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I'm Officially Sensitive!

As some of you may know, I recently was involved as a tester in a research study at USC. As testers, we were required to perform repeated muscle tests on subjects quadriceps using 4 different types of tests. I was reviewing the final manuscript and found the following paragraph:


“The sensitivity of both the isometric and dynamic manual muscle tests found in the current study was much lower than would be desired for an adequate screening test. This finding was also most likely contributable to the overwhelming tendency of tester two to find no difference in strength, on both the isometric and dynamic tests, when one was detected by the Biodex dynamometer. When analyzed separately, the sensitivity of manual muscle testing as determined by tester one (Se range of 56% to 100%) was much greater than that determined by tester two (Se range of 11% to 33.3%). This means that tester one was much more likely than tester two to correctly identify those individuals with quadriceps weakness. “

I was tester one.

This is good, as I performed the data collection in fear that I would be proved to be a poor muscle tester.

To be fair, I also had a high level of false positives, finding a difference when one was not detectable on a machine. Maybe I’m more sensitive than the machine???

In all seriousness, part of my training was unique in that I had a couple of instructors who placed a large emphasis on developing expertise in palpation skills. I was guided and praised often in this area and I am proud of my ability to feel different movements with a high degree of sensitivity. I was very lucky to have teachers so focused on palpation skills.

I wonder what the other professions or even other schools do to improve a student’s ability to sense movement.

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What Are You Looking For?

Perhaps you may have noticed, perhaps not, but for the past several weeks, a new functionality has been added to this blog. I created my own custom search engine using Google Custom Search. The premise behind my search is that I attempted to combine a mix of high quality consumer and professional information sources into one comprehensive rehabilitation search.

I browsed through many sites and it is a work in progress. My hope is that when you search for something like, “back pain, “the results you get will be from high quality, evidence-supported web sites. Google has been steadily improving their medical search as well, but the search results are still targeted to a wide audience.

Run your own test search. Pick a condition like, “TMJ,” and search Google Regular and my search and compare the results. I would love any feedback or site suggestions you might have on this. Enjoy!

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Who are the Experts in Musculoskeletal Care?

This interesting article published in Military Medicine, a smallish peer-reviewed journal asked just that question. The investigators administered a standardized examination that assesses knowledge in managing musculoskeletal conditions to uniformed Physical Therapists. They then compared the results to other healthcare providers. The results:

  1. Orthopedic Surgeons
  2. Physical Therapists
  3. Everyone else.

Everyone else consisted of: medical students, physician interns and residents, active duty military physicians, and all physician specialists except for orthopedists.

As as side note, Physical Therapists who were not trained in the Army system or had not attended their specialized training did not as well as those therapists who had.

The lack of musculoskeletal education for generalized physicians is well documented. This study tells us a couple things: Not all healthcare providers are the same. The Army is very proud of its program.

As a first hand observer of this issue: I concur.

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Comparative Visual Healthcare Spending

This is interesting: MSNBC did some calculations of the US budget and presented it in terms of a $1000 household budget. Most of your tax dollars go to finance healthcare. Personally disturbing for me, b/c I spent less than $400 on healthcare for myself last year!

For the picture, click here.

I wonder how much we could deduct off that amount if no needless MRI’s were performed. (see previous post)

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Why Referal for Profit is Dangerous and Thoughts on Radiology

Yesterday, the journal, Health Affairs, published a study that investigated referral for profit in the context of advanced radiological imaging. Here is what they found:

ABSTRACT:

Using data from a large insurer in California, we identified the self-referral status of providers who billed for advanced imaging in 2004. Nearly 33 percent of providers who submitted bills for magnetic resonance imaging (MRI) scans, 22 percent of those who submitted bills for computed tomography (CT) scans, and 17 percent of those who submitted bills for positron-emission tomography (PET) scans were classified as “self-referral.” Among them, 61 percent of those who billed for MRI and 64 percent of those who billed for CT did not own the imaging equipment. Rather, they were involved in lease or payment-per-scan referral arrangements that might violate federal and state laws. [Health Affairs 26, no. 3 (2007): w415-w424 (published online 17 April 2007; 10.1377/hlthaff.26.3.w415)]


In other words, and put less politely, 60% of doctors were illegally billing for imaging studies. As you know, MRI and CT scans are expensive, often over $1000. The ability of a doctor to be paid for a test like this is just way to fishy for me. I wonder if the patients sent for theses images have the ignorant good fortune to hear, “Good news, your MRI was negative!” more than those patients whose doctors were not getting illegal kickbacks.

The proper use of advanced imaging is to rule in/out a diagnosis. The overuse of these images is rampant, as many people just order the image to “see what’s going on in there” as opposed to performing a thorough and telling clinical exam.

Another excerpt from the article:

“Under federal law, it is generally illegal for a physician to refer Medicare or Medicaid patients for designated health services in which the physician has a financial interest. Nearly half of the states have similar prohibitions that apply to the privately insured. These bans on self-referral were enacted during the early 1990s in response to several empirical studies that found that the financial incentives inherent in physician self-referral arrangements resulted in increased use of services and higher payments from third-party payers.”
Ok, so my question now becomes two-fold:
  1. What is going to be done about this, because I’m sure there is a lot of needless expense in overuse of advanced imaging?
  2. Why is this referral for profit ban NOT inclusive of Physical Therapy? Why is it ok for a doctor to profit from self-referrals to his PT, but not from an MRI?

I guess this is just another bit of evidence for why we should, as a society, increase our skepticism of the medical profession. They are, after all, human. Check out the WSJ Health Blog on this subject.

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Why this Plica makes me sad…

Today a patient came to see me with knee pain that she’s had for over 6 months. She had been to see a variety of care providers at different locations around the globe. Radiological imaging was performed and the resounding result of all her previous exams and imaging was “Nothing Found.”

Usually I get defensive when a patient with this background comes in, as it triggers my “scammer alert” instincts. Upon interviewing this patient it immediately became clear that she was in legitimate pain and was frustrated that “no one can see it, feel it or tell me what’s wrong, but I just know it hurts.” Game on!
The interview revealed she could run 2 miles very quickly, but has some pain after, stairs frightened her, and sitting in meetings really hurt. My physical exam lasted all of about 3 minutes, including several special tests to rule out any injuries not suggested by her history. She had a patella plica. (And here.)
This is a small fold of soft tissue that everyone has between the kneecap and femur. In some cases, it becomes angry and hurts. It is not uncommon and is really a simple diagnosis to make. Her treatment would include some basic stretching and strengthening, and a referral to an orthopedist for a steroid injection. With any luck we can avoid surgery. Her prognosis is good.
So what makes me sad about this plica? The fact that no less than 5 physicians examined this knee without findings and this poor girl was labeled as a scammer. This story underscores the importance of seeing a musculoskeletal expert for musculoskeletal pain.
Who are these experts? Physical Therapists and Orthopedic Surgeons. That’s it.
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God Bless You, Mr. Vonnegut…


Kurt Vonnegut has died. He split his head in a fall and last night he died. And so it goes…

“When the last living thing

has died on account of us,

how poetical it would be

if Earth could say,

in a voice floating up

perhaps

from the floor

of the Grand Canyon,

“It is done.”

People did not like it here.”

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Can Exercise Help Breast Cancer?

Perhaps not directly, but a recent BMJ article says it can help in improving physical function and quality of life measures in patients with early stage breast cancer. Some of the physical measures noted were a 12 minute walk test and a measurement of shoulder mobility. Interesting to note, the physical measures improved right away, but it took some time for the quality of life measures to show an intervention effect.

There have been a series of studies (and this one) recently dealing with the issue. I find the concept refreshing, as it really makes sense to get some supportive literature behind some good integrative care. Perhaps with enough of this type of literature, a woman diagnosed with breast cancer will be able to receive treatment not just for her cancer, but also for her receding quality of life and upper limb function…and have it reimbursed!

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There's a Fungus Among Us!

I may have mentioned this in a previous post, but this article provided a nice overview of the events surrounding the emergence of a potentially fatal fungus in the Pacific Northwest.

A quote from the article:

“An alien fungus took root on Vancouver Island eight years ago and has since killed eight people and infected at least 163 others, as well as many animals.”