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  • Study: More 'Collaboration and Consistency' Needed Between PTs and Surgeons in TKA, THA Measures

    As health care moves toward value-based approaches, it's going to become increasingly important for physical therapists (PTs) and orthopedic surgeons (OSs) to pursue more "collaboration and consistency" when it comes to outcome measures used in total knee and hip arthroplasty cases, say authors of a new study. That study, based on a survey of PTs in New England, found that many PTs relied on a range of performance-based outcome measures (PBOMs) and were less likely to use certain patient-reported outcome measures (PROMs) preferred by OSs—though that could be changing.

    The study, which appears in Arthroplasty Today, is based on a survey of 122 PTs in Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, and Connecticut. Researchers were trying to uncover differences between outcome measures commonly used by PTs, and those recommended for use in the American Joint Replacement Registry (AJRR), which authors of the study believe reflects measures most commonly used by OSs.

    To qualify for inclusion in the survey, a PT must have treated patients undergoing total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) in the past 5 years. PTs were asked to rate their current use of various outcome measures on a 4-point scale, from "not familiar" to "considerable experience." The respondents further were asked to estimate their future use of the outcome measures, also based on a 4-point scale: "unable to rate," "unlikely to use," "likely to use," and "will use and recommend."

    As for the outcome measures being evaluated, authors selected the Lower Extremity Function scale (LEFS), the numeric pain rating scale, Oxford Knee Score (OKS), Oxford Hip Score (OHS), EQ-5D quality of life measure, Knee Injury and Arthritis Outcome Score (KOOS), Hip Injury and Arthritis Outcome Score (HOOS), and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) as the PROMs. For PBOMs, they asked PTs to rate walking speed, the 6-minute walk test, timed up-and-go (TUG), timed stair climb, Tinetti Mobility Test, Single-Leg Balance Test, and functional reach test.

    Here's what they found:

    Respondents. The PTs included in the survey were mostly from mixed urban-rural areas (62.3%). Over half (53.5%) reported practicing in a private practice clinic; nearly 1 in 5 (18%) practiced in an outpatient clinical associated with an academic hospital or medical center. About a third of respondents (32.8%) reported 25 years' experience or more; 17.2% reported between 10 and 14 years of experience, and 13.9% listed experience at between 15 and 19 years. Just over 42% of PTs surveyed said they'd treated 25 or fewer TKA/THA patients in the past year; nearly that many (38.9%) reported treating between 26 and 49 such patients during the past year.

    Use of PROMs. The Numeric Pain Rating Scale and the LEFS were the measures most often cited by the respondents in terms of both current and future use of patient-reported data. Nearly all (99.2%) of the PTs reported current considerable experience with the pain rating scale, with 97.5% saying that they'd use and recommend the scale in the future. LEFS was also popular among the PTs, with 76.2% reporting considerable current experience and 77% supporting future use and recommendation.

    Use of PBOMs. In the performance-based category, the PTs cited the Single-Leg Balance Test and the TUG as the most relied-upon measures. For the Single-Let Balance Test, 90.2% of respondents reported current use, with 87.7% saying they would use and recommend that test in the future. The TUG was even more popular, with 93.4% of the PTs reporting current use, and 85.2% reporting future use and recommendation.

    The problem, according to the study's authors, is that the PTs' choices for PROMs don't line up with the AJRR recommendations, which lean more toward general quality of life measures and specific joint measures such as the HOOS, KOOS, and Oxford knee and hip measures. "It is difficult to explain why [the surveyed PTs] prefer the LEFS," authors write. "LEFS is easy to implement and broadly applicable to all lower extremity sites in various stages of disability, but is not specific to hip and knee osteoarthritis. The HOOS and KOOS are joint specific, including the [WOMAC] score, and have been shown to be more sensitive and responsive than the LEFS in total joint replacement. However, they take longer to administer." [Editor's note: APTA encourages the use of HOOS and KOOS for PTs participating in the Comprehensive Care for Joint Replacement bundled care model.]

    And while authors point out that PROMs are probably more reflective of the direction health care is heading, they acknowledge that PBOMs such as TUG have their place, too.

    "PROMs may overestimate patient mobility, especially in the immediate postoperative phase after both TKA and THA," authors write. "Because [PTs] evaluate TJA [total joint arthroplasty] patients multiple times in the early postoperative period, they may utilize PBOM more frequently to avoid overestimation of function during the early phase of rehabilitation." It's an approach that the researchers say echoes recommendations from the Osteoarthritis Research Society International, which supports use of the sit-to-stand test, walking speed test, timed stair climb, 6-minute walk test, and TUG.

    "PROMs and PBOMs also assess different time periods of recovery," authors write. "PROMs generally assess a period of weeks of overall symptoms and function while PBOMs objectively measure function at a particular point in time. Both types of information are valuable in assessing patient recovery."

    Still, they argue, the evolution toward patient-centered care means that patient-reported outcomes are likely to become more important in the future. And while the PTs surveyed may not yet be fully in sync with this trend in THA and TKA measures, there are some signs of positive movement.

    "This study showed that of the 16 outcome measures queried for clinical decision making, [PTs] indicated that they were less likely to use 4 of them in the future, all them PBOMs, and more likely to use 2 in the future, both PROMs," authors write. "As surgeons and [PTs] work more closely, developing better understanding and consensus in the use of PROM and PBOM between surgeons and physical therapists will allow for improved assessment of TJA patient outcomes."

    Authors acknowledge several limitations of their study, including a low response rate and the lack of data indicating when the various measures were used in the course of treatment. Another potential limitation: a large proportion of PTs (42.6%) reported seeing fewer than 25 patients with THA or TKA annually.

    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: Adding Dry Needling to Exercise for Shoulder Pain Could Reduce Broader Costs

    Adding trigger point dry needling to an exercise program for patients with chronic shoulder pain may be more cost-effective than exercise alone, according to a recent clinical trial. The combined intervention led to “improved quality of life and lower…costs than exercise alone,” write authors in Pain Medicine (abstract-only available for free).

    The study is an expansion of earlier published results of the trial, which indicated that including trigger point dry needling was just as effective as exercise alone at reducing shoulder pain intensity, and better at improving pain-related disability. That open-access article appears in The Journal of Pain.

    Researchers recruited 50 participants with unilateral shoulder pain lasting more than 3 months from a hospital in Madrid, Spain. All patients had been diagnosed with subacromial pain syndrome and had no history of shoulder or neck injury, cervical radiculopathy, fibromyalgia, shoulder or neck surgery, shoulder steroid injections, or any type of shoulder or neck intervention.

    Patients were randomly assigned to 1 of 2 groups; both groups received treatment once per week for 5 weeks. Both groups received a supervised, clinical practice guideline-based exercise program of 3 exercises targeting the supraspinatus, infraspinatus, and scapular stabilizer musculature. The second also received trigger point dry needling on the second and fourth sessions.

    Authors analyzed societal costs and measured health-related quality of life during the 12-month follow-up period. Here’s what they found:

    Direct health care costs. Patients in the exercise-only group made more visits to their physicians. They also received more supplemental treatments, such as cold packs and extra physical therapy sessions, compared with the exercise plus trigger point dry needling group.

    Indirect costs of lost productivity. Work absenteeism and average cost of absenteeism were significantly higher for patients in the exercise-only group.

    Quality of life. Patients who also received trigger point dry needling “reported significantly better quality of life” compared with those who only received exercise.

    Cost-effectiveness. Exercise plus trigger point dry needling was “more likely to be cost-effective” than exercise alone. The greatest cost savings, say researchers, came from lower work absenteeism in the trigger point dry needling group.

    While authors acknowledge that the study results do not necessarily apply to other countries, they suggest “these differences would not alter the direction of current results.”

    Authors of the study include APTA members Joshua Cleland, PT, DPT; and Shane Koppenhaver, PT, PhD. Both Cleland and Koppenhaver are board-certified orthopaedic clinical specialists and fellows of the American Academy of Manual Physical Therapy.

    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: Optimal Exercise Dose for Knee Disorders Still Unclear

    While much research has shown positive effects of therapeutic exercise for common knee disorders, “optimal dosing is still unclear,” say experts, largely a result of the way authors report their results. Identifying the best dosage is important, they write, because overdosing can have adverse effects, while underdosing can lead to no improvement for the patient.

    In a systematic review published in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free), authors examined 45 “fair-quality” studies on the use of therapeutic exercise to treat knee osteoarthritis (OA), patellar tendinopathy, or patellofemoral pain (PFP). Researchers analyzed duration of a single session, frequency of sessions, total number of sessions, duration of treatment, and effect size. Here's what they found:

    • Effect sizes in the included studies varied widely because so many different outcome measures were used, even for the same conditions.
    • For all 3 conditions, some studies did not report or were unclear about the length of each therapy session, frequency of sessions, and whether or not the exercise was supervised.
    • While nearly all studies clearly reported total number of sessions, the number ranged from 3 to 108 for knee OA, from 36 to 180 for patellar tendinopathy, and from 12 to 146 for PFP.
    • Researchers were able to identify only 3 trends from their analysis—all for knee OA. Both 24 total number of sessions and 8-week and 12-week durations were most often related to large effect sizes.
    • Once-per-week session frequency had no effect for knee OA.

    The review’s findings illustrate the challenge of appropriate dosing.

    “Exercise dosing is complex,” note authors, speculating that “an identical bolus of 315 minutes of exercise per week could be disseminated in a variety of ways.” More frequent sessions could be more effective, they write, but that would likely be affected by the duration and intensity of each session.

    Authors acknowledge the balancing act between tailoring exercise prescription to each patient while establishing general dosage parameters that help “standardize effective care, inform clinical practice guidelines, and decrease dosage variance in clinical trials.” It is critical, they say, to improve the quality of dosage reporting in clinical trials, because “these data can better allow researchers to fine tune exercise dosage in subsequent trials, and improve our understanding of exercise parameters that work better than others.”

    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: Falls Among US Adults 65 and Older Cost $50 Billion in 2015

    The US health care system spent an estimated $50 billion on falls in 2015, an amount representing 6% of all Medicare payments and 8% of all Medicaid payments, according to a new study. Authors say that unless the US steps up its game when it comes to falls risk assessment and prevention, costs are certain to climb steadily higher as the baby boomer generation continues to age.

    Researchers based their estimates on data from the Medicare Current Beneficiaries Survey (MCBS), then applied these data to data from the National Health Expenditures Accounts (NHEA) to estimate nonfatal falls expense. For fata falls, they used the Web-based Injury Statistics Query and Reporting System (WISQARS) to assess expense. The final MCBS sample included 3,460 community-dwelling individuals 65 and older. Respondents who were employed, died during the survey period, or lived in Puerto Rico were excluded.

    Results of the study were published in the Journal of the American Geriatrics Society. Among the findings:

    • Based on the survey, researchers estimate total 2015 health care expenditures for nonfatal falls in the US at $49.5 billion--$28.9 billion for Medicare, $8.7 billion for Medicaid, and $12 billion for other payment sources including private insurance and out-of-pocket expense.
    • Nearly 1 in 4 adults in the survey reported a fall in the past year. Of those, 52.1% fell once, 21.3% fell twice, and 24.1% fell 3 or more times.
    • Individuals who reported falls had significantly lower self-rated health and more chronic conditions, and were more likely to be female, white, and from lower income levels.
    • Estimated costs were not distributed equally among service types, with an "other" category—spending in areas such as home health services, long-term care facilities, and durable medical equipment—leading the way at $29.2 billion. That amount was more than double hospital-related spending, which was second at $12.9 billion, followed by physician/other provider spending ($10.8 billion), prescription drugs ($2.1 billion), and dental ($400 million).
    • Unintentional fall deaths were recorded at a rate of 59.64 per 100,000 population in 2015, with associated medical costs of $754 million—about 1% of the total estimated expenditures.
    • Overall, spending on falls in 2015 increased by nearly 32% from 2013, when total spending was estimated at $38 billion.

    "The economic burden from falls is likely to increase substantially in the coming years," authors write. "Monitoring cost trends is important, because 75% of the cost of older adult falls is financed through public health insurance programs that are already financially stressed."

    Authors believe that given the undeniable demographic pressure that will increase as baby boomers age, it's imperative that more attention be given to falls assessment and prevention.

    "Preventive strategies that reduce falls in older adults could lead to a substantial reduction in health care spending," authors write.

    The researchers stress that "evidence-based strategies including medication management and strength and balance exercises…have been associated with reductions in older adult falls," and point to guidelines such as those included in the US Centers for Disease Control and Prevention's Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative as a good place to start

    But there's no time to lose, they add. Authors of the study believe that providers need to act with urgency and do a better job of identifying falls risk, assessing which risk factors may be modified and providing evidence-based interventions to decrease that risk.

    "Clinical care is an important component of falls prevention," they write. "By broadly implementing and scaling up initiatives like STEADI, we can improve health and decrease the future economic burden of older adult falls."

    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.

    Editor's note: Want more on falls prevention? Check out the falls-related resources at PTNow, including a unilateral vestibular hypofunction clinical summary, a summary on falls risk in community-dwelling elders, an osteoporosis clinical summary, and tests and measures such as a fracture risk assessment, a clinical test of sensory interaction and balance, and a self-paced walk test. APTA also offers resources on its Balance and Falls webpage.

    JAMA Study: Opioids No Better Than Nonopioids in Improving Pain-Related Function, Intensity for Chronic Back Pain, Hip/Knee OA

    In brief:

    • 240 patients with chronic back pain or hip or knee osteoarthritis pain were divided into 2 treatment groups: 1 group received opioids, 1 group received nonopioid medications
    • After 12 months, researchers found no differences between the groups' reported improvement in function, and a slightly better improvement rate in pain intensity for the nonopioid group
    • Among individuals who achieved improvements of 30% or more, numbers were nearly equal for the 2 groups in terms of function, and better for the nonopioid group in terms of pain intensity
    • Authors conclude that given the potential risks associated with opioids, results of the study do not support opioid prescription for chronic back pain or knee or hip osteoarthritis pain

    APTA's #ChoosePT opioid awareness campaign makes the case that opioids simply "mask" pain—but a new study in JAMA has concluded that the drugs probably don't even do that much, at least not any more effectively than nonopioid medications. The research, which focused on individuals with chronic back pain or hip or knee osteoarthritis (OA) pain, led authors to an unequivocal conclusion: there's no support for opioid therapy for moderate-to-severe cases of those types of pain.

    The published findings (abstract only available for free) are based on a study of 240 randomized patients in the Minneapolis, Minnesota, Veterans Affairs (VA) health care system who reported chronic back pain or knee or hip OA pain, defined as daily moderate-to-severe pain for 6 months or more with no relief provided by analgesic use. Participants were divided into 2 groups: 1 that received an opioid regimen, and a second group that received nonopioid drugs.

    To more closely resemble real-world treatment, researchers used a "treat-to-target" approach that stepped up the drugs as needed for participants to reach identified goals. The opioid regimen began with immediate-release morphine, hydrocodone/acetaminophen, and oxycodone, but the regimen could advance to sustained-action morphine and oxycodone, and on to transdermal fentanyl. The nonopioid approach began with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS), but it could move on to topical analgesics and finally to drugs requiring prior authorization (such as pregabalin and duloxetine), including tramadol. All participants also were permitted to pursue nondrug treatment during the study, but researchers did not evaluate data related to those treatments.

    Participants were monitored throughout the study and evaluated at 12 months using a range of tests, with the primary focus on how pain interfered with function, assessed through the Brief Pain Inventory (BPI); and pain intensity, measured using the BPI severity scale. Both measures are 10-point scales, with higher numbers indicating more pain-related interference or pain intensity. Other areas assessed as secondary outcomes included quality of life, depression, sleep disturbance, headache, anxiety, sexual function, and fatigue.

    At the 12-month mark, researchers found no significant differences in pain-related interference between the 2 groups (average BPI function scores of 3.4 in the opioid group and 3.3 in the nonopioid group), and a greater reduction of pain intensity among the nonopioid group (average of 3.5 in the nonopioid group vs 4.0 in the opioid group).

    When it came to the achievement of what authors called a "functional response"—a 30% or better improvement in a BPI score—the number of participants who achieved that level of improvement in function was roughly equal among groups, with 69 patients in the opioid group and 71 patients in the nonopioid group reaching the threshold. But the difference was notable in pain intensity scores, with 63 participants in the nonopioid group reporting improvement of 30% or more, compared with 48 participants in the opioid group reaching that level of improvement.

    The researchers also analyzed group differences by the type of pain treated:

    Back pain

    • Average score, interference with function: 2.9 in opioid group; 3.3 in nonopioid group
    • Average score, pain intensity: 3.7 in opioid group; 3.6 in nonopioid group

    Hip or knee OA

    • Average score, interference with function: 4.4 in opioid group; 3.4 in nonopioid group
    • Average score, pain intensity: 4.5 in opioid group; 3.4 in nonopioid group

    Similar to a study published recently, researchers also found that quality-of-life measures did not differ significantly between the 2 groups. The only area in which results from the opioid group bettered the nonopioid group in a notable way was in reduction of anxiety symptoms, although authors point out the only a small number—9% of all participants—reported moderate-to-severe anxiety at baseline.

    Authors acknowledged observational studies that associate long-term use of opioids with poor pain outcomes but say that those outcomes may not tell the whole story.

    "In this trial, pain-related function improved for most patients in each group," authors write. "Poor pain outcomes associated with long-term opioids in observational studies may be attributable to overprescribing and insufficient pain management resources rather than to direct negative effects of opioids."

    Still, they argue, given the "risk for serious harms without sufficient evidence for benefits," there seems to be no compelling reason to even begin a course of opioid-based treatment for certain conditions

    Among patients with chronic back pain or hip or knee osteoarthritis pain, treatment with opioids compared with nonopioid medications did not result in significantly better pain-related function over 12 months," authors write. "Overall, opioids did not demonstrate any advantage over nonopioid medications that could potentially outweigh their greater risk of harms."

    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

    APTA's award-winning #ChoosePT campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Members can also learn more about the PT's role in pain management through offerings on PTNow, including a webpage with resources for pain management and an opioid awareness checklist.

    Easier Said than Done: A Third of Patients Told to Lose Weight Have Functional Limitations That Could Make Exercise Difficult or Unsafe

    Physicians increasingly may be prescribing exercise for patients who need to lose weight, but nearly a third of those patients have functional limitations that could interfere with their ability to safely follow those recommendations, according to new study. Researchers see physical therapists (PTs) as providers who are uniquely positioned to help fix that disconnect.

    The study's findings, published in Physiotherapy Theory and Practice (abstract only available for free) are based on data from 5,480 participants in 2 rounds of National Health and Nutrition Examination Surveys (NHANES) who answered yes to 1 or more of 3 questions about whether a doctor or health professional had recommended physical activity or weight loss in the past 12 months. Researchers looked at how this group answered other questions about functional limitations—activities such as walking for a quarter mile, walking up 10 steps without resting, preparing meals, dressing, standing up from an armless chair, and pushing or pulling large objects—as well as questions about past attempts at weight loss. Here's what they found:

    • Among respondents (56.5% female, 43.5% male ranging in age from 40 to 65) who were told to lose weight, nearly 1 in 3 (31%) reported 1 or more functional limitations.
    • More than 20% reported difficulties with instrumental and basic activities of daily living (IADL and BADL) and with lifting, pushing, or pulling objects.
    • More than 90% of respondents who reported difficulties with IADL and BADL also had a history of obesity, prediabetes, diabetes, hypertension, heart failure, angina, or a myocardial infarction, either alone or in combination.
    • Among the functional limitation group, 57.6% reported intentionally attempting weight loss, with 40.7% using exercise as a weight-loss method.
    • Only 9.9% of respondents who were told to lose weight reported seeking professional advice for weight loss: 48% of that group sought advice from a nutritionist or dietitian, 26% sought out a personal trainer, 23.5% met with a "doctor," and 2% reported "other." Physical therapists were not listed as a separate option.

    Authors of the study acknowledge that while the relationship between functional limitations and lower levels of physical activity (PA) may be a 2-way street, with low levels of PA leading to functional limitations and vice-versa, this relationship only underscores the need for carefully planned and monitored prescriptions for exercise in this population. That's where they believe PTs can play an important role.

    "Physical therapists are well-suited to manage the PA and exercise programs of individuals with functional limitations given [their] education, expertise, and documented self-efficacy in primary, secondary, and tertiary prevention with exercise testing, prescription, and implementation," authors write. "This perspective is strengthened by the documented low self-efficacy of physicians with PA counseling."

    Authors acknowledge that their study may have limitations, including the "bidirectional" relationship between low PA and functional limitations and the NHANES loose use of provider terminology—specifically its reliance on the generic term "doctor." Additionally, they write, more research is needed to assess the impact of functional limitations on the ability to exercise, as well as to explore why PTs don't seem to be a regular part of prescribed weight-loss efforts.

    Nevertheless, they argue, the data in the study point to the need for a more thoughtful approach to weight-loss recommendations.

    "Individuals with these limitations should be identified at the time of health professional recommendation to increase exercise or lose weight and referred to an appropriate health professional for exercise testing, prescription, and program implementation," authors write. "Physical therapists have an opportunity to assist with these efforts."

    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.

    Editor's note: APTA offers resources on encouraging healthy, active lifestyles at APTA's Prevention, Wellness, and Disease Management webpage as well as its webpage on arthritis management through community programs. The association has also launched a new knowledge-sharing opportunity: The Council on Prevention, Health Promotion, and Wellness in Physical Therapy.

    Study: Opioids Don't Improve Quality of Life for Individuals With Chronic Noncancer Pain

    Researchers have found that for individuals with chronic noncancer pain, opioids probably aren't delivering on what many presume to be their primary function—to improve overall quality of life by reducing pain and the emotional toll it takes.

    In a study published in Health Services Research (abstract only available for free) researchers tracked data from individuals who participated in the Medical Expenditure Panel Survey (MEPS), a project that collects health information by way of 5 rounds of surveys, each spanning a 2-year period. The survey asked about respondents' level of pain, use of opioids, and health-related quality of life (HRQoL) based on responses to 2 questionnaires, 1 on mental health and 1 on physical health.

    Authors of the study then focused on 5,876 respondents who reported chronic noncancer pain (CNCP), further dividing them into 3 groups: a no-use group, nonchronic opioid users (those who reported receiving at least 1 opioid prescription over a 12-month period but with a supply for fewer than 90 days), and chronic opioid users—those who reported receiving a prescription for opioids with a supply of 90 days or more in a 12-month period.

    After controlling for demographic variables, comorbidities, and diagnoses, researchers found that physical and mental health scores did not vary significantly among chronic, nonchronic, and no-use groups—a result indicating that the use of opioids did not improve HRQoL any better than no opioids for individuals experiencing the same kinds of pain.

    In fact, researchers point out, if there was any change to be noted, it would be that the chronic-use group reported slightly decreased physical health scores over time—but those changes did not result in a minimally clinically important difference from the other 2 groups.

    "The ultimate goal of using opioids for the treatment of CNCP is to ease the burden of pain and hopefully improve HRQoLs," authors write. "Overall, these results suggest that opioid use for CNCP is not associated with better HRQoL [as measured through the tests included in MEPS]. Considering the risk of development of opioid dependence and addiction and unclear benefit on HRQoL, clinicians should carefully evaluate a treatment goal and whether participants with CNCP should continue receiving opioid therapy."

    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.

    APTA's award-winning #ChoosePT campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Members can also learn more about the PT's role in pain management through offerings on PTNow, including a webpage with resources for pain management and an opioid awareness checklist.

    Study Contradicts Popular 'Text Neck' Theory

    Is there a connection between "text neck" and neck pain in young adults? Researchers from Brazil don't think so.

    Authors of a new study of 150 18-21 year-olds in Rio de Janeiro claim they found no connection between handheld device use posture and the presence or frequency of neck pain—a conclusion that runs counter to popular media reports that "text neck" is contributing to increased rates of neck pain worldwide. Results were published in the European Spine Journal (abstract only available for free).

    To study the possible connection, researchers asked the participants about the amount of time they spent "reading, writing, or playing" on their mobile phones, and then asked them to identify what they believed their texting posture was based on a series of 4 drawings: 2 that were dubbed by researchers to be "no text neck" (phones held higher, farther away from the body, resulting in a less tilted head position), and 2 labeled as "text neck" positions (phones held lower and closer to the body, forcing a greater head drop).

    Next, participants were photographed in profile while texting to establish a more objective view of texting posture. The photographs were analyzed by 3 physiotherapists and individual texting postures rated as "normal," "acceptable," "inappropriate," or "excessively inappropriate." Finally, participants were asked about the occurrence and frequency of neck pain and the degree to which they worry about body posture.

    While the physiotherapists identified 40% of the participants as demonstrating text neck, in the end, authors of the study found no association between reported neck pain and text neck—whether self-perceived or identified in photographs. "Unquestionably, there is an awkward neck position to be found in many mobile phone users but this does not, according to our results, imply an association with neck pain," authors write.

    That's not to say that handheld device use is harmless—or even that the use is not linked in some way to neck pain, researchers say. With 76.6% of participants reporting that they spend 5 hours or more day "reading, texting, and playing" on their mobile phones, authors believe it's entirely possible for problems to develop, even if they're not directly related to posture.

    "The high percentage of participants who use a mobile phone more than 4 hours per day…is a concern, since the time spent with this device seems to be a risk factor for hand/finger symptoms," authors write. "Furthermore, an excess of screen time could lead to physical inactivity which is associated with neck and back pain in young adults."

    Just don't pin that pain on posture, according to the study's authors, who write that the findings of their admittedly limited study "challenge the belief that inappropriate neck posture during mobile phone texting is the leading cause of the growing prevalence of neck pain."

    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: To Avoid LBP, Runners Should Think Deep

    Even though they are keeping fit, up to 14% of American runners experience low back pain (LBP) each year. But runners can reduce their risk by developing their deep core muscles, say authors of a recent study in the Journal of Biomechanics (abstract only available for free).

    While many fitness enthusiasts focus on their abs, they may neglect the trunk muscles they can’t see. “Improper function of this musculature may lead to abnormal spinal loading, muscle strain, or injury to spinal structures, all of which have been associated with increased low back pain risk,” say researchers.

    To test this idea, authors used motion capture technology to collect kinematic data from 8 participants with no history of back pain and no recent injuries. The data, gathered while the participants ran, was used to create simulated full-body models in OpenSim, a software tool for modeling movement.

    In the simulations, researchers gradually weakened the models’ deep core muscles, both individually and together. They found that when deep core muscles are weak, superficial core muscles, particularly the superficial longissimus thoracis (LT), tend to overcompensate, which may result in muscle injury or fatigue. And since the superficial LT was most often the muscle overcompensating for weak deep core muscles, it may be “most at risk for fatigue or injury” if deep core muscles are not functioning properly.

    The authors believe that certain deep core muscles appear to be more important than others in runners. “The deep erector spinae required the largest compensations when weakened individually,” note authors, who conclude that “it may contribute most to controlling running kinematics.”

    When all deep core muscles were weak, or when only the deep erector spinae was weakened, there was a significant increase in both compressive and shear spinal loading in the upper back, with a decrease in the lower back. Over time, this could result in damage to the spine and increase the risk of injury, authors warn.

    Authors suggest further research using simulated models to examine core function in running. The study, researchers observe, “is the first step in providing evidence to support the common notion that poor core strength and stability may influence a runner’s risk of developing injuries such as LBP.”

    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.

    Film Star Kathy Bates Helps to Spread the Word on Lymphedema Management in APTA Oncology Section's Journal

    Health care providers are increasing their knowledge of lymphedema management, but there's still much work to be done. Just ask film and television star Kathy Bates, author of a letter to the editor in a special issue of Rehabilitation Oncology (RO) entirely devoted to the disease. RO is the science journal of the APTA Oncology Section.

    Bates' letter, available for free, not only gives an account of her experience with lymphedema after a bilateral mastectomy but also provides insight into how much the patient experience has changed over the decades. Bates explains that her mother experienced lymphedema after cancer surgery in the 1970s, and that, "with no treatment in those days, I watched her spirit defeated as she realized she would have to live with the pain and heartache for the rest of her life."

    Given the experience with her mother and another individual she knew who lived with lymphedema after surviving stage 4 melanoma, Bates was well aware of the effects of lymphedema and pleaded with her surgeon to leave as many lymph nodes intact as possible. Bates writes that when her surgeon later told her that he felt it necessary to remove 19 lymph nodes from her right armpit and 3 from her right, she was "devastated" and experienced what she describes as an "emotionally draining" recovery.

    Eventually Bates came to terms with the necessity of the node removal, but she now lives with the reality of lymphedema. In the editorial, she writes of her treatment and management of ongoing symptoms, and her more recent work with the Lymphatic Education and Research Network (LEARN), where she now serves as spokesperson.

    Bates writes that with an estimated 140 million individuals with lymphedema—some undiagnosed—it's imperative that efforts to educate both patients and providers continue.

    "Lymphedema needs to be recognized as a disease that deserves money for research," Bates writes. "We need awareness. …Please help me spread the word."

    In an accompanying open-access editorial, guest editor Nicole Stout, PT, DPT, FAPTA, and certified lymphedema therapist from the Lymphology Association of North America, describes the advancements that have been made in both lymphedema management and clinical knowledge among health care providers, but she adds that more needs to be done.

    "The true measure of our advancement is in how our patients are impacted by the evolution in the field," Stout writes. "Decreased wait times to access therapy, more knowledgeable therapists, and better and higher-quality materials and treatment devices have emerged in the last decade. However, there are still significant barriers to care and clinical questions that we must set our sights on solving in the next decade," including payment, access to specialty care, and the slow growth of telehealth services.

    Still, Stout believes that continued technological breakthroughs and increased clinician understanding could pave the way for significant positive change, writing that "the future is bright, the future is smart, and we must continue to seize on opportunities to advance novel approaches to lymphedema management."

    This year, APTA's American Board of Physical Therapy Specialties will begin offering its first-ever specialist certification in oncology physical therapy. Deadline for applications is July 31, 2018.