While it appears that physical therapist (PT) education programs have increased the amount of time spent on pain education over the years, only 63% of faculty respondents to a recent survey believe that today's students are receiving adequate instruction in pain management, according to study published recently in The Journal of Pain (abstract only available for free).
Authors Marie Hoeger Bement, PT, PhD, and Kathleen Sluka, PT, PhD, surveyed accredited PT programs on a range of issues around pain education, including how much time is spent on pain instruction, whether that instruction is delivered in a standalone course, what areas were covered, and whether the education reflected Institute of Medicine (IOM) and International Association for the Study of Pain (IASP) recommendations and guidelines for curriculum development. The survey was conducted between October 2012 and January 2013, and was sent to all PT programs listed in APTA's Physical Therapist Centralized Application Service.
In the end, 167 programs (76%) answered the first portion of the 10-part survey—the section that focused on time spent in pain education—while 137 (62%) completed the remaining sections, which focused on specific content covered and respondent perceptions about the adequacy of instruction.
Among the findings:
Authors describe a lack of data on how pain curriculum has evolved in PT programs, but they cite a 2001 survey that reported a modal of 4 hours. Although the current and earlier studies are not directly comparable, they write, the recent results "appear to be an improvement."
Still, despite increased hours and range of topics covered, only about 6 in 10 respondents felt that their programs offered sufficient instruction in pain management (63%), with 69% reporting that their programs provided inadequate education on pain across the lifespan. "These results suggest that not all PT programs adequately provide pain education in their curriculum, especially pain assessment and management in the young and old," authors write.
Authors also reported that less than half of the respondents were aware of IASP curriculum guidelines, or an IOM report calling for increased education on pain across health disciplines. Among the elements in the IASP guidelines is the recommendation that pain curriculum be taught as a freestanding course.
"Ensuring that PT students receive adequate instruction in pain mechanisms and management would likely result in improved patient outcomes and lower health care costs," authors write. "To stay current in pain education, PT programs should be aware of the latest educational advancements, including the IOM report, IASP guidelines, and pain competencies."
APTA has been a strong advocate for the ways in which physical therapy can be a transformative agent in the treatment of chronic pain. The APTA Orthopaedic Section sponsors a special interest group in pain management, and the PT's role in chronic pain management was featured in the September 2014 issue of PT in Motion magazine.
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 in Sweden are questioning the general trend toward reduced hospital stays after a hip fracture, concluding that for patients whose hospital stays are 10 days or fewer, every 1-day reduction in stay increases the odds of death within 30 days of discharge by 16%.
The study, published in the British Medical Journal, tracked length-of-stay and later mortality of 116,111 patients 50 and older (mean age 82) who experienced a hip fracture and were admitted to hospitals in Sweden from 2006 to 2012. During that period, 30,052 individuals (25.9%) died within 1 year after admission for hip fracture; of those, 5,863 died during the initial hospital stay, and 6,377 died within 30 days of discharge. Researchers in this study focused on the individuals who died within that 30-day mark.
The most common cause of death within 30 days of discharge was listed as "expos[ure] to non-specified factor—home" (21.5%), followed by myocardial infarction (13.2%), cancer (10%), dementia (7.2%), falls 5.9%), and stroke (3.7%). Authors acknowledge the low frequency of autopsies conducted may affect the accuracy of these figures.
Researchers found that patients who were released 10 days or fewer after admission were not only significantly more likely to die within 30 days of release, but this risk increased in relation to the number of days of reduced stay, and seems have grown over time—from an 8% per-day increased likelihood in 2006, to the 16% increased likelihood recorded in 2012. Mean length of stay for hip fracture in Sweden over that time period decreased from 14.2 to 11.6 days.
When authors compared groups at either end of the study spectrum, they found that patients whose hospital stay was 5 days or fewer had twice the risk of death within 30 days of discharge than patients whose stay was 15 days or more.
Although researchers were able to identify a linear increase in risk as inpatient days were reduced, they weren't able to extend that trend in the other direction—stays longer than 11 days didn't seem to decrease the likelihood of death within 30 days of release at rates corresponding to length-of-stay.
Authors theorize that the connection to length-of-stay and mortality at the 10-day mark may have something to do with the time it takes to provide a full geriatric assessment of a patient. "Shorter length of stay … reduces the time available for comprehensive evaluation of medical conditions during hospitalization," authors write. "A growing body of evidence suggests that comprehensive geriatric assessment decreased the risks of complications after hip fracture and death after discharge in elderly patients."
According to the study's authors, future research should not only focus on how diagnoses in addition to hip fracture play into mortality rates, but also "evaluate whether early discharge to rehabilitation centers or nursing homes is associated with a worse outcome."
Researchers in Austria say that they've successfully completed "bionic reconstruction" procedures that allow individuals to use their minds to control a prosthetic hand that can engage in complicated motor control activities such as unfastening buttons, picking up coins, and pouring water from a cardboard carton. All 3 patients who received the prosthesis suffered brachial plexus avulsion injuries and elected to have the injured hand amputated.
The prostheses are controlled through 2 "cognitively separate" electromyographic signals in the forearm—one from nerves and muscles already present in the patient's damaged forearm, and another surgically transferred into the affected arm from the leg. After the signal sites were established, the patients underwent cognitive training by, at first, controlling a graph on a computer screen via electrodes attached to the sites, and then through the operation of a "virtual hand" on the screen.
The final phase of the cognitive training involved a "hybrid hand" that was attached to the nonfunctional hand by way of a "splint-like" device. "As crude as it seems, the device provided direct proof for patients that better hand function could be achieved using the prosthesis than with their denervated hand," authors write.
After the patients completed cognitive training, they underwent amputation of the damaged hand, and were fitted with the bionic prosthesis. Patients completed 3 assessments of global arm function before and after the intervention—the Action Research Arm Test (ARAT), the Southampton Hand Assessment Procedure (SHAP), and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire—and recorded significant improvement in all areas.
Results were published the Lancet (abstract only available for free), accompanied by free videos that show hand function in the patients before the intervention, during the "hybrid" stage, and after being fitted with the prosthesis. The videos show the patients using the prostheses to unscrew a jar lid, unfasten buttons, pick up coins, and pour water, among other activities. News of the research was also featured in major media outlets including theNew York Times and CNET.
"Pre-interventional testing showed that all patients had dismal hand function," authors write. "The patients did not use the impaired hand in daily life, even when the bimanual tasks were specifically requested." After becoming accustomed to having 2 functional hands, the patients engaged in bimanual tasks, and were able to wear their prostheses 8-12 hours a day. Tests of overall psychological wellbeing also showed improvement—another positive sign for the researchers who had purposefully selected patients "who had had great psychological harm as the result of the injury."
"The loss of hand function after global brachial plexus injury with lower root avulsions poses a reconstructive challenge that is difficult to overcome," authors write. "Present surgical techniques for such injuries are crude and ineffective." However, they argue, the technique they pioneered presents "no technical or surgical limitations that would prevent this procedure from being done in centers with similar expertise and resources."
Physical therapy is front-and-center in a high-profile $64 million program that seeks to anchor research to real-world practice: this week, the Patient-Centered Outcomes Institute (PCORI) announced that 2 of its 5 inaugural funds have been awarded to projects led by prominent physical therapy researchers Pamela Duncan PT, DPT, FAPTA, and Anthony Delitto , PT, PhD, FAPTA. Combined, the researchers will receive nearly $28 million in support.
Both projects are focused on getting physical therapists (PTs) involved in patient care early-on, and both will be conducted as "pragmatic clinical studies"—research that analyzes a care option’s effectiveness in real-life practice situations, such as typical hospital and outpatient care settings, with diverse patient populations. According to a PCORI news release, unlike standard clinical trials that "test whether a care approach works under optimized conditions with carefully selected patients in research centers," the findings from pragmatic studies "are more likely to be applicable to a wide variety of patients."
Duncan is professor of neurology at Wake Forest Baptist Medical Center. Delitto is associate dean of research at the University of Pittsburgh School of Health and Rehabilitation Sciences.
PCORI awarded $14 million for Duncan's project, which will involve stroke patients in 50 hospitals in North Carolina to find out if early discharge with ongoing support by PTs and other providers results in better daily function outcomes than longer hospital stays and standard transitional care. The study "will also consider caregiver strain, hospital readmission rates and mortality, use of health care, consistency of physician care, use of transitional care services, and death," Duncan writes in her summary of the project.
Delitto received $13.9 million in PCORI funding to look at the individual's transition from acute low back pain (LBP) to chronic LBP by focusing on 2 approaches in the outpatient primary care physician (PCP) setting—one "usual care" approach, and a second approach that would team up PCPs with PTs to provide cognitive behavioral therapy (CBT). Patients who have LBP and risk factors for moving from acute to a more persistent state of LBP will be the targeted population for the project, which will involve 12 PCP clinics in 5 different areas across the country. Delitto hopes to recruit 2,640 patients and acquire data on 2,400 over 6 months after enrollment.
"This study is designed to look at the value of a stronger partnership between primary care and physical therapy, particularly for painful musculoskeletal conditions," Delitto said. "A number of studies have come out detailing the success of the PCP plus PT-CBT approach, but they've all been conducted in Europe. Before we can recommend any approach, it should be thoroughly and rigorously tested in the US, with its unique health care system."
The program, with its focus on pragmatic trials, is intended to encourage exactly that kind of approach, according to PCORI Executive Director Joe Selby, MD, MPH.
"A critical feature of these studies is that they will involve all major stakeholder groups as partners, increasing the chances that the studies will be implemented in a useful way and analyzed with an eye toward implementation," said Selby in the news release. "And, if warranted, their results will be put to use in practice much more quickly than most research."
"We are extremely pleased that APTA member PT researchers are among those selected," said Paul A. Rockar Jr, PT, DPT, MS, APTA president in an association news release. "With improved patient outcomes based on evidence, we will be closer to achieving APTA's vision of transforming society by optimizing movement to improve the human experience."
PCORI is an independent, nonprofit organization authorized by Congress in 2010. Besides the Duncan and Delitto projects PCORI will also be funding research on breast cancer screening, the intensity of CT surveillance needed to detect lung cancers, and how a standing-order entry system advising physicians when to prescribe a medication to prevent infections reduces over- and underuse of this medication among patients with breast, lung, or colorectal cancer.
When patients with Parkinson disease (PD) were told that their injections cost $1,500, their motor function improved significantly more than when they received a $100 injection ... even though both were placebos.
Researchers conducted a prospective double-blind study in 12 patients with moderate to severe PD and motor fluctuations who were randomized to a “cheap” or “expensive” subcutaneous “novel injectable dopamine agonist placebo”—which actually was ordinary saline solution. Patients were crossed over to the alternate arm approximately 4 hours later.
Blinded motor assessments in the “practically defined off” state before and after each intervention included the Unified Parkinson’s Disease Rating Scale motor subscale, the Purdue Pegboard Test, and a tapping task. Brain activity measurements were performed using a feedback-based visual-motor associative learning functional MRI task. The results were e-published ahead of print in Neurology (abstract only available for free).
Although both placebos improved motor function, the benefit was greater when the patients were randomized first to the expensive placebo, with a magnitude halfway between that of the cheap placebo and levodopa.
The knowledge of cost also seemed to affect brain activity. "Our data showed that brain activation of visualmotor associative circuits is greatest when cheap placebo is given first and lowest when expensive placebo is given first, suggesting greater brain 'effort' (more activity) under placebo conditions of lowered expectations," authors write.
The researchers conclude: “Expensive placebo significantly improved motor function and decreased brain activation in a direction and magnitude comparable to, albeit less than, levodopa. Perceptions of cost are capable of altering the placebo response in clinical studies."
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.
Therapeutic taping may be getting increased exposure through its use by high-profile athletes, but authors of a new systematic review say that existing evidence doesn't support the idea that the procedure is superior to other treatment approaches in reducing pain and disability for individuals with chronic musculoskeletal pain.
In an article published recently in the British Journal of Sports Medicine (abstract only available for free), researchers describe their analysis of 17 randomized controlled trials that included taping (often referred to as "Kinesio taping" or KT) with minimal or placebo intervention, as well as with more active treatment approaches including exercise, stretching, traction, and manipulation.
Authors limited their analysis to trials that focused on individuals with chronic pain and disability, which they defined as a condition last for more than 4 weeks. Combined, the trials involved 416 patients in the experimental group and 406 in the control group.
While therapeutic taping was found to be "superior to minimal care"—approaches that included sham taping, no taping, and "usual care"—authors write that "KT is not more effective than other forms of intervention in reducing pain," and "is also not more effective than minimal or other forms of intervention in the reduction of disability."
They write that "the null effect of KT on disability signals the need for conventional therapy, for example, other active forms of intervention, over and above passive treatment, in the management of musculskeletal pain lasting [longer than] 4 weeks."
While taping alone didn't seem to produce significant reductions in pain and disability, authors did find evidence supporting its effectiveness as an adjunct to exercise-based treatments in some instances.
"Our review suggests that KT, when used in combination with conventional therapy, may be effective in reducing pain," authors write. "Our clinical impression is that many clinicians use KT in this way—as an adjunct to exercise."
The researchers cited limitations that include the small number of studies analyzed and "somewhat varying methodology and treatment 'dosage'" of taping application. That variance included not only how the tape was applied, but the number of treatment sessions (from 1 to 12), the frequency of sessions (from 1 to 5 times a week), the length of treatment (from 1 to 6 weeks) "There is a need for the use of standard application procedures (by body parts) to determine efficacy of [therapeutic taping] in future studies," authors write.
Partly because of the attention therapeutic taping has received through its use by professional and Olympic athletes, the research results were reported by media outlets including Reuters news service.
A systematic review on therapeutic taping for spinal pain and disability was recently e-published ahead of print in APTA's journal, Physical Therapy. Full text of that article is available for free to APTA members.
The CoHSTAR research center that aims to play a transformative role in physical therapy health services research has officially opened its call for postdoctoral fellows.
Applications are being sought for 1- or 2-year fulltime postdoctoral fellowship trainees committed to advancing health services and health policy research capacity in physical therapy. with the fellowship will provide didactic training, travel support, information resources, secretarial and technical support, and a proposed stipend of $55,000 annually. Health benefits, vacation time, and sick days are also included.
Fellowships may be based at participating CoHSTAR sites at Brown University, Boston University, or the University of Pittsburgh. Terms could begin as early as July 1, 2015.
Application instructions (.pdf) are available at the Foundation for Physical Therapy's (Foundation's) CoHSTAR webpage. Initial application requirements include a curriculum vitae, an essay, 3 current reference letters, and a copy of written work. Qualified candidates will be physical therapists with a PhD, ScD, or DrPH, or doctors of physical therapy (DPT) with formal research training and doctoral-level publication experience.
CoHSTAR (official name: the Center on Health Services Training and Research) was created through a $2.5 million grant awarded by the Foundation through its "Center of Excellence" initiative. In addition to the fellowships, CoHSTAR will host visiting scientists and provide special summer training sessions. The center will also fund several pilot studies each year from investigators inside and outside the program.
For more information about the CoHSTAR fellowship program, email Audrey Kidd or call 401/863-3631.
When it comes to complementary health practices, Americans love their dietary supplements—but yoga and other ancient movement practices are gaining ground.
A new study (.pdf) from the US Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics (NCHS) looked at the use of complementary health techniques and found that in 2012, 34% of adults in the US reported using 1 or more of the approaches, with 17.7% reporting the use of nonvitamin/nonmineral dietary supplements.
The second most-reported complementary approach was deep breathing exercises (10.9%), followed closely by yoga, tai chi, or qi gong (10.1%). Of these, yoga, tai chi, and qi gong showed the biggest increase since a similar study in 2002, when only 5.8% of respondents reported engaging in these activities. Other approaches remained at similar levels in 2002 and 2012, with a slight uptick noted in a 2007 study.
Approaches defined as "complementary" for purposes of the most recent study included: acupuncture, Ayurveda, biofeedback, chelation therapy, chiropractic care, energy healing therapy, special diets (vegan, vegetarian, macrobiotic, Atkins, Pritkin, and Ornish), folk medicine/traditional healers, guided imagery, homeopathic treatment, hypnosis, naturopathy, nonvitamin/nonmineral dietary supplements, massage, meditation, progressive relaxation, qi gong/tai chi/yoga. The use of deep breathing was collected as a part of other approaches such as hypnosis and meditation.
Although many overall numbers didn't change dramatically, authors of the report noted some shifts within categories—most notably around the use of supplements.
According to the report, while still the most popular complementary approach, Americans have moved their use of nonvitamin/nonmineral supplements away from glucosamine and chondroitin (though still very popular), and are also not taking as much Echinacea, garlic, ginseng, ginko biloba, methylsulfonylmethane (MSM), and palmetto as they did in 2002.
The real favorite? Fish oil, which increased from 4.8% in 2007 to 7.8% in 2012. Another big gain was in the use of prebiotics and probiotics, which rose from .4% in 2007 to 1.6% in 2012, becoming the third most commonly used nonvitamin/nonmineral dietary supplement.
Although the study merged yoga, tai chi, and qi gong under the same category, authors report that yoga amounted to 80% of the reported use within that category. According to the report, use of yoga has risen across all age groups, with the most marked increase in adults aged 18–44, from 6.3% in 2002 to 11.2% in 2012.
How do complementary, alternative health approaches integrate with physical therapy? That's the subject of a feature story in the July 2014 issue of PT in Motion magazine, available to APTA members.
Authors of a new study conclude that incidence rates for new-onset tennis elbow have decreased "significantly" since 2000, while the use of surgery continues to rise. What's harder to pinpoint is exactly why the numbers look the way they do.
In what its authors believe is the first-ever study to describe the incidence and natural history of lateral elbow tendinosis (LET), researchers closely examined medical records of 5,867 patients in a single Minnesota county for incidence and surgery rates between 2000 and 2012. Additionally, a random 10% sample of this patient population was reviewed more carefully to focus on "describing the natural history, recurrence rates, and utilization of nonsurgical and surgical treatments.” The study was e-published ahead of print in the American Journal of Sports Medicine(abstract only available for free).
Researchers included all diagnoses consistent with lateral epicondylitis, medial epicondylitis, synovitis–upper arm, and synovitis–forearm.
Researchers found that during the 12-year study period, overall rates of new-onset LET decreased "significantly," from 4.5 per 1,000 in 2000 to 2.4 per 1,000 in 2012. During that same period the rates of surgical procedures for LET increased, from about 1% of all diagnosed cases between 2000 and 2008, to 3% of the cases from 2009 on. The rates were similar for men and women.
Authors write that the reasons for the drop in incidence are unknown "but could potentially include … a true change in incidence, changes in the diagnosing patterns among physicians, or fewer patients with mild disease seeking professional care after using alternative resources for self-diagnosis and treatment."
As for the rise in surgical procedure rates, authors speculate that surgical options have become more widely available "as techniques become more refined and outcomes more predictable." At the same time, they write, the rise could be linked in some ways to the decline of reported incidence, "as fewer patients with mild disease seek professional care."
Among other findings in the part of the study that focused on the 10% sample:
Of the 576 patients studied, 8.5% experienced recurrence of LET, with a median time to recurrence of 19.7 months.
Authors acknowledged limits to their research that included a lack of racial diversity among subjects, absence of data on self-diagnosed LET and individuals who do not seek medical attention, and a possible underestimation of recurrence rates due to the use of the 10% cohort for data. Still, they write, the "unique medical records linkage system" provided by the county hospital system "allows for near-complete ascertainment and validation of all clinically recognized cases of [LET] in a well-defined population."
According to results of a new systematic review, moderate-grade evidence seems to support strengthening and stretching exercises to help ease chronic neck pain, while the use of endurance and stretching exercises alone don't seem to make much of a difference. But the real takeaway of the recently published Cochrane review is that much more work needs to be done to better classify this type of pain and to better track exercise dosage information.
The review, published on January 28, examined 27 trials (2,485 participants) aimed at identifying whether exercise reduced neck pain and disability, improved function, and increased patient satisfaction and reported quality of life. The trials included studies that compared an exercise treatment with no treatment or a placebo, as well as those that combined exercise with another intervention such as manipulation, massage, education, heat, or medications. Reviewers excluded trials that included exercise as part of a multidisciplinary or multimodal treatment and those that "required application by a trained individual."
While none of the studies produced what reviewers classified as strong evidence, authors pointed to "moderate"-level evidence that "there appears to be a role for strengthening exercises" in treatment of not only chronic neck pain, but cervicogenic headache and cervical radiculopathy, "if these exercises are focused on the neck, shoulder, and shoulder blade region."
As for specific exercises and approaches, reviewers also found limited evidence that sustained natural apophyseal glides seemed to be among the more effective exercises for treatment of cervicogenic headaches, and "mindfulness exercises" such as Qigong possibly beneficial for mechanical neck pain, though the improvement may be slight.
Among other findings in the review:
The lack of strong evidence overall points not only to a need for more rigorously constructed research, but for more agreement on some fundamentals around neck pain and exercise interventions, according to the review authors.
"To date, there is no standardized definition of mechanical neck pain even if it has evolved over the last three decades," authors write. Given the variability of the group identified as experiencing neck pain, they write, "subgrouping based on diagnosis, treatment, or prognosis system classification would be useful to increase homogeneity for research and clinical applicability."
Another impediment to strong research in this area: exercise classification and dosage requirements. Authors of the review advocate for a classification system that describes "the physiological effect of exercise on the body rather than describing the types of activity used to produce that effect" and "allow[s] … researchers to classify exercises into a specific category by recognizing their mechanisms of actions." Additionally, authors of the review assert that "in general, there is also limited evidence on optimal dosage requirements … for exercise therapies and other modalities used to treat neck disorders."
Until more solid research is produced, providers should take a careful approach when considering evidence to date, authors state.
"The level of evidence of these studies varied from low to moderate," authors write. "Thus clinicians should not underestimate their clinical judgment in the choice of optimal treatment modality for client needs."
APTA members can access the full text via the Cochrane Database of Systematic Reviews in PTNow ArticleSearch; nonmembers can access the abstract only for free via PubMed.
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