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The AB783 Story Continues

PT in Motion News Now now alerted me that AB783 has been re-scheduled for hearing on Monday June 27th. This bill will be heard in the California Senate Standing Committee on Business, Professions, and Economic Development.

The drama surrounding AB783 has taken some interesting turns over the past few weeks.

  • June 13th: AB783 fails to pass out of committee with 3 yes votes, 2 NO votes, and 4 abstains
  • June 20th: Mary Hayashi pulls the bill from reconsideration. Oddly, she states she would like to meet to work something out with the California Chapter of the American Physical Therapy Association [Rumor has it this never happened]
  • June 27th: AB783 is again slated for reconsideration. If it fails to pass out committee AGAIN, it can can not be re-heard until 2012 [which if history is any indication, it will be back]

Luckily, NBC LA continues to provide top notch coverage and analysis of the issues in their THIRD article entitled Caution: State Laws Hazardous to Your Health. In the comments section Johnny Chen makes a great point:

There is a reason why doctors are not allowed to own pharmacy clinics/establishments. It’s called conflict of interest. The same should apply to physical therapy clinics. Hayashi should be ashamed of herself — why would she support a bill that takes the power out of the consumer’s hand and costs taxpayers/health care system.

Unfortunately, there is a very, very easy cure to this legislation and ongoing POPTS battle:

Physical therapists need to stop working for Physician Owned Physical Therapy Clinics.

Remember the Stop POPTS Campaign has a website, Twitter, Facebook, and You Tube Channel. Read, follow, friend, and watch! Then spread the word.

Also, please take a few moments to read the 3 NBC LA Articles and leave your comments + feedback.

  1. Physician Run Physical Therapy Clinics Scrutinized
  2. Physical Therapy Bill Delayed
  3. Caution: State Laws Hazardous to Your Health

The truth is incontrovertible, malice may attack it, ignorance may deride it, but in the end; there it is.                            –Winston Churchill

The ‘continuity of care’ argument is dead. It is hard for me to get a hold of a physician when I page them in a hospital, or call them from the private physical therapy practice I practice within. They are busy. We are busy.

The issues surround physician employment, and ownership, of physical therapists are fairly simple: conflict of interest and referral for profit. What makes legislators, payors, and the public believe this will improve communication, care, and patient outcomes?

The American Physical Therapy Association doesn’t support it. The American Academy of Orthopaedic Manual Physical Therapists doesn’t support it. In fact, the American Medical Association ethics committee doesn’t support it.

The data doesn’t support it. Human behavior and psychology research don’t support it. Logic doesn’t support it. Ethics doesn’t support it.

Dear Assemblywoman Hayashi: Physical Therapists, data, logic, ethics, and human behavior all say NO! This is a bad idea!

But, physicians support it and say it is best, so it must be true…right?

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AB783 and the California Campaign to STOP POPTS

On Monday, June 13th California Assembly Bill AB783 failed to pass out of committee in the California Legislature. The bill, which would explicitly allow physicians to employ physical therapists, would have been in stark contrast to current State of California Legislative Counsel opinion which states that it is illegal for physical therapists to be employed by physicians.  The bill has been pushed by Mary Hayashi, who not surprisingly receives quite a bit of campaign money from physician groups.

Recently, the issue has received increased attention as physical therapists and activists have taken to twitter and facebook to spread the word. Even more impressive, NBC LA has now run two articles critiquing the bill: Doctor Run Physical Therapy Clinics Scrutinized and Physical Therapy Bill Delayed.

Some sources have reported that supporters of AB783 have spent upwards of 2 million dollars while physical therapists and the CA Private Practice Section have spent a mere 57 thousand dollars. I think the relative success of the PT campaign illustrates the importance of viral, social medial in the form of Facebook, Twitter, and an online presence. Most notable is the Stop POPTS campaign which I have written about previously in the post Anti-POPTS Movement goes Web 2.0. But, even the California Private Practice Section has been slamming their website with information and announcements

But, in the end, I think it also illustrates the fact that the bill is grossly illogical as it promotes a huge conflict of interest in medicine: referral for profit. I wrote an extensive piece about a year ago on conflict of interest and POPTS which can be found on the AAOMPT Student Special Interest Group Blog.

Interestingly, the Medical Code of Ethics States:

“[u]nder no circumstances may physicians place their own financial interests above the welfare of their patients.”

And, what about The American Medical Association (AMA) Council on Ethics and Judicial Affairs (CEJA)?

“physicians should not refer patients to a health care facility which is outside their office practice and at which they do not directly provide care or services when they have an investment interest in that facility.”

Please, take a few minutes to read the articles. Then comment and share. Tweeps on twitter are using the hashtags #StopPOPTS  and #VoteNoOnAB783. The more physical therapists continue to articulate the many problems with referral for profit and physician employment/ownership of physical therapy the more press it will receive. Both articles have already received countless comments from individuals regarding the problem with POPTS.

What are you waiting for?

  1. Doctor Run Physical Therapy Clinics Scrutinized
  2. Physical Therapy Bill Delayed

The continued success of the anti-POPTS movement hinges on involvement from the bottom up. Every comment, like, tweet, and shared link are useful. Every mention in conversations with patients and the public add up. A big thank you to all the physical therapists who have gone to capitol to meet with legislators and testify. And of course, the importance of  the California Private Practice Section and California Section of the APTA can not be underestimated.

Continue to spread the word!

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Manage the Evidence Like a Pro

The problem. You are trying to stay current with the literature because that’s a great way to ensure quality treatment of your patients OR your a student in a physical therapy school that has a strong evidence based practice curriculum AND you end up having a hard drive littered with PDFs, like this:

Image by mekentosj.com

The solution. Papers2 by software developer mekentosj. This app makes it dead simple to organize your PDFs. Think of it as iTunes for PDFs, where instead of double clicking a track to listen, you double click to open the PDF in your favorite PDF viewer. You can search for articles quickly, email them to a colleague, even takes notes, all within the app. There are so many neat features I just had to put together a brief screencast demo, which you can view below:

Managing Physical Therapy Articles Like a Pro from Mike Pascoe on Vimeo.

In this 5 minute screencast, I show off some of the key features of Papers2. This video is directed toward those with a physical therapy background.

Papers2 can be downloaded here:
http://www.mekentosj.com

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From Bench to Bedside: Spinal Cord Physiology -> Clinical Interventions

Having just defended a dissertation in the field of neuroscience, this session was my guilty pleasure. I felt right at home hearing about the modulation of intrinsic motor neuron properties. But, the question I’ve had since graduate school was the focus of this session – how does the lab work in cat/rat/monkey motor neurons translate to human patients?

This session was presented by four brilliant researchers interested in brainstem modulation of the motor system. The patient population discussed was spinal cord injury, a condition in which the connection between the brainstem and the motor neurons are disrupted. Each researcher discussed the implications for force generation, spasticity, and locomotion. I’ll summarize their reports below.

Allison Hyngstrom, PT, PhD

First up, Dr. Hyngstrom highlighted a few key researchers that have influenced treatment of patients:

  • Sherrington – contributed the concept of the spinal motor neuron as the final common pathway – contributed to the understanding of locomotion by examining “air stepping” elicited by stretching hip muscles of spinalized
  • Eccles – introduced the idea that inhibition could sculpt the output of motor neurons, particularly the reciprocal inhibition pathway
  • Brown/Grillner/Lundberg – descending input, as well as specific neurotransmitters, could activate spinal networks without sensory inputs

The Dr. Hyngstrom progressed to ‘Motor Neurons 101’, including these key points:

  • MNs possess huge denritic trees to receive inputs from several sources (higher brain, local interneurons, afferent)
  • Two categories of receptors are expressed on the MN membrane – ionotropic and metabotropic
  • The activation of metabotropic receptors by monoamines create persistent inward currents (PICs)
  • PICs can amplify the output of the MN
  • In acute spinal cord injury there is a loss of seratonin in the spinal cord that decreases the excitability of spinal MNs

Moving to the spinal cord injured cat, researchers have found that by adding monoamines to the spinal cord the cat could walk again [link to article in PubMed]

Next Dr. Hyngstrom described some of her own work on MNs. In her dissertation she was interested in the factors that regulate PICs. One way she did this was by altering the amount of reciprocal inhibition.

In summary

  • Monoamines (like seratonin) increase the gain of the MN > which implies PTs could reduce effort for a given movement
  • Monoamines facilitate automatic movements
  • Dysregulation of monoamines likely contributes to alterations in cellular excitability in chronic spinal cord injury
  • Altered cellular excitability not necessarily a bad thing > consider other ideas
  • Targeted medications could be used to harness spinal network excitability

Chris Thompson, PT, DPT

Next up Dr. Thompson presented his talk, titled – “Activation of spinal networks in patients with spinal cord injury to improve volitional movements”.

He began with a bold statement – “indiviuals with motor incomplete SCI do not fatigue”. How could this be? It seems that in a repeated stimulation protocol, patients with acute SCI  do not exhibit a reduction in force generating capacity, whereas patients with chronic SCI and healthy controls do exhibit a reduction in the same protocol.

I also seems that people with incomplete SCI have a reserve of volitional force generation – 115% of maximal force can be achieved across the first 4-5 maximal contractions.

In acute spinal cord injury there is a period of spinal shock and spinal reflex responses are suppressed. But after time (chronic) the responses become super sensitive to seratonin.

Dr. Thompson want to know why and he looks to the motor neuron persistent inward current as a mechanism for the following three reasons:

  1. There is an increased EMG amplitude across contractions, through increased recruitment and rate modulation of motor units
  2. Prolonged torque in response to electricla stimulation using top hat stim protocol, which was abolished when a nerve block was in place
  3. There are alterations in motor unit activity due to pharmacological agents (SSRI), which block the reuptake of seratonin

Dr. Thompson concluded by review attempts at translation of the findings in animal models to humans patients. The idea best examined by his lab group basically involves applying a ‘top-hat’ stimulation protocol made popular in cat experiments to human patients. Something very interesting happens when comparing humans and cats. The amount of force and the strength of the persistent inward current are larger when muscles are at shorter lengths IN HUMANS. However, the amount of force and the strength of the PIC are larger when muscles are at longer lengths IN CATS. Explaining this difference is the next task on Dr. Thompson’s plate.

Arun Jayaraman, PT, PhD

Alright, that was a lot of motor neuron physiology and I appreciate you hanging in there so far. So, how can the above information be put into clinical practice? This is what Arun enthusiastically addressed – developing the rehabilitation protocol.

His main question was how can we harness the reserve in force generating capacity seen in patients with incomplete spinal cord injury?

This was tested in 10 patients with chronic motor incomplete SCI in a cross-over design with a two month washout period between the testing conditions. The phenomenon examined was that the harder you work, the more force enhancement you observe in the SCI population. As the time between maximal contractions gets longer, the enhancement in force production becomes lower (15 s is best). This phenomenon is present both concentric and isokinetic contraction modes.

Subjects trained with 65-80% of their one repetition maximum until they plateaued in function. Arun found that just isometric trained alone enhanced berg balance scores and walking distances in the 6-min and timed up and go tasks. Noxious stimulation at an intensity of 50 mA on the stomach skin was not so effective.

A follow up direction Arun is investigating is the use of intermittent hypoxia. It has been shown in rats that electromyography and force measurement improved in a ladder climbing task following a hypoxic state. How will patients with chronic SCI respond to hypoxic conditions during locomotor training? Arun is hopeful that benefits are realized in his patients.

In summary

  • Volitional drive can be enhance by working very hard
  • Does improve walking and balance
  • Can be done at home
  • What are long term effects?
  • Can this be complimented with intermittent hypoxia?

George Hornby, PT, PhD

The topic addressed by Dr. Hornby at the end of the session was the combination of physical therapy and pharmacological interventions.

It seems that providing glutamate can generate locomotion patterns and we also know that monoamines can excite central pattern generators (CPGs).

There is an increased Babinski Sign in SCI due to effects of monamines.

Seratonin (5HT) is effective in initiating locomotion in rats with SCI.

It seems that humans respond better to 5HT than norepinephrine (NE) when administered.

Lastly, Dr. Hornby has seen that strength, not spasticity, is related to locomotion function.

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CSM 2011 – The Pauline Cerasoli Lecture

Photo taken from APTA website

This lecture honors one of physical therapy’s best and brightest – Pauline ‘Polly’ Cerasoli (Feb 25, 1939 – Sept 11, 2010).

The Cerasoli lecture began with a tribute to Polly by a long-time friend and colleague Bette Ann Harris in which we learned more about the places she spent time:
  • Northeastern University (1967-1981)
  • Massachusettes General Hospital (1981-1987), doctorate in education
  • University of Colorado Denver (1988-1996), director of physical therapy program
We also learned of the major contributions made by Polly to the physical therapy profession:
  • Started the Boston Education Consortium in the 1970s
  • Published a landmark paper titled ‘Research experience in an undergraduate physical therapy program’ – [pubmed link]
  • First appointed clinical specialist at Massachusetts General Hospital in 1981
  • Mentored a blind physical therapist in 1992
Next, APTA President Scott Ward asked for a moment of silence, as it was the first Cerasoli lecture since she passed away in Sept of 2010. Dr. Ward announced that the 2012 Cerasoli Lecture will be given by Christine Baker from UT Galveston.
Dr. Ward then introduced us to the 14th Cerasoli Lecturer – Dr. James Gordon. Dr. Gordon is associate dean and chair in the division of biokinesiology and physical therapy at USC.
Dr. Gordon’s talk was titled ‘Excellence in Academic Physical Therapy – What Is It and How Do We Get There?’ I’ll try my best to summarize the talk below.
We (physical therapists) must accept the challenge that lays before us – pursue excellence.
On January 15, 1921, that 30 PT aides formed the APTA at the Keene’s Chop House in NYC. Now, a century later, Vision 2020 is lies ahead. It is the challenge.
What is needed to meet this goal is a strong academic foundation. It is in the academic setting that the physical therapy profession does its thinking.
Dr. Gordon defined a strong academic foundation as having three pillars – Education, Research, and Clinical Practice. All three pillars need to be in place. A classic three legged stool analogy, the foundation will topple with the absence of just one of the three pillars.
Dr. Gordon stated that excellence today is the norm for tomorrow. Excellence is the engine of the train, accredidation is the caboose (crowd chuckles).
So what is the agenda to achieve excellence? It is fulfilling all three pillars of the academic foundation.

1. Education

The most urgent task is to standardize curricular competencies. There is “unwarranted variation in physical therapy practice”. For example, there is large variation in the prerequisites, and program length. An emphasis on preparing generalists is the problem. Accreditation offers a list but no priority. Curricular competency needs to be standardized. Students need to have the ability to treat a patient with a defined condition under a defined set of characteristics (settings, acuity, age).

2. Research

Not much to say here. All programs should be involved and the big should help the small.

3. Clinical Practice

All programs across the country need to be involved. Currently, only 22% of programs have any form of program sponsored practice. Practice is important because it enhances teaching and provides a venue for research.
Lastly, Dr. Gordon addressed the infrastructure requirements to achieve program growth. Of the 213 accredited physical therapy programs in 200 institutions, 206 offer a DPT degree. Currently, 75% of faculty are PhD-level prepared. Many of these programs are very small. 50% are in Universities with research institutions and 35% of physical therapy programs are in medical centers. The average class size is 42.5, and 20% of programs have class sizes less than 20.
Why emphasize program growth? Dr. Gordon argued that this will bring a greater breadth of knowledge, support more research, and meet the need for more physical therapy students.
Dr. Gordon then wrapped up with his two take-home points:
  • A strong academic foundation is essential for achieving excellence in physical therapy
  • A strong academic foundation is dependent on three pillars (Education, Research, Clinical Practice), and you need them all
Photo taken from APTA website
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It’s Not About the Patient

If you have not yet viewed this video from Jack Bert, MD, from which the above screen shot was taken, please check it out now. Brace yourself. At the 8-minute mark, he discusses PT. He gets excited that a physician in SC was able to hire a chiropractor through this contact form and “athletic trainers to do the PT” and bill for it, and ran 60% of the physical therapy business out of town.

Is there not some really big problem with this situation? Does this not border on breaking the law? The unrestricted medical license of physicians allows them to bill for whatever medical service they want. Thus, the athletic trainers can indirectly become physical therapists. As a licensed physical therapist in the state of SC, I wonder why I’m paying a fee for licensure, when the state could simultaneously allow non-licensed individuals to perform the service that I’m trained to provide. Why are consumers not being protected from this action?

In the comments on the site, which by now are littered with offended physical therapists, Jack Bert responds:

“Now that I have thought about this, the discussion on ancillary services really has nothing to do with physician arrogance or greed. It really has to do with what is best for the patient.”

I simply don’t buy it. How is having patients be treated by providers with less training and a different skill-set than PT’s (the athletic trainers) equate to something better for the patient. Yes, physicians do medicine. They do it well. Physical therapists, well we do rehab and do it well. Can’t we both exist together?

He goes on to suggest:

“For ancillary providers, such as physical therapists and chiropractors, to believe that they have the same training and ability to diagnose musculoskeletal pathology as a boarded orthopedist with a minimum of 5 years of post-medical school training, excluding a fellowship, is truly astounding.”

Perhaps Jack Bert is not aware of the body of research that suggests overall, that physicians are not adequately trained in musculoskeletal care either. In fact, I find it astounding that a general practitioner with little specific training on the subject finds themselves capable of diagnosing the specifics of an injured shoulder or neck. I fully agree that Jack Bert, a board certified, fellowship trained, orthopaedic surgeon has very capable musculoskeletal examination skills, but I also feel that his disregard of physical therapists to also have those skills offensive and reflective of an old-school physician mentality whose time has passed. There is research to support my claim. Physical therapists are musculoskeletal experts!

If this was truly about the patient, we would give the patients choices. We would empower them to choose their providers. We would act to reduce limited providers and wait times and work towards an equitable distribution of resources. There’s enough demand for everyone to play together. Comments like those of Jack Bert simply shed light on what these turf battles over physician-owned PT services and direct access restrictions are really about. It certainly isn’t about the patient.

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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?

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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:

  • Knee Pain Intensity
  • Knee Flexion ROM Deficit
  • Quadriceps Weakness
  • Fear of Movement and Re-Injury

**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

  • 49% of their cohort had not returned to sport 1 year post operatively
  • 50% of those that had not returned to sport cited fear as primary reason
  • Fear was the most commonly cited primary or secondary reason for not returning to sport

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:

  • What interventions can/should be utilized?
  • At what point during rehabilitation?
  • How do confidence, self-efficacy, and pain castrophizing affect return to sport?

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!

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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

  • Plain Film Radiographs: High Specificity (good at ruling in). Low Sensitivity (poor at ruling OUT)
  • So, if negative plain film study, still concerned about a fracture!
  • CT: High Sensitivity and Specificity. Good at ruling out and ruling in.

[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

  • T1 Weighted MR is the best imaging study
  • Areas of black (decreased signal) suggest AVN

Cauda Equina

  • Need to be in an Emergency Department within 48 hours to prevent possibly permanent neurologic damage
  • Urine retention is a specific and sensitive (.90) finding
  • Saddle Anesthesia is also a strong clinical finding

Shoulder: Rotator Cuff Tears

  • Fatty infiltration and atrophy on MR of the supraspinatus and infraspinatus. Poor prognosis for success with surgery.

Low Back Pain

  • Only indicated when severe and progressive neurologic deficits are present
  • HIGH suspicion of specific, serious pathology such as cancer, fracture, or metastases
  • Correlation between pathoanatomy and function is sketcy at the absolute best

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!!

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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:

  • Not knowing the literature
  • Not performing appropriate statistics
  • Not using appropriate measures
  • Overall insufficient planning and thought (e.g. sufficient controls for the test groups)

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

  • Where to begin? What are some good sources to inspire me to develop a good question?
  • Who are the primary drivers of PT educational research?
    • Clinical scholars
    • Academic clinical faculty
    • Traditional academics
  • What questions have been asked in the last 25 years?