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The Bionic PT

Bionic-Woman 

Most in physical therapy profession are a bit slow on the uptake of technology.  Most…but surely not all!  Some of my colleagues are really doing some interesting things with bionics.  As practitioners with expertise in prosthetics, it's a natural progression to this new generation of prosthetic technology.  

The first "real" bionic woman was Claudia Mitchell, who was part of the bionic? program at the Rehabilitation Institute of Chicago. 

Silicon valley is also getting into the mix, with the new PowerKnee by Tibion.  This device seems like an external brace vs. what is pictured above.  Physical Therapist Nancy Byl, Chair of the Physical Therapy Department at UCSF, was interviewed about a patient using this new device.  Key to progressing this technology is mastering user interfaces with the machine components.

Those really interested in the topic might find this New Yorker article (pdf) on the new generation of bionic prosthetics a good read.

ERIC

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Dissecting Manipulation, Q&A with John Childs

Jmmtcover

The current issue of JMMT includes a very nice review of evidence supporting Spinal Manipulative Therapy (SMT) for low back pain.  This interesting review is a solid piece of work, and useful in bringing to light the current picture of where we stand: namely that SMT should be used for low back pain, but questions still exist about the best way to use it.  

The authors of the review have recently published some evidence that calls into question some of the recent guidance we have been getting in terms of clinical prediction rules for spinal manipulation.  In one study published this year, they conclude:

"The clinical prediction rule proposed by Childs et al. did not
generalize to patients presenting to primary care with acute low back
pain who received a course of spinal manipulative therapy."

I was interested in speaking with Dr.Childs and getting his opinion about the recent review and what he considers the current big picture in SMT.  He was kind enough to oblige my questions!

NPATT: The authors of this review have suggested a return to a paradigm focused on making a specific patho-anatomical diagnosis for low back pain patients.  This seems in contrast to the treatment-based classification approach where treatment decisions are made according to patient presentation, not a patho-anatomical cause.  What does history, and current evidence tell us about finding a specific diagnosis for low back pain?

Childs
John Childs:  Pathoanatomy is only relevant for guiding treatment decisions in roughly 10-15% of cases of LBP. Even in these cases, the pathoanatomy may be serious (ie, cancer, fracture, etc) so the percentage of cases in which pathoanatomy is relevant for guiding physical therapy treatment decision-making is even less. This is the reason why concepts of “treatment-based classification” and “subgrouping” patients with LBP  based on clinical examination findings have become such an important research priority over the last 10 years. The elusive search for the pathoanatomic diagnosis and “magic bullet” treatment lies at the root cause for the disaster of LBP management in the U.S. and a re-focus around identifying pathoanatomy would be a big step backward rather than forward. 

NPATT:  The authors speak at length about the generalizability your CPR validation. Can you respond breifly on the issue?

Childs:  The manipulation CPR as developed by Flynn and validated by Childs can only be generalized to similar patients that were included in these 2 initial studies and only using similar treatments. In both the Flynn and Childs studies, the SMT intervention was standardized and limited to a single high velocity thrust technique. Childs et al also included a comprehensive exercise strengthening program to the intervention. In contrast, Hancock et al allowed therapists wide latitude in which manual therapy techniques to use. The large majority of therapists (97%) elected to use lower velocity mobilization techniques and the 4-week intervention did not include an active exercise component (strengthening or otherwise), thus it’s difficult to compare the 2 studies. It is not surprising at all that Hancock did not find any differences in outcome based on whether patients fit the manipulation prediction rule because they tested an altogether different treatment approach. Their study does provide strong evidence that lower velocity mobilization procedures, in the absence of an active exercise component, is likely ineffective for patients with LBP.
 
NPATT:  Along the same lines, the authors suggest focusing SMT treatment  on specific painful segments.  I've also seen evidence arguing that SMT is not, by nature, able to address specific segments and is a more global approach.  Couple this with a proposed neurophysiologic mechanism, and I'm not sure targeting a specific segment is realistic or necessary.  What is your opinion on this?
 
Childs:  There is no evidence to suggest that SMT directed to a specific segment can be done in a reliable and valid way. Even presuming it could be done, there is no data to suggest that a “specific” approach is more clinically effective than a general approach. Many studies have demonstrated that the effects of SMT are likely occurring above and below the targeted segments. Much research is now being directed at understanding the mechanism through which SMT acts to improve pain and function. It seems that selection of the right patient is a more important priority than which technique is used. There is data now in the lumbar spine to suggest that SMT incorporating high velocity thrust manipulation is more effective than mobilization in the subgroup of patients who fit the manipulation rule.
 
NPATT:  What's the big picture here for SMT and low back pain? 

Childs:  Pick the right patient and use SMT frequently in conjunction with an active exercise strengthening program. Don’t lose sleep if the models of “diagnosing” presumed biomechanical dysfunctions confuse you or don’t make sense. In all likelihood, they are mostly invalid and not useful for decision-making anyways. The key is being able to match patients to the right treatment based on key clinical examination variables associated with a successful outcome from a particular standardized treatment approach.

Thanks for the great conversation, John!  This is an important debate and I'm eager to see where it ultimately leads us.
ERIC
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The Punctuated Evolution of Gait Training Technology?

One of the staples of physical therapist practice is teaching individuals to walk using assistive devices. In fact, just today I'm prepping to introduce the skill to first year students. Not much has changed in how one uses crutches, except that perhaps splinters have become less of a problem with the emergence of metal vs. wooden crutches. 

At some point, technology will touch upon everything, and I wonder if these auxiliary legs might be the wave of the future for assistive devices. Instead of a clumsy rolling walker, one might simply strap on these robo-legs and go.  Could I be instructing how to strap on and use robo-legs in a couple of years?  

ERIC
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Got Diabetes? Be Strong!

Logo_date_short

The LA Times recently picked up this APTA press release reporting on the results of a study in Physical Therapy, which found that improving strength through resistance training can help with blood sugar control. Subjects in the study participated in a 16 week exercise program supervised by a physical therapist.  The key to the program was the addition of resistance training to aerobic training.  Those who recieved that program had improved health in terms of BMI and increased muscle mass compared to those who only performed aerobic exercise.  Lean tissue helps regulate blood sugar levels.

The study is part of PT Journal's Special Diabetes Issue, which is a pretty slick issue!  Of course, November 14th is World Diabetes Day!  Diabetes is estimated to have an economic cost of $174 Billion in the United States and effects up to 24 million individuals.

ERIC
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Manipulating the Brain

Seattle Blues 

I've been at the annual conference of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) in Seattle, WA over the past few days. This is one of my favorite conferences, in part because of the high-powered attendees, but also because it is plain fun!  The theme of the conference was "Pain:  From Science to Solutions."  

This year, we were treated to some wonderful neuroscience as delivered by David Butler, PT, who combined cutting edge information with humor during his talk, "Manipulating the Brain."  
His message: Pain is in the brain! 

Read about it at his website for the Neuro Orthopaedic Institute Australasia which includes links to his 3 different blogs. 

I had the great opportunity to present a session at the conference. Not surprisingly, I spoke about using web technology to improve evidence-based practice. I really got to show off my inner geek!  If you're interested in the resources from my presentation, find them here.

Image courtesy of:  http://www.flickr.com/photos/chuckrobinson/2401273711/
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What is the Best Approach to Mechanical Neck Pain?

ResearchBlogging.org

Every so often a study comes along that you know is going to garner loads of attention and be cited by many for years to come.  This month’s issue of Spine includes just such a study.  Walker et al. published their work entitled, "The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain."  This well designed study compared a group of patients receiving impairment-based manual physical therapy and exercise (MTE) to a group receiving a minimal intervention consisting of sub-therapeutic ultrasound,advice and range of motion exercise (MIN).

The researchers included some important key design features in the study that help make it very generalizable to practice.  First, the allowed for subjects to present with or without upper extremity symptoms while still falling under the umbrella of "mechanical neck pain."  This was controlled by excluding those subjects with more than 2 neurological signs on the same nerve root level.  Secondly, the authors limited their intervention period to 6 sessions in an attempt to replicate "realistic reimbursable practice patterns."

The intervention delivered to the MTE group consisted of an impairment-based evaluation and treatment, a framework where the clinician carefully examines the patient and employs manual therapy techniques alongside continual reassessment to address a prioritized list of patient impairments.  Both thrust and non-thrust mobilization techniques were employed followed by a standardized home exercise program.  Therapists were not limited in terms of technique selection or body region to treat, and could also prescribe additional exercises to reinforce the manual techniques performed.

In short, the MTE group achieved superior outcomes across the entire study.  Here are the key points as summarized in the paper:

● "Manual physical therapy and exercise consisted of impairment-based
manual interventions and reinforcing exercises directed to the
cervico-thoracic spine and ribs. Subtherapeutic ultrasound provided by physical therapists was added to a minimal intervention approach of education, motion exercise, and medications to maintain patient expectations for physical therapy care and symptom improvement.

● Manual physical therapy and exercise was significantly more effective
in reducing neck pain and disability, and increasing patient-perceived
improvements during short- and long-term follow-ups.

● Statistical and clinical improvement in upper extremity pain scores was demonstrated at all follow- up periods for patients receiving manual physical therapy and exercise.

● Treatment success rates, as determined by those patients achieving a
large improvement in  symptoms,were significantly greater in the manual
physical therapy and exercise group at all follow-up periods.

● Manual physical therapy and exercise is a safe and effective treatment approach for patients with mechanical neck pain, with or without unilateral upper extremity symptoms."

This study joins others showing similar results to provide broad support for manual physical therapy for patients with mechanical neck pain.  The decreased healthcare utilization rate for the MTE group compared to the MIN group was promising in that the MIN group sought additional care twice as often as the MTE group.  In fact, those versed in evidence-based lingo will take note of the number needed to treat reported in this study:  to achieve a benefit in 1 patient, 4 will need to be treated.  A very strong number! 

Congratulations to all the authors for a nice study that will provide support for the physical therapy profession, at a time when it is desperately needed.

ERIC

Michael J. Walker, Robert E. Boyles, Brian A. Young, Joseph B. Strunce, Matthew B. Garber, Julie M. Whitman, Gail Deyle, Robert S. Wainner (2008). The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain Spine, 33 (22), 2371-2378 DOI: 10.1097/BRS.0b013e318183391e

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Direct Access and Reimbursement Part II

Reimbursement for Direct Access to physical therapy services
is nothing if not variable and for all intents and purposes, mostly
non-existent. Some states have providers
than cover services without a previous referral, but most do not. This stands in stark contrast to practice
acts, where the majority of states permit patients to physical therapy services
without a referral. So the question
becomes, if it is legal to access therapy services without a referral, why is
this not covered by payors? The answer
to this question lies in complicated political forces, and that some insurance
providers regularly operate outside the realm of reason. That said, we can look at events in New
Jersey to shed some light coverage for Direct Access.

Dr. Robertson, the
author and publisher of this blog has been kind enough to invite me to provide
some commentary on how the efforts now underway in New Jersey relate to
reimbursement in general and Direct Access specifically. As a matter of full disclosure, I am the
current President of the New Jersey Society of Independent Physical Therapists
(NJSIPT) which is the organization currently promoting the legislative efforts
noted above. It should also be noted
that as the invited author of this article that any opinions expressed in this
article are solely mine and do not necessarily represent the opinions of the
NJSIPT.

There is probably no single more complex or controversial
issue in health care than reimbursement and a full treatment of this issue is
not possible in a blog article. That
being said it does deserve continued exposure, exploration and discussion and
that is the spirit in which I am approaching this topic.

The complexities of reimbursement arise from an abyss of the
highly varied payer policies of profit driven commercial payers, a heavily
regulated Medicare program, the compendium of state regulations regarding
provision and payment for services and an entire medical industry struggling to
survive in a competitive environment where margins are extraordinarily thin or
non-existent.

As a practicing clinician and private practitioner it is
from the perspective of standards by which I view these legislative
efforts. As the healthcare industry has
consolidated, there has been a concomitant decline in reimbursement as the
insurers increased their stranglehold on the marketplace. Despite this, healthcare costs for
musculoskeletal care have steadily increased. Over the past few years as draconian cuts in reimbursement approaching
60% have put my colleagues and I on the verge of financial collapse, it became
evident that a severe conflict had developed pitting compliance with practice
standards at direct odds with remaining financially viable. The question was how to rectify this
imbalance. The answer was legislatively. This was confirmed at a recent legislative
committee hearing where a member of the committee commented that it was the
purpose of the legislature to ensure fairness when one party utilizes its
position to the detriment of others.

In short this legislative effort in NJ seeks to ensure that
providers are compensated fairly based on prevailing fees as determined by the
state, that barriers to access are removed by ensuring that third party payers
pay for medically necessary services when sought by consumers without a prior
referral from a physician and that payers pay providers their share of the
liability directly without regard for network participation status.

Although there is great variability as to what
“Direct Access” means depending on the various state practice acts and other
statutes, as previously mentioned in this blog by Dr. Robertson one of the
greatest barriers to the actualization of “Direct Access” to Physical
Therapists is the lack of coverage by third party carriers. The legislation currently pending in New
Jersey provides for the coverage of Physical Therapists’ services when accessed
directly by consumers. Considering the
mounting evidence that medical costs are reduced when Physical Therapists’
services are accessed directly I am certain that all interested parties will
realize benefit from this legislation including the third party payer
community.

Mark F. Schwall, PT

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Direct Access: Reimbursement

Money_3
The entire concept of reimbursement for healthcare services is vast and complicated.  But, examining costs for healthcare is not so complicated.  Certain services are expensive, others less so.  For example, orthopaedic surgeons are expensive with certain procedures like spinal fusion costing $40,000 or more.  Pharmaceuticals, which are the tool of choice in primary care, and needless radiological imaging are also expensive.  Very few of these expensive items are effective, yet reimbursement for them is provided all the time. 

Conversely, direct access to physical therapists is not expensive and can produce outcomes superior to the expensive options noted above, yet coverage for this by payors is rare.  When it does occur, costs go down.

Yet reimbursement for direct access to physical therapists is rare, despite a large transition of state practice acts to allow for this.  Some in the profession think it is a matter of time before payers realize the potential savings and alter their policy, others are taking a more active approach through the legislature.  Up next, a guest post furthering this discussion of reimbursement for direct access.

Image by TWCollins

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Meetings Be Gone

Meeting_2
I’m taking a couple days off from work to ride mountain bike on the most awesome FATS trail system here in SC.  I’m really looking forward to it before the fall semester begins.  The last thing I did at work before I left was to sit in a meeting.  It was a typical meeting.  As someone who likes speed and excitement rather than laborious discussion, meetings are not my best friend.

So, for all my friends in academia in particular and others who are subject to mind-numbing meetings, here are a couple links to ponder:

Do Meeting Make Us Dumber? [via Lifehacker.com]

Shorten Meetings by Standing Up. [via Lifehacker.com]

The Meeting Miser calculates the real cost of meetings based on pay scale.  (And we wonder why education is so expensive!)  I calculated that my meeting yesterday cost over $300 for my institution!

5 Alternatives to Meetings.  This one is my favorite, of course! 

Here’s a cool video of the Brown Wave Trail at FATS.  Way better than meetings!

[Link to Video]