiagnostic examination to verify deficits in sensory and motor median nerve conduction.

    Once accepted into the program, the women were randomly divided into 2 groups of 50: 1 group received endoscopic decompression and release of the carpal tunnel through surgery, and 1 group received 3 treatment sessions of manual therapies that targeted areas "anatomically related to potential entrapment of the median nerve (eg, shoulder, elbow, forearm, wrist, and fingers)," as well as the cervical spine (more on that later). The specific techniques included:

    • Soft tissue compression over the pectoralis minor muscle
    • Longitudinal stroke over the biceps muscle
    • Transversal stroke of the bicipital aponeurosis
    • Dynamic stroke of the pronator teres muscle
    • Stretching of the transverse carpal ligament
    • Stretching of the palmar aponeurosis
    • Manual compression of the lumbrical muscles
    • Lateral glides applied to the cervical spine
    • Longitudinal stroke over the scalene muscles
    • Posteroanterior nonthrust mobilization of the mid cervical spine
    • Transversal stretching of the costoclavicle spine

    Patients in the physical therapy group also received cervical spine exercises for stretching neck muscles, which they were encouraged to perform at home during the follow-up period as needed. Based on earlier studies by others, researchers hypothesized that patients with CTS were also experiencing limits on cervical range of motion and that manual therapy would show improvements in this area as well. Ultimately, the cervical work didn't result in any notable changes in cervical range of motion for the women in either group.

    But a different story surfaced when it came to improvement in self-reported function as measured through the Boston Carpal Tunnel Questionnaire (BCTQ), as well as pinch-tip grip force. The physical therapy group showed average 1-month gains that exceed those of the surgery group by nearly 1 point on the 5-point BCTQ scale. Pinch-tip grip force improvements also bettered the surgery group at the 1 month mark. When reassessed at 6 and 12 months, however, both groups posted similar scores on both assessments.

    "The findings of the current study have potential clinical implications and open new lines of research," authors write. "Because better short-term outcomes were found with manual therapy, patients may be able to return earlier to their activities of daily living and work when they receive manual therapy, compared to those who undergo surgery."

    While earlier studies tended to give surgery the edge over conservative treatments, those "conservative" approaches usually lumped in physical therapy with a host of ineffective treatments including splints, steroid injections, lasers, and transcutaneous electrical nerve stimulation. Authors of the current study say theirs is the first to make a clean comparison between surgery and well-defined multimodal manual therapy.

    As for the lack of change in cervical function, authors think there may still be a connection but that the interventions used in the research didn't provide "sufficient management of the neck impairments." Previous studies showing this connection employed neurodynamic interventions—something not used in the current study—and it's possible that had those interventions been used, improvements may have been gained, they write.

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

    Editor's note: the following story was modified to clarify terminology in the study, specifically around the authors' use of "modality."

    In brief:

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

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

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

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

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

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

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

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

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

    In brief:

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

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

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

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

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

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

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

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

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

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

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