• Tuesday, March 31, 2015RSS Feed

    Study: Early Mobility Sparks Biochemical Change to Fight Acute Respiratory Distress Syndrome

    The benefits of early movement and exercise for patients in intensive care units (ICUs) are well-known. Less clear is what happens within the body to bring those benefits, particularly in patients with acute respiratory distress syndrome (ARDS). Now researchers working with mice on treadmills think they're closer to understanding at least some of the positive biochemical changes that are triggered by early mobility.

    Researchers from Wake Forest University injected mice with a chemical that produced acute lung injury similar to ARDS, and then exercised them on treadmills from 5 minutes a day to 35 minutes twice a day. What they found was that exercise acts on several different proteins that serve as a "rheostat" to turn down the immune response associated with ARDS.

    In other words, not only did early mobility counter muscle wasting, it helped regulate body chemistry in ways that diminished ARDS. The results were published in the March 11 edition of Science Translational Medicine(abstract only available for free).

    After tracking the changes in protein levels in mice, researchers then looked at banked plasma from patients with acute respiratory failure (ARF) who had participated in an earlier clinical trial examining early mobility vs no exercise. Once again, they found decreased levels in at least 1 of the proteins associated with regulation of the immune response—a 68% reduction after day 7 of early mobility, compared with a 29% reduction in the no-exercise group.

    "There is a complex immune response to injury and it appears that exercise is acting on multiple different proteins that involve the innate immune system and dampen this over-exuberant immune response," lead author D. Clark Files, MD, said in a Wake Forest University press release. "This study gives a lot of biological relevance to how and why early mobility tends to work."

    ARDS is estimated to affect 200,000 people a year in the US, occurring most often in individuals who are critically ill. The study's findings were reported by the Associated Press, and stories on the research have appeared in the Minneapolis Star Tribune, the Washington Times, and ABC News.

    Researchers conclude that in addition to underscoring the benefits of early mobility, the study makes a case for the sooner the better. "Our findings imply that early mobility therapies in the critically ill should start as early as possible," they write.

    Physical therapists (PTs) are an integral part of the ICU team, and key providers able to demonstrate the benefits of early rehabilitation. Many resources on the role of the PT in the ICU are available from APTA and its Acute Care Section, including special issues on critical care in the journal Physical Therapy (here and here); a clinical summary on physical therapy in the ICU; and a text-based ce program on promoting early mobility and rehabilitation in the ICU. More resources are being developed.

    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.

    Thursday, March 26, 2015RSS Feed

    Foundation Announces 2015 Award Recipients

    This year's recipients of the Foundation for Physical Therapy's (Foundation) Service Awards have advanced the cause of physical therapy research in a variety of ways, from providing funds to partnering with the Foundation, and from helping behind the scenes to leading its work.

    The 2015 awards and winners are:

    • Spirit of Philanthropy Award: Lansdale and Gladys Claggett (posthumous award)
    • Charles M. Magistro Distinguished Service Award: Robert C. Bartlett, PT, MA, FAPTA
    • Premier Partner in Research Award: Neurology Section of APTA
    • Robert C. Bartlett Trustee Recognition Service Award: William G. Boissonnault, PT, DPT, DHSc, FAPTA, FAAOMPT, and Anthony Delitto, PT, PhD, FAPTA

    "Each of our service award recipients has played a vital role in the Foundation’s ability to carry out its mission to fund and publicize physical therapy research," said Foundation Board of Trustees President Barbara Connolly, PT, DPT, EdD, FAPTA, in a Foundation news release. "We recognize that much of the hard work and support of these individuals and organizations occurs behind the scenes, and we are extremely appreciative."

    This year’s recipients will be recognized during the Foundation’s gala on June 4, 2015, during the NEXT conference in National Harbor, Maryland.

    Wednesday, March 25, 2015RSS Feed

    More Studies Question Advisability of Imaging for Back Pain

    The back is back.

    Last week, PT in Motion News reported on a new study supporting the idea that initial referral to a physical therapist (PT) for new uncomplicated low back pain (LBP) resulted in lower overall costs and utilization than referral for advanced imaging. Since then, more articles have surfaced that question imaging as a "go to" strategy for the condition.

    According to an article in HealthDay News, a March 17 study published in JAMA (abstract only available for free) concludes that for older adults, receiving diagnostic imaging for new back pain not only fails to produce better outcomes but actually tends to increase the costs associated with health care over time.

    "Although early imaging is not associated with better pain and function outcomes, it is associated with greater use of health care services, such as visits [and] injections," study author Jeffrey Jarvik, MD, MPH, is quoted as saying in the HealthDay article, adding that it's a difference that "translates into a nearly $1,500 per patient additional cost, for no measurable benefit."

    In another small study e-published ahead of print in the journal Spine (abstract only available for free), researchers analyzed the results of 300 blinded MRI scans conducted by medical radiologists, chiropractors, and chiropractic radiologists to assess both the consistency of readings across disciplines and, secondarily, the ability to diagnose LBP in the first place based on imaging.

    Their findings? There was "considerable misclassification in all 3 groups," and agreement between chiropractic and medical radiologists was "modest at best."

    "This study supports recommendations in clinical guidelines against routine use of MRI in low back pain patients," authors write.

    The findings contained in both articles echo the results of a study by physical therapist researchers Julie M. Fritz, PT, PhD, FAPTA, Gerard P. Brennan, PT, PhD, and Stephen J. Hunter, PT, PhD, OCS, that found initial referrals for physical therapy for patients with new episodes of low back pain (LBP) resulted in less than half the cost of an imaging-first approach, and generated lower costs associated with use of health care resources over time.

    The study, published in the journal Health Services Research (abstract only available for free), cited average savings of nearly 72% when physical therapy was used as the first-referral option.

    "This is one of many studies demonstrating that physical therapy is a cost-effective alternative to medication and surgery," said APTA President Paul Rockar Jr, PT, DPT, MS, in a news release about the research. "Patients benefit from an active approach to their care and, in turn, society is transformed through the benefits from reduced financial burdens on our health care system."

    Available at the APTA Learning Center:  pre-recorded CE on manipulation for LBP presented by study author Julie M. Fritz, PT, PhD, FAPTA. 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.

    Friday, March 20, 2015RSS Feed

    Systematic Review: Dry Needling, Ischemic Compression for Neck Pain Supported by Moderate-to-Strong Evidence

    Authors of a new systematic review of neck pain interventions say that while it's clear more research is needed, there is already moderate-to-strong evidence that both dry needling (DN) and ischemic compression (IC) can lessen pain intensity and increase range of motion, at least in the short-term. Evidence on the treatments' effects in other areas associated with functionality and quality of life, however, is another story.

    The review, e-published ahead of print in the American Journal of Physical Medicine & Rehabilitation (abstract only available for free), examined 15 clinical trials focused on trigger points (TPs) in the upper trapezius (UT) muscle in patients with neck pain, comparing either IC (7 studies) or DN (8 studies) with other interventions. None of the studies compared DN with IC.

    The studies themselves varied in size (from 39 to 117 patients), and some employed more than 1 intervention (for instance, the use of stretching exercises in all groups in some studies), but all were limited to randomized clinical trials in which all participants had neck pain with active or latent TPs in the UT—a feature of myofascial pain syndrome. Only studies that focused on the therapeutic effects of treatment were included, with articles about side effects or complications excluded.

    Researchers found strong evidence that DN (which they defined as an intramuscular procedure that could include insertion of needles into the TP) reduced both pain intensity and the pressure pain threshold, although not necessarily any more than other treatments, including lidocaine injections, passive stretching, and muscle energy techniques (MET). Similar results were found for the IC studies, which presented moderate-to-strong evidence that both pressure pain threshold and pressure pain intensity were reduced.

    The other area that returned moderate evidence of effectiveness had to do with range of motion (ROM)—specifically, side bending. Here, researchers found evidence, albeit sometimes weak, that both DN and IC were as effective as other approaches, and that in at least 1 study, IC seemed to have an effect over time as well. "The increase in side-bending ROM after IC was equal to MET and passive stretching immediately after treatment," authors write, "but it was significantly greater 24 [hours] and 1 [week] after treatment."

    The review found little available evidence to support the interventions' effects on functionality or quality of life, including how the interventions may lessen depression.

    Areas for future research abound. Authors noted, for example, that "there is strong evidence that DN has an analgesic effect," but that "the optimal dosage remains unclear and requires further research."

    Also lacking--research on DN and IC compared with each other, as well as studies on the effectiveness of the interventions over time.

    "Until now, most studies have evaluated the immediate effect of IC and DN, with only a few studies describing longer-term effects," authors write. "Although the goal of DN and IC is often rapid relief of pain so that patients can be progressed to other forms of therapy, further research of long-term effects is needed."

    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.

    Wednesday, March 18, 2015RSS Feed

    Referral to Physical Therapy Lowers Care Utilization for LBP vs Referral for Imaging

    A recently published study of patients with new low back pain (LBP) who received referral from a primary care provider concludes that not only is physical therapy a less expensive next step than advanced imaging, it's an approach that results in lower utilization costs over time.

    Researchers Julie M. Fritz, PT, PhD, FAPTA, Gerard P. Brennan, PT, PhD, and Stephen J. Hunter, PT, PhD, OCS, analyzed utilization records and other health information for 841 individuals who consulted with a primary provider about uncomplicated LBP and were referred for management outside primary care within 6 weeks. Of those individuals, 385 received advanced imagining and 377 received physical therapy (the remaining 79 patients received a physician specialist visit or "other care," including chiropractic). The study focused on records obtained from 21 different providers around Salt Lake City, Utah, between 2004 and 2010.

    What they found was that across the board, physical therapy was the less costly approach. Initial referral for physical therapy cost $504 on average (for an average 3.8 visits), compared with an average of $1,306 for magnetic resonance imaging (the technology used in "almost all" of the imaging, according to authors).

    Even more dramatically, average subsequent costs over the next year were over 66% lower for the patients who began with a physical therapy referral--$1,871, compared with $6,664 charged to the imaging group over the same time period. Those differences remained largely in place even when researchers matched individuals for covariates including prior surgery, use of medication, osteoporosis, and mental health issues. Results of the study appear in the journal Health Services Research (abstract only available for free).

    Authors found that patients who receive imaging as a first referral often follow a different path than those who receive physical therapy, writing that referral to imaging "increased the odds of surgery, injections, specialist, and emergency department visits within a year."

    Researchers attribute some of the variation to perceptions around imaging. "Advanced imaging often 'labels' a patient's LBP that might otherwise be viewed as nonspecific and uncomplicated, causing heightened concern in some patients and providers and motivating additional care-seeking," they write.

    On the other hand, they write, "physical therapy may avoid the negative consequences of a labeling effect from imaging" by "provid[ing] patients with an active approach to LBP, enhancing patients' perceived ability to self-manage their condition."

    "This is important research, because it provides even more evidence that physical therapy is a less costly alternative to medication, surgery, and other invasive medical procedures," said Nancy White, PT, DPT, APTA executive vice president of professional affairs. "Not only do patients benefit from the improved outcomes resulting from an active approach to care, society benefits from the reduced financial burden on our health care system. The cost savings Fritz and her colleagues describe here are significant enough to be recognized by health policy makers, payers, and other health professionals."

    Authors acknowledge that their study was limited to newly reported and uncomplicated LBP, and that patient-centered function or satisfaction outcomes were not recorded. Still, they write, for individuals with this type of LBP who have expectations for additional care beyond a primary provider, "physical therapy may be the preferred initial step instead of advanced imaging."

    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.

    Tuesday, March 17, 2015RSS Feed

    Study Says Predictors of Parkinson Disease May Be Present 10 Years Before Diagnosis

    New research from England is connecting the dots between Parkinson disease (PD) and a range of motor and nonmotor symptoms that could occur as much as 10 years before a PD diagnosis is made—some of which, like depression or shoulder pain, may escape a connection to the disease and instead be diagnosed as a separate condition.

    In an article published in the January issue of The Lancet (.pdf), researchers report on their study of 54,000 British men and women over a 14-year period (1996-2012), 8,166 of whom were diagnosed with PD at some point, and 46,775 who did not have the disease. By following health records over time, authors were able to trace several "prediagnostic features" that could have a connection to the earliest signs of damage from PD.

    The features studied included not only tremor, rigidity, balance impairment, and neck and shoulder pain and stiffness, but also constipation, hypotension, erectile dysfunction, urinary dysfunction, and dizziness. Additionally cognitive-behavioral features including memory problems, late-onset anxiety or depression, cognitive decline, and apathy were traced over time.

    Among the findings:

    • At 2 years before a PD diagnosis, the prevalence of all features studied—except neck pain and stiffness—was greater in patients who went on to develop the disease.
    • At 5 years before a PD diagnosis, those who were later diagnosed showed a higher incidence of tremor, balance impairments, constipation, hypotension, erectile dysfunction, urinary dysfunction, dizziness, fatigue, depression, and anxiety than the control group.
    • At 10 years before a PD diagnosis, the incidence of tremor and constipation was higher among the individuals who would later be diagnosed with the disease.

    "The results of this study support the existence of a long prediagnostic phase of Parkinson disease, which comprises both motor and non-motor features," authors write.

    "The features that we identified as occurring many years before diagnosis included those that are often regarded as symptoms of advanced Parkinson disease … [as well as those] that are non-specific … or that … are likely to be initially diagnosed as different disorders," they write. "Nevertheless, all of these symptoms are not only common in typical Parkinson disease, but also might represent the earliest stages of Parkinson disease."

    The study was the subject of a New York Times article that also reported on efforts to identify biomarkers that could home in on the presence of disease early on, given that the prediagnostic conditions listed in the Lancet article can be "common and quite nonspecific," according to the NYT.

    Authors of the Lancet article write that recognition of the prediagnostic conditions may prove to be useful not only in developing further research on the progression of PD but could also open the door to earlier intervention.

    "Our finding of multiple prediagnostic symptoms and their pattern of presentation in the 10 years before diagnosis suggests that screening might be feasible in the general population," they write, noting that any screening program "would need to be carefully considered and several preconditions, such as benefit of early treatment, should be fulfilled."

    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.

    Thursday, March 12, 2015RSS Feed

    Study: Postacute Care Outcomes More About Facility, Less About Region

    Authors of new research on postacute care settings have found that variation in outcomes for inpatient stroke rehabilitation may have more to do with individual facilities than geography—a conclusion they contend should make the US Centers for Medicare and Medicaid Services (CMS) think twice about how it will address differences.

    In a study of 145,460 Medicare patient records from 1,209 rehabilitation facilities across the US, researchers found that from 2006 to 2009, while functional status levels at discharge varied by 29.2 points across facilities, variation was only 3.57 points when outcomes were grouped by hospital referral region (HRR). Functional status was measured close to admission and discharge using the inpatient rehabilitation facility patient assessment instruction (IRF PAI), which includes 18 items from the functional independence measure (FIM) aimed at assessing cognitive and motor skills.

    Researchers analyzed those functional outcomes by way of 3 models—outcomes of patients within individual facilities, outcomes of patients by HRR, and outcomes of patients within facilities by HRRs.

    What they found was that variation differed according to—and was affected by—how the outcomes were grouped. When outcomes were analyzed according to facilities alone, the researchers found that once demographic and clinical covariates were accounted for, variation for cognitive and motor outcome ratings were 8.7% and 9.5%, respectively. When outcomes were analyzed only by HRR, overall variance was 3.7%.

    When authors "nested" the 2 settings—facility within HRR—they found marked differences in the way the settings impacted each other. Researchers estimate that while the HRR did reduce facility variation by as much as 8%, factoring in individual facility data into HRRs reduced variation among HRRs by 82%.

    "Our findings suggest that facility effects account for more variation in functional status following inpatient stroke rehabilitation than geographic region," authors write. "Each of our multilevel models supports this interpretation." The study was e-published ahead of print in the Archives of Physical Medicine and Rehabilitation (abstract only available for free).

    Authors believe that their results are a counterpoint to an Institute of Medicine (IOM) study, whose findings "suggest that some regions are more efficient than others at delivering quality care." That study has been a factor in CMS consideration of more standardized measures for postacute care facilities--measures that will have payment implications for providers.

    Authors of the new study call for more research into why, precisely, the facility variation exists, but suggest that "systematic selection of patients at facilities" might have something to do with the differences, as well as "patterns of care" affected by "differences in stroke guidelines and treatment approaches."

    "As CSM moves forward with identifying and implementing functional status as a quality measure for rehabilitation, it is critical that facility administrators, policymakers, and researchers explore facility strategies that influence variation in outcomes of care," authors write. "The IOM report highlighted the need to focus efforts on improving the quality of rehabilitation among low performing regions. Our study of functional status at discharge suggests that improvements that minimize regional variation in post-acute care cannot focus solely on regional reimbursement adjustments."

    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.

    Wednesday, March 11, 2015RSS Feed

    Systematic Review: Telerehabilitation Data 'Encouraging' but Not Conclusive

    Telerehabilitation is on the rise, but conclusive research on its effectiveness in regaining motor function is still lacking—except maybe when it comes to recovery from total knee arthroplasty (TKA).

    A systematic review published in the February 22 issue of the Journal of Telemedicine and Telecare (abstract only available for free) analyzed the results of 12 randomized clinical trials that focused specifically on the use of telerehabilitation and the regain of motor function in 3 areas: neurological, cardiac, and TKA. A total of 1,047 individuals participated in the study, with 543 patients receiving telerehabilitation.

    While not definitive, researchers did find that telerehabilitation had a "significant positive effect" on individuals who had received TKA surgery. Results of Timed Up and Go (TUG) tests showed that "a researcher would expect patients treated by telerehabilitation to improve 6.5 seconds more than patients treated routinely, on average," authors write. They caution that of the 3 TKA studies reviewed, 1 was at high risk of selection and attrition bias, which could have affected overall analysis.

    The studies on individuals affected by neurological or cardiac conditions were less conclusive, but for different reasons. Authors found a "paucity" of eligible trials on telerehabilitation and cardiac conditions, and were only able to include 2 in their analysis. And although telerehabilitation trials related to neurological conditions represented 7 of the 12 trials included in the analysis, those numbers couldn't make up for small sample sizes and the difficulties of conducting these kinds of trials given the "broad range of disability experience by patients, the burden of care on caregivers and the long time needed to observe meaningful changes of clinical outcomes," authors write.

    For purposes of their analysis, researchers only included studies involving rehabilitation delivered "by means of any technological device" allowing for online and offline provider/patient interaction, and involving remote supervision.

    Authors write that while the analysis did not provide "final evidence" of the effectiveness of telerehabilitation on motor function, "the current data are encouraging and support continuity of rehabilitation care through [Internet and communication technologies]."

    "The main potentiality of telerehabilitation is the possibility to increase the frequency and intensity of care provided to patients and consequently motivate clients in their own home environment," authors write. "But the quality of primary research has to be improved dramatically to have a clearer picture of benefits and risks associated with assisting patients at a distance, once discharged at home."

    In 2014, APTA's House of Delegates approved a resolution that supports the adoption of telehealth technologies in physical therapy as "an appropriate model of service delivery" when provided in ways that are "consistent with association positions, standards, guidelines, policies, procedures, Standards of Practice for Physical Therapy, Code of Ethics for the Physical Therapist, Standards of Ethical Conduct for the Physical Therapist Assistant, the Guide to Physical Therapist Practice, and APTA Telehealth Definitions and Guidelines; as well as federal, state, and local regulations." The association offers resources on its telehealth webpage.

    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.

    Friday, March 06, 2015RSS Feed

    Use Your Words: Small Study Says Descriptions Make a Difference in Men's Pelvic Floor Training

    When it comes to training men to activate their pelvic floor muscles, it may be good to have a way with words.

    A new study from Australia conducted on a small group of men has found that the words used to describe activation of pelvic floor muscles (PFM) made a difference in the extent to which the striated urethral sphincter (SUS) muscle is activated with limited increase in intra-abdominal pressure (IAP)—the optimal combination to help men counter urinary incontinence, authors believe.

    Researchers recruited 15 healthy men under the age of 50 (6 of whom were physical therapists) to respond to verbal instructions aimed at activation of pelvic floor muscles. Activation was monitored through ultrasound imaging, and 3 of the 15 individuals participated in a follow-up experiment that used invasive fine-wire electromyography (EMG) to measure the effectiveness of sonography as a way of tracking activation. Results were published in Neurourology and Urodynamics (abstract only available for free).

    Authors write that they used 4 specific instructions: "tighten around the anus," "elevate the bladder," "stop the flow of urine," and "shorten the penis." Participants were instructed to follow the verbal cues to perform 3 repetitions, with each contraction sustained for 3 seconds and separated by an approximate 10-second rest. The verbal instructions were given in random order.

    The most effective instruction in terms of midurethra (MU) displacement? "Shorten the penis," followed by "stop the flow of urine." The instructions that resulted in the best anorectal junction displacement were "tighten around the anus," followed by "stop the flow of urine."

    A secondary finding: results from the 3 individuals who participated in EMG monitoring seemed to reveal that sonography captured displacement effectively enough to serve as a useful monitoring system—a result that researchers believe could help foster further noninvasive studies.

    Authors note that results of clinical trials on the effectiveness of pelvic floor muscle exercises for men with incontinence have been "mixed"—but that inconsistency may be linked to the instructions men were given.

    "It is plausible that the variability in results between seemingly similar clinical trials might be influenced by the strategies used to train muscular mechanisms for urinary continence," they write. "The optimal instructions to activate the pelvic floor muscles are likely those that induce the greatest amplitude of pelvic floor muscle shortening with minimal increase in abdominal muscle activity and IAP. From the current data, the best instruction to shorten the SUS is 'shorten the penis' or 'stop the flow of urine.'"

    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.

    Friday, March 06, 2015RSS Feed

    Demand for PTs Likely to Increase, Even With More Graduates Available

    The latest data from APTA show that while an increase in graduates from physical therapist (PT) education programs could help to slightly lower projected workforce shortages in the future, the trend toward increased health insurance coverage nationwide will likely still mean that the demand for PTs will continue to climb between now and 2020.

    The new workforce model now available online incorporates 2014 data on the number of licensed PTs, the number of PT graduates, and US population with health insurance into a workforce demand formula that projects demand for PTs under 3 different attrition scenarios—1.5%, 2.5%, and 3.5% yearly attrition rates. Those scenarios were developed to accommodate a still-uncertain picture of how many PTs retire or otherwise drop out of the workforce every year. The model is updated annually by the association's research department.

    Most of APTA's projections continue to show physical therapy as a growing profession, with unmet demand ranging from 606 to 26,696 PT full-time equivalents (FTEs) over the next 5 years depending on how many PTs leave the workforce. Before the 2014 adjustments, APTA predicted a 1,530 FTE surplus at the lowest attrition rate. That surplus was changed to a shortage of 606 when the increased number of individuals with health insurance was factored in. A projected shortage was estimated downward by about 1,000 at the highest attrition rate, largely due to an anticipated growth in the number of PT program graduates.

    The total number of licensed PTs is projected to rise from about 192,000 to between 203,000 and 234,000 by 2020. The supply and demand data are part of a suite of resources on the physical therapy workforce available on APTA's website.

    The projections for shortages echo similar predictions made by The Conference Board and Forbe's magazine, which listed physical therapy as 1 of the "top 10 jobs in high demand."