Physician Owned Physical Therapy Services (POPTS) in California. The anti-POPTS movement goes Web 2.0

Physical Therapists in California are taking to all forms of the web and utilizing Web 2.o Principles to oppose recent efforts by the California Medical Association and Legislator Mary Hayashi to LEGALIZE Physician Owned Physical Therapy Services in California through AB783. This bill would provide explicit language legalizing the employment of physical therapists by physicians. Those who have followed the POPTS debate in California are left scratching their heads because…

Interestingly, the State of California Legislative Counsel recently rendered an opinion on September 29, 2010 that it is illegal for PTs to be employed by any professional corporation except for those owned by physical therapists. The California Physical Therapy Association provides details

The opinion from Legislative Counsel confirms that, because the California Corporations Code does not specifically include physical therapists on the list of those who may be employed by a medical corporation, a physical therapist is prohibited from providing physical therapy services as an employee of a medical corporation and may be subject to discipline by the Physical Therapy Board of California for doing so.

Now in response to this new, proposed legislation the California Physical Therapy Association released an electronic memo opposing the new bill.

But, a group of concerned consumers (and I am assuming physical therapists) has leveraged technology and taken the movement to a whole new level. They have crated a campaign entitled “Stop POPTS.” So, what Web 2.0 tools are they utilizing? Well here is the list:

But, wait, that is not all! They have also created a Stop POPTS iPetition which currently has over 880 electronic signatures. They were able to amass over 500 within the first 24 hours of creation!

While it is important for our professional organizations to disseminiate opinions, information, and press releases on the national, state, and local level I am always left wondering: Are they effective? Do they even reach, and more importantly affect, the target audiences: the public, legislators, and other health care professionals? Now, the California Medical Association has been able to provide some information through news paper articles and other publicity. Unfortunately, they are able to use their clout as physicians in such outlets, and Joe Public will likely accept what they present at face value (with little questioning or skepticism). Which is a point we sometimes miss. Yes, it is important to spread this information to our PT colleagues, but we need to be reaching the public, legislators, and other health care professionals. Patients, small business owners, and legislators should be outraged! And WE need to light that fire.

Maybe the APTA, the CPTA, AAOMPT, and other organizations should take notes from the Stop POPTS Campaign in California. They are leveraging the web and technology to spread this information virally and aggressively. I believe such an approach is more effective. So, if you support the profession of physical therapy and oppose POPTS please spread the word via facebook, twitter, you tube, and even sign the petition! The Stop POPTS website has an abundance of great information.

Want more Information about POPTS?

Tim Richardson of the blog Physical Therapy Diagnosis recently wrote a post entitled Is Physical Therapy in California a Zero Sum Game?

Last year I authored a long post about POPTS and Referral for Profit on the AAOMPT Student Special Interest Group Blog detailing current rulings in Washington State as well as providing links and information about Stark Laws. The post has a TON of links to other information including APTA press releases and the American Academy of Orthopaedic Surgeons (misguided) view points.

What’s your story and opinion about POPTS? How do we spread it? Can we empower patients to tell their stories?

February 28, 2011 | Filed Under Empowered Patients, Health Policy, Physical Therapist 2.0

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Fear of Re-Injury and Return to Sport Following ACL Reconstruction

Fear of Re-injury and Low Confidence 1 Year after ACL Reconstruction: High Prevalence and Altered Self-ratings: CSM2011 Sports Section Platform Presentation
Trevor Lentz, PT, CSCS

This study won the Excellence in Research Award from the Sports Section of the APTA. Trevor’s primary clinical and research interests include rehabilitation of shoulder pathology, especially of the overhead athlete, and ACL rehabilitation including advanced rehabilitation timeframes. He is part of the research group at University of Florida that includes Dr. Steven George PT, PhD. Dr. George has been involved in a large magnitude of research related to psychosocial variables in musculoskeletal conditions. His primary research interests involve the common theme of utilizing biopsychosocial models to prevent and treat chronic musculoskeletal pain and dysfunction. So, I am not the least bit surprised he is involved in this line of questioning.

Background:

34-47% of individuals do not return to prior sports participation following unilateral, isolated anterior cruciate ligament reconstruction. This number maybe up to 70% for contact sports.

Clinical Factors Associated with Disability Following ACL Recon:

**Multiple studies have supported those findings**

Differences Between Individuals Who Return to Sport and Those Who do Not:

Fear of movement and re-injury consistently associated with self-reported function. But, not routinely measured or addressed in post-operative care.

Essentially, the group wanted to study whether fear of re-injury and or fear of movement was present, and a factor, in return to sport following anterior cruciate ligament reconstruction. They included individuals in their study who had isolated, unilateral anterior cruciate ligament reconstruction. Return to sport status was measured 1 year post-operatively. Roughly 100 participants were enrolled. They gave participants a questionnaire asking if they had returned to sport. If the answer was no, they gave a list of reasons including pain, weakness, lack of ROM, lack of clearance by MD, fear of re-injury/movement, and some other variables…

Findings

A subset of the population may not only benefit from, but require, fear of re-injury interventions. Addressing psychosocial impairment may aid in function and return to sport status. But:

The speaker did a nice job of pointing out that we need to do a better job of operationally defining and measuring “return to sport.” For example, return to any sport? return to their sport? I would go one step further and say return to previous level of function (40 yard dash time, vertical leap, strength)? Previous level of performance (minutes played, game statistics, self-perceived ability)?

In my opinion, future investigations MUST specifically tease out return to sport and return to previous level of sport performance. It is useful whether measured subjectively through self-perception and self-report OR objectively through playing time, statistics, etc. Any athlete, especially high performing athletes, will tell you that there is a difference between playing/participating in their sport AND performing at their pre-injury level.

As far as intervention, it may range from graded exposure of feared activities/sport specific tasks or graded activity progression. [Many of these cognitive behavior approaches are being utilized and studied in patients with chronic and persistent pain] Some may require even further intervention (psychological or otherwise) for their biopyschosocial impairments and barriers for return to sport.

So, fear of re-injury has been identified as present following ACL surgery and a very real, patient perceived barrier for return to sport. Now, we need to figure who develops it and why? What are the risk factors? When do we intervene and how? And, what are the long term consequences of this impairment? Looks like we have some work to do!

February 14, 2011 | Filed Under APTA, Research, Sports

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American College of Radiology Appropriateness Criteria for Imaging

Integrating the American College of Radiology Appropriateness Criteria for Imaging for Musculoskeletal Conditions into Physical Therapist Practice

The presenters of this session discussed the decision making process of when a patient seen by a physical therapist may require (or benefit) from further imaging studies. They provided evidence for not only when a patient needs imaging, but what type of imaging has the best sensitive or specificity. Real patient scenarios were also presented to illustrate the decision making process, and statistics.

One of the problems that plagues physical therapy decision making in the clinical setting is the routine (and accepted!!) use of clinical tests (i.e. Homan’s Sign in screening for DVT) that actually have poor statistics and poor clinical utility. Below I will briefly summarize some of the material presented, as well as provide links to some great websites to help with a decision making process founded on proper statistical studies and grouping of findings.

Before, I get started one of the biggest take home points was a concept that is taught to all physician residents. Do not order a study or tests unless the results will alter the course of treatment or diagnosis. On a side note, I think this a concept we need to incorporate into physical therapy clinical examinations and clinical reasoning more rigorously. How many clinical tests or measures are we performing that do not alter our treatment or decision making? Major Michael Ross adapted the above principle to the physical therapist’s perspective and role in imaging:

Use imaging ONLY if a positive test will result in a change in treatment

I will expand upon this by saying that physical therapists will also be referring for imaging or further work up if they need to rule OUT a more sinister cause of the patient’s presentation before initiating, or while concurrently, initiating PT treatment. So, if you can not sufficiently rule out a DVT, fracture, or other occult pathology in your clinical examination using the best available clinical tests and statistics then we must refer that patient for further testing. Obviously, a positive test for DVT, a visualized fracture on CT, or a tumor on MR are going to change (or halt) physical therapy treatment.

Fractures

[Disclaimer, I have not thoroughly reviewed the statistics for overall sensitivity and specificity of plain films vs. MR for fractures OR the statistics for various body regions. But, this aligns with what I knew previously. I am presented the information as it was presented. Citations in their handouts if you have access to them. Please comment if you have references that suggest otherwise.]

Avascular Necrosis

Cauda Equina

Shoulder: Rotator Cuff Tears

Low Back Pain

We are obviously (hopefully!!!) preaching the choir in regards to over-imaging in individuals who have low back pain. There has been an explosion of data over the past 5-10 years illustrating the presence of unnecessary and over-imaging. But, far more scary, is the findings that more imaging in low back pain is correlated with more invasive procedures and higher health costs. That is something to shoot from the rooftops: There is the potential for increased exposure to more invasive and potentially less successful treatment approaches with unnecessary imaging. Remember an image is never going to make your pain go away. One last sickening statistic. More dollars are spent each year on spinal fusions that on cancer. Here are the American College of Physicians Recommendations.

Physical Therapists can and do utilize imaging for different reasons than physicians.

Sometimes it is important to know the relevant pathoanatomy. This may guide the application of our manual therapy treatment. It may also help us make better recommendations on pursuing surgery or not. Many times we are requesting or using imaging to rule out sinister causes of a patient’s presentation.

What I think is most exciting about the ACR guidelines is that they are readily available online and there is also a Mobile App!! There is also a great website, MDCalc, that integrates current evidence into decision tools that you can use instantly on the web:

As Albert Einstein said: Intelligence is not the ability to store information, but to know where to find it!

What a great way to leverage technology to utilize the best evidence for imaging and referral appropriateness. I do not think there is any data on this, but I would assume that clinicians that leverage this tools in clinical practice make better, and better informed decisions. For those of you familiar with Dr. Tim Richardson’s blog Physical Therapy Diagnosis: Make Decisions Like Doctors, he is actually developing clinical decision making support tools that can be easily integrated into EMR programs. Exciting times!!

February 13, 2011 | Filed Under Research

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Getting Started in Educational Research

Educational research is critical to ensure physical therapy students are receiving the best training as possible. However, educational research needs to live up to high standards. Fortunately, this session provided several good tips on how develop and implement good educational research questions.

This presentation took on a panel format, with speakers from left to right:

As much educational research is present annually at CSM, the panel addressed many common problems of those that submit abstracts for presentation at the conference. The biggest problems include:

In terms of developing a good education research question, the presenters offered the following pointers:

February 12, 2011 | Filed Under Research

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State-of-the-Art in Postural Control: Pelvic Floor

Dr. Paul Hodges undertook the difficult task of explaining the intricate connection between the respiratory / pelvic floor / and abdominal muscles. I have the difficult task of summarizing what he presented! Dr. Hodges has a presentation style I really enjoyed – pose a question first and then proceed to address that question.

Question 1 – Do the muscles of respiration and continence contribute to postural control of the trunk?

Yes. Many of the muscles of the trunk (diaphragm, scalenes, erector spinae, intercostals, pelvic floor muscles) and pelvic floor (anal, periurethral, vaginal) are active during breathing and they are modulated in concert with breathing. Dr. Hodges provided evidence of this by presenting recordings from many systematic studies which measured the all of the above muscles in tasks such as respiration, modifying posture, and when a mass was unexpectedly dropped into a box held by the participate.

Question 2 – Can postural control, respiration, and continence be coordinated?

It seems that concurrent modulation of all these muscles is normal and that tonic and phasic activity can be modulated concurrently by the nervous system. In chronic respiratory disease, posture is compromised with greater disturbances in the ability to balance in the medial/lateral direction (trunk and hip stability). One obvious example of coordination is when someone is sprinting or lifting something heavy –  you don’t breath for a short time (Dr. Hodges had us stand on our toes, reach up as high as we could, and notice how we held our breath).

In low back pain, postural function is disturbed for sure. But why? It seems that there is reduced activity of the transversus abdominis muscles, which leads to delayed activation, less tonic activity, muscle atrophy, and cortical reorganization.

Question 3. What are the conseqeunces of poor coordination of postural muscles?

The immediate implication is that breathing disorders, back pain, incontinence are linked together. Sure enough, Dr. Hodges presented results from an epidemiological study showing that those who had a breathing disorders were more likely to develop low back pain!

Question 4. What are the implications for rehabilitation?

For low back pain:

For pelvic floor disorders:

For breathing disorders:

Although Dr. Hodges used the specific example of low back pain rehabilitation, the principles apply to other areas

Conclusions

Patients will present with a range of issues, but it is impossible to separate the systems. You must look at your patients as a whole and develop a strategy that addresses all of their problems.

Bottom line – YOU MUST BE A MULTISYSTEM THERAPIST

February 12, 2011 | Filed Under Bad Back, Research

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Physical Therapists in the Emergency Department

Findings indicated that these physicians found ED physical therapy services to be of value to themselves, to their patients, and to the department as a whole and described specific manners in which such consultations improved emergency care. Implementation and maintenance of the program, however, presented various challenges.

Emergency Department Physical Therapist Service: Removing Barriers and Building Bridges

To start, a brief introduction of who comes into the emergency department. Fewer and fewer are coming via ambulance, even fewer by life flight. People are using the ED in new and different ways. For example, many have non-urgent and non-life threatening conditions.

The average wait is upwards of 1 hour, with the average length of stay in the ED upwards of 4 hours. The ED physician spends an average of 11 minutes on direct care. That time includes research, orders, and making referrals.

Patient satisfaction with ED care is generally low. Management of common musculoskeletal, pain, and soft tissue injury complaints is varied and poor. Individuals are routinely given cervical soft collars for neck pain, immobilization including CASTS and or instructions for non-weight bearing for ankle sprains, and MULTIPLE days of bed rest for low back pain.

What do the PATIENTS want? Answers, instructions, and to feel better!

What do the patients receive? Imaging. Medications. Prescriptions. No follow up.

The fact of the matter is this that more and more individuals are utilizing the ER as their primary stop for health conditions. By the time they seek care these conditions are more chronic and less well controlled. Thus, more and more people seen in the ED are not necessarily in an emergent state. And, I believe, more and more would benefit from the skills of a physical therapist.

Now, I also believe physical therapist’s can play a vital role in deciding when imaging of musculoskeletal conditions is and is not necessary. Further, the treatment they provide may (again my belief) decrease imaging, medication prescription/usage, and decrease re-visit rates for the same complaint. And maybe, just maybe, if we plug these people into physical therapy sooner their conditions (pain, chronic medical diagnoses, etc) will be better managed and controlled. And, I think, that all links back to the Physical Therapist’s Role in Health, Wellness, and Prevention as per Healthy People 2020.

The data that does exists suggest that having PT’s in the ED results in decreased wait time and increased patient satisfaction. [Unfortunately, much of the data on PT's in the ED has been obtained outside the United States.] At the large, academic hospital I practice high priority is placed on “patient satisfaction.” [However, flawed that concept may be. Refer to Patient Satisfaction is Useless Part I and Part II on the Evidence In Motion Blog]. Further, wait time in the ED is directly related to the costs for that department. Therefore, decreasing wait time is a very real way to decrease costs. Not surprisingly, wait time is inversely related to patient satisfaction. So, already those are two powerful take home points regarding the positive effects PT’s ARE ALREADY having in the ED already. But, what does the future hold?

In expanding PT services in the ED, we can look to other sources of evidence and data to support PT treatment of individuals in the emergency department:

Specifically, there is evidence supporting specific PT approaches to common orthopaedic conditions such as low back pain, neck pain, knee pain, ankle sprains, etc. Also, there are innovative practice models where physical therapists are involved earlier in care providing FRONT end intervention for painful episodes. Virginia Mason (out of my hometown of Seattle) received a lot of publicity even a Wall Street Journal Article for their model of sending patients with work related musculoskeletal complaints to a PT FIRST. They decreased costs by over 50% (!!!) and decreased time away from work.

Future Research and Data Tracking

The talk was very interesting, and I think this practice area will continue to grow. It actually reminds me of the growth of early mobility and rehabilitation of individuals in intensive care units. I also think there is really good research and data from other areas of practice supporting not only the treatment PT’s can provide, but also our training, decision making, and skills in medical screening and aiding in diagnosis. Not to mention, I did not even mention fall risk screening and intervention, splinting, wound care, assistive device recommendations, and aiding in discharge planning.

Where will physical therapy go next?

Resources

  1. Physical Therapists in the Emergency Department: Development of a Novel Practice Venue. Physical Therapy. March 2010.
  2. The Physical Therapist as a Musculoskeletal Specialist in the Emergency Department. Physical Therapy. March 2009
  3. Emergency Department Physical Therapist Service: A Pilot Study Examining Physician Perceptions Internet Journal of Allied Health Sciences and Practice. 2010.

February 10, 2011 | Filed Under APTA, CSM 2011, Physical Therapy, Research

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Multiple Sclerosis: Improving Physical Therapy Outcomes by Minimizing Neurogenic Fatigue and Maximizing Neuroplasticity

My first educational session at my first physical therapy conference was on what seems like a very challenging condition to manage in the clinic – Multiple Sclerosis.

Hebert Karpatkin began his talk by stating his main goal – to “change the way you treat MS”.

Why are these patients difficult to treat? Here are Karpatkin’s thoughts:

Dr. Karpatkin then went on to suggest four main areas to consider for successful management of your patients with MS.

1. Fatigue

This is the most commonly reported symptom of patients with MS (74-89% of patients). The origin of fatigue is separated into two categories:

PT can help by intervening with four of the  secondary fatigue sources – disuse, sedentary lifestyle, pain, movement compensation = GET THEM MOVING!!!

2. Thermoregulation

Another commonly reported symptom is thermosensitivity. Simply meaning that symptoms become more severe with higher temperatures. This is a fundamental problem as it limits the amount of exercise patients can perform.

How can therapists can intervene?

3. Intermittent Training

A patient with MS once said:

“Trying to get better makes me worse”

This quote really hit home because it highlights the main problem: the exercise itself is making me fatigued, how do I get better!?!?!

You need your patients to reach a critical dosage of exercise to improve, but how? Intermittent training:

Dr. Karpatkin the provided preliminary data that demonstrated that in four patients their 6 minute walk time performance was better with an intermittent protocol (1158) as opposed to a continual exercise protocol (966).

It was also suggested that PTs could apply this protocol to gait, strength, balance, functional activities as well.

4. Secondary Deficits

Posture and stretching

Posture can be poor in patients with MS. One of Dr. K’s patients was given PT 1-2 x/week +home exercise program and this significantly improved his posture and gait. Why was this not addressed with previous therapists? It was suggested that maybe those other PTs neglected posture because of a bias towards his condition.

Foot drop is a common presentation in gait with MS. Dr. K suggested plantarflexor stretching. This ca

n be done during sleep using a night splint.

February 10, 2011 | Filed Under Physical Therapy, Research

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Healthy People 2020: Physical Therapists in Health and Wellness

CSM kicked off with a talk about how physical therapist’s can fit into the Healthy People 2020 initiative . Further, the roles and potential roles of physical therapists in health, wellness, health promotion, and public health.

The speakers gave broad information about health promotion and physical therapists. Each gave some interesting case examples. Each advocated for physical therapy in serving the societal needs of not only health, but living with disability. I absolutely agree! But…

Especially in private practice how do we not only incorporate health promotion, but make it fiscally sustainable and or profitable? Sometimes it is difficult enough to obtain reimbursement and or private pay for a current condition let alone chronic health conditions such as hypertension control, obesity, healthy exercise habits, and smoking cessation. But, on the other hand, the personal fitness and health industry (i.e. weekend trained personal trainers at 24 hour fitness) is booming. How can PT’s obtain a slice (or a big chunk) of this market?

I think they speakers brought a good point that we need a critical mass of not just PT’s, but legislators, public policy makers, patients, and other healthcare professionals committed to societal health in various practice settings. And a recognition of rehabilitation and physical therapy as essential parts of not only health care, but health promotion.

Why aren’t we moving in that direction? Do we all need to broaden our view of our professional role? What is the SWOT [Strengths, Weakness, Opportunities, and Threats] Analysis of the PT profession, and each us as individual practitioners, in regards to health?  I think there are a lot of opportunities, but many, many barriers.

Do we have what it takes to step up to the plate? Or, at least get a place at the table?

I think the first talk brought up many, many questions, problems, and ideas…

February 10, 2011 | Filed Under APTA, Empowered Patients, Health Policy, Physical Therapy

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CSM Kick Off

Arrived in New Orleans, and man I am excited!

A full flight from Denver to New Orleans, with many Denver area physical therapists and even some PT students from University of Southern California. Oddly enough, I sat next to a very nice PT Student from UCSF. We chatted the entire flight about early mobility in the ICU and physical therapy treatment of individuals who are critically ill (which if you know me gets me talking!) as well as PT education and research.

We even exchanged e-mails via our smart phones. Tomorrow should be a great day. Stay tuned here at PT Think Tank for updates and information.

Follow Me on twitter for quick blurbs and links.

Follow the Hashtag #CSM2011 for tweeps chatting about the conference! Let the technology leveraging begin…

February 9, 2011 | Filed Under Announcements, APTA

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Mrs. Smith: you have an upcoming PT appointment…

Another guest post from Bronwyn Spira, PT, and Tejal Ramaiya, DPT, CSCS, this one an apt follow-up to my post on Physical Therapist Use of Smart Phones:

One of the most frustrating issues plaguing physical therapy practices has to be no shows and late cancellations of scheduled visits. Poor patient attendance results in lost revenues and poor patient outcomes. Practices traditionally employ rudimentary strategies to counter-balance the impact of missed appointments including reminder calls and charging hefty cancellation fees. Unfortunately, these solutions require additional administrative time and effort and can create poor relations between the patients and administrative staff. There must be a better solution!

The answer may be one that 78% of Americans keep in their pockets or purses: a cell phone. The average American spends 619 minutes per month on their phone and, according to a ComScore study from March 2010: 63% of Americans are using text messaging. The use of SMS or text alerts as patient reminders has been shown to reduce the ‘noshow’ rate by 73% (or 1,837 fewer ‘lost’ visits) according to a recent study for Kaiser Permanente by mobilStorm. Kaiser was able to contain their communication infrastructure costs, while saving $150 per appointment (their no-show cost) which equaled a total cost savings of more than $275,000 at just a single clinic.

Ideally, SMS text and/or email alerts should be integrated into a clinic’s scheduling system; automatically alerting patients to upcoming appointments or schedule changes. And why stop there? The potential impact of these alerts could extend to reminding patients to complete their home exercise programs, or give therapists updates on symptomatic responses to new treatment regimens.

A study conducted by comScore found that daily use of Smartphones to access emails rose by 40 percent in the last quarter of 2010. Laptops and desktops it seems, have become primitive mediums for real-time communication. As our patients become more and more tech-savvy, they will begin to expect these type of mobile conveniences from their service providers. In addition to the considerable cost-saving benefits, automated communication can also serve to improve patient/therapist interaction, increase patient participation in their rehabilitation regimen and thereby improve patient outcomes. Have you considered integrating automated SMS text or email alerts into your clinic?

Bronwyn Spira, PT, and Tejal Ramaiya, DPT, CSCS authored this guest post. They can be found at www.forcetherapeutics.com, www.facebook.com/forcetherapeutics, or www.twitter.com/ForceTherEx.

February 8, 2011 | Filed Under Empowered Patients, Health IT

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