Saturday, June 28, 2008

Forget 2020...How about Vision 2008?

I know we are all fired up about the utopia that will be 2020, but it might be a good time to take an honest look at the here-and-now.

The Good

I am amazed at some of the pessimism and complaining that runs rampant in our profession. I think some of this general crankiness comes from a serious lack of perspective. Firstly, we now generate more relevant clinical research not only in our own journals, but in many well-respected journals of the medical profession. Secondly, despite relevant misgivings about the current state of our education and training, we are arguably kicking out more well-rounded and academically prepared therapists into the work force. Lastly, although I hear PT's complain about their pay entirely too much, salaries have never been higher. Basically there has never been a better time to be a physical therapist and we are doing some things very well.

The Bad

At the same time, we do have our share of important issues to deal with. Reimbursement is declining across the board. Regulation of our practice (guided by the flagship CMS) is at an all time high. While innovation is being championed in the form of inspiring new clinical research, emerging and potentially useful practice patterns are too often fractured by suffocating reimbursement and regulatory guidelines. To whom should we cast the first stone?
  • Ourselves in not policing our practice patterns when the money was good.

    Thanks to our gluttonous billing patterns of yesteryear (Can you say "HUMing?), we are currently paying the price. Everyone was doing it it's ok right? Right.

  • Third party payors in realizing they could actually make more money by regulating us more tightly (say cheese ACN). Sometimes, its hard to explain how the corporate world could be even more irritating than the federal government. The blame shifts again back on us however, as we have gently rolled over for these jerks and it continues to pay off...for them.

  • The federal government in wielding restrictive legislation with the precision of a sledgehammer. The result is an inexplicably complex federal health care system that is confusing to it's beneficiaries and frustrating for it's providers. Are we sure we want to turn the whole thing over to these hacks? If your answer is 'yes', you clearly have never picked up a copy of our federal tax code.

  • Our patients in creating a culture of unaccountability from of our actions. The founders of our country would probably get nauseated at the sight of our behaviors.
    Despite incontrovertible medical evidence, public awareness, corporate and federal funding, our nation continues to resist adopting healthy behaviors. Trips to the local gym aren't nearly as frequent as those to the troughs of the local all-you-can-eat buffet. Pictures like the well-nourished gentleman above would be hilarious if they weren't so sad.

The Ugly

One might say we aren't handling these challenges very well. We whine at legislative defeats, but refuse to contribute to our PAC. We bemoan the pitiful reimbursement from third-party payors, but continue to feed off these scraps. We get upset at fringe providers who continue to practice voodoo like craniosacral and myofascial therapy, but don't have the guts to force our own professional organization to marginalize them. Lastly, we complain our patients are fat and smoke too much, yet don't take enough time to counsel them in an appropriate manner. Basically, we aren't contributing much to a solution.

Working Toward a Solution

We are free to blame the federal government, third party payors, and even patients for our problems. In the end, it's wasted energy without salient action. Those actually doing the heavy lifting for our profession are too busy to complain. They are busy actively researching, teaching, and advocating for a profession that largely doesn't act like it wants to play in the big leagues. The next time you complain about reimbursement, POPTS, payors, or patients, you may want to take an inventory to decide just which side of this funny little equation you are on.

Sorry, but treating patients isn't enough. We get paid to do that remember? Conscious effort beyond the call of duty is required to shift this equilibrium toward a favorable outcome. Contribute to our profession beyond the time-clock. Teach. Perform clinical research. Write your congressman. Give time to your local school district, community, or church. Doing something will always trump complaining about everything.

Lastly. I would be remiss if I didn't state the obvious: It is an election year with serious implications for the future of our health care system. Please vote! Remember. Our vision for 2020 is worthless without action in 2008.

Thursday, June 26, 2008

Preventing Stiffness after Rotator Cuff Repair Postoperative rehabilitation of the shoulder can be both rewarding and frustrating for even veteran physical therapists. While a significant number of patients recover with little to no disability, the process is not free of clinical land mines.

One of the more notable land minds for the postoperative shoulder is stiffness. If you've practiced long enough, you've probably developed some sense of what kind of patients or perioperative variables may be associated with the stiff shoulder. My running hypothesis was that it had a lot to do with preoperative stiffness and disability, much like we often see with knee arthroplasties.

Today's article, from Clinical Orthopedics and Related Research, prospectively examines the relationship between preoperative and postoperative characteristics that might predict patients more likely to become stiff following shoulder surgery.

The sample consisted of 209 patients with primary rotator cuff repairs. Operative procedures were standardized to a reasonable degree and involved subacromial decompression and rotator cuff repair. Interestingly the postoperative course was fairly well managed but did not involve supervised rehabilitation. The subjects were instructed in a 3-month home exercise program. Range of motion and manual muscle force were assessed preoperatively and at 6, 12, and 24 weeks by physical therapists. Lastly the patients were administered a Shoulder Service Questionnaire at the final postoperative follow up at a mean of 76 weeks (95% CI, 68-84 weeks).

The sample was retrospectively divided into two groups based on PROM at six weeks post-op:

  • Group A (Early motion recovery): Patients who ranked in the upper quartile of ROM for at least three of the four primary measured motions of flexion, abduction, external rotation, and functional internal rotation.

  • Group B (Shoulder stiffness): Patients who ranked in the lower quartile for at least three of the four motion categories

The subjects meeting the criteria for early motion recovery (39 total) and shoulder stiffness (36 total) were compared using ten descriptive and clinical characteristics. In reading the article, the progression of each characteristic is interesting to observe regardless of statistical significance. However, there were a few very interesting statistical and clinically significant findings.

  • Preoperative functional IR (hand behind the back) was the best predictor for postoperative shoulder stiffness

  • Age, gender, arm dominance, preoperative symptom duration, worker's compensation, type and size of tear were not predictive of shoulder stiffness

These were interesting findings of themselves but what followed really caught my attention:

  • The total range of motion achieved for group A (early motion) and group B (shoulder stiffness) were remarkably similar at 76 weeks. This finding indicates a delay in regaining full shoulder ROM rather than a permanent loss in ROM as has been previously proposed.

  • Although pain levels for group A were significantly better than group B, these differences only lasted up to the 12th postoperative week. After this they became remarkably similar. Again, this raises questions as to whether early postoperative pain and stiffness predicts permanent pain and disability as has been proposed.

  • Postoperative pain and stiffness for group B was at its worst at the six-week point, and then steadily improved until the final follow up to be comparable to group A.

I was really impressed with this study for a few reasons. I typically push the worry button around 4-6 weeks post-op if the patient isn't' making satisfactory progress or has high pain levels. I might be inclined to loose a few less hairs now - believe me I cherish them dearly!

Secondly, this study provides some relief that postoperative stiffness may not predict long-term pain or disability. In fact many of the subjects achieved good results regardless of their early postoperative course. It will be nice to present this kind of information to patients who are struggling in the clinic next to their "group A" cohorts!

More research on this topic needs to be done as the present study does contradict some of the conventional wisdom we have in the clinic regarding postoperative shoulder stiffness. What this study does provide is very good fodder for discussion and opens up more dialogue for improving our outcomes following this fairly common procedure. Take care and talk to you soon!

Trenerry, K., Walton, J.R., Murrell, G.A. (2005). Prevention of Shoulder Stiffness after Rotator Cuff Repair. Clinical Orthopaedics and Related Research, &NA;(430), 94-99. DOI: 10.1097/01.blo.0000137564.27841.27

Sunday, June 22, 2008

Cutting Edge Technology: The Spell Check

Wow...just realized I submitted my last blog prior to spellchecking!! If you want a good laugh or just like bad spelling, please read my most recent blog entry on pain in your reader or inbox.

If you are merciful, please visit my website and read the literate version of the Persistent Pain blog entry. Sorry about that! See you next time.


Thursday, June 12, 2008

Persistent Pain: An Independent Disease State? I recently began reading C.S. Lewis' The Problem of Pain. As with many of Lewis' writings, it is remarkable in both it's depth and simplicity. So many questions arise when it comes to the issue of pain, particularly for this therapist. Because I don't like weak links, I figured I'd better start looking for answers!

One aspect of a good question is that it often gives rise to more even better and more clinically relevant questions. Many physical therapists (myself included) emerge from entry-level training with a rather unsophisticated understanding of pain. We are more apt to enter the workforce with a strong understanding of pathoanatomy and biomechanics as it pertains to movement. If our goal is for our profession to evolve into becoming entry-level providers, we should have no tolerance for blind spots.

In the coming weeks, I will be incorporating the rather complex subject of pain as it pertains to common orthopedic conditions we encounter. More importantly, I will place emphasis on relevance to both assessment and treatment. I hope you will get as much out of the articles as I have in researching them. Mercifully, the topics will appease those of you with an appetite for physiology versus psychology.

Today's article comes from the Journal of Pain and Symptom Management on the issue of persistent pain and is truly an eye-opening read. Based on our study of pathophysiology, the concept of persistent or chronic pain doesn't always connect with our understanding of the inflammatory process. While there is clearly an inflammatory component to the acute pain our patients' experience, the relationship between tissue damage and persistent pain becomes much less clear in more.

The review provides evidence for "independent, pain-perpetuating pathophysiologic changes that occur after, or in the absence of, acute painful conditions or concomitant painful conditions." The review's author, anesthesiologist Michael Cousins, makes a very strong argument for persistent pain as a distinct pathological entity warranting specific attention from diagnosis through management. Cousins' contention is that failure to acknowledge the distinct physiology of persistent pain is likely to result in suboptimal care.

Contrary to much of the cognitive-behavioral pain literature I've tried to choke down over the years, this article provides the reader with some pretty significant pathophysiology supporting the concept of persistent pain as a distinct entity. I was particularly impressed with the physiology of peripheral sensitization, spinal cord events, and central nervous system changes that result from persistent pain. There is a relatively brief discussion of psychologic and environmental contributors,but the weight of the article is devoted to the biologic processes behind persistent pain.

Pain is not something orthopedic therapists may find particularly interesting or even relevant to their daily practice. The "no pain no gain" philosophy does have its time and place. However, what if there is a better way? I have no illusions of becoming the next pain-guru nor will I turn this into another freaky pain-blog, but I think we can take our practice to the next level by improving our understanding of pain in an orthopedic setting.

COUSINS, M. (2007). Persistent Pain: A Disease Entity. Journal of Pain and Symptom Management, 33(2), S4-S10. DOI: 10.1016/j.jpainsymman.2006.09.007

Saturday, June 7, 2008

The Pelvic Floor and an Unexpected Lesson...
It's been six months since starting this blog and I'm amazed what the process has taught me to this point. Sitting down in front of a computer has given me numerous opportunities to learn more about our profession, enhance my clinical skill, and in this case, grow up a little.

If you know me personally, I tend to be a pretty fun-loving and somewhat irreverent guy who is prone to cracking wise about a variety of topics. In most settings, this characteristic is simply what makes me "me". In the context of a public discussion on a physical therapy website, it could transform "me" into a bit of a jerk.

I recently made a pretty insensitive comment regarding pelvic pain on the Rehab Edge forums. I won't delete the post as accountability and transparency is something I believe in and don't think running away from what I said is the right approach. In response to my comments, two ladies associated with a blog called Pelvic Pain Matters descended upon me with what turned out to be understandable mix of outrage and disappointment.

With a strange sense that I really might have stepped in it with my comments, I ran them by my wife, mother, and academic mentor from physical therapy school. The result of my informal poll was unanimous and a bit humbling: I was a total jerk for what I said. Not the easiest things to hear from three people who you respect and admire, but the consensus struck a chord nonetheless.

Pelvic floor dysfunction is not an area I have previously held any interest in addressing as a orthopedic clinician. In fact, it is not likely to ever be an area I develop a strong skill set in assessing or managing. However, it is worth noting that pelvic floor dysfunction is a distinct clinical issue that can be present in a broader population than I had previously understood.

JOSPT: Lumbopelvic dysfunction, Incontinence, and the use of Rehabilitative Ultrasound

In keeping with the theme of this blog, today's entry comes to us from JOSPT on the topic of lumbopelvic dysfunction and stress urinary incontinence. The paper is a case study on a 35 y/o female soldier presenting with stress urinary incontinence and left buttock pain. These symptoms were limiting her tolerance for physical activity necessary to complete basic training.

The study's authors utilized a multimodal approach to managing what was determined to be an SIJ dysfunction coupled with active pelvic floor insufficiency contributing to stress incontinence. Of particular focus in the study was the use of rehabilitative ultrasound as a biofeedback device to retrain the pelvic floor musculature.

At a six-week follow up, the patient had no subjective or objective signs of SIJ dysfunction or stress urinary incontinence. This allowed her to complete all the requirements of basic training without limitation. A six month telephone follow up was equally positive with no evidence of lumbopelvic dysfunction or incontinence.

What can this study tell the orthopedic therapist?

While I wasn't bowled over with the methodology or outcomes of this particular study, I did learn quite a bit regarding pelvic floor dysfunction. Firstly, I discovered just how prevalent pelvic floor pain and/or dysfunction can be in both men and women. Secondly, I got a better appreciation for the biomechanics of the pelvic floor and its possible role in low back pain. Lastly, I gained an appreciation for another clinical syndrome physical therapists may be able to benefit.

What has this process taught me?

Well...that remains to be seen! Some might say you can take the boy out of the locker room but it's hard to take the locker room out of the boy. I might agree with this statement. However, there comes a time when us boys have to realize we are professionals and people do read what we say on blogs and internet forums. I make no guarantees of future perfection. In fact, I'm more prepared to guarantee future imperfection. That doesn't mean I can't grow up along the way. Have a great day.

Painter, E.E. (2007). Lumbopelvic Dysfunction and Stress Urinary Incontinence: A Case Report Applying Rehabilitative Ultrasound Imaging. Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2007.2538

Sunday, June 1, 2008

Imaging and Shoulder Pain: Why we don't treat MRIs....

How many of us have heard patients tell us they'll be relieved if they could just get an MRI to "tell them what's wrong."? I'll be the first to admit I too jumped on this bandwagon early in my career. I was very eager to see an individuals MRI report to correlate their clinical symptoms. You've heard me quote a wise old PT friend of mine who said "We don't treat MRIs". Well RV, this one goes out to you. ;)

This fascination with "seeing" what's wrong has lost a bit of its luster as I've read some very interesting reports on the lack of agreement between MR and clinical presentations. We've seen this phenomenon in low back and shoulder pain where imaging studies don't necessarily correlate with the patients clinical presentation.

It'd been a while since I've seen a good study on this topic so I figured I'd look up what the American Journal of Roentgenology had to say on the issue. The article takes a whopping 1079 consecutive patients referred for shoulder MRI. The subjects were asked to complete validated shoulder questionnaires regarding pain and disability. These were correlated with the radiologists' MR findings.

What did the authors conclude?
  • MRI is highly accurate at detecting the presence of a partial or full-thickness rotator cuff lesion.

  • There was no relationship between pain or disability with the size or location of the rotator cuff tear.

  • Rotator cuff lesions may be thought of as a natural correlate of aging

  • It is not clearly identified why some rotator cuff lesions are symptomatic while others are "silent"

  • Factors such as bursitis, capsuloligamentous lesions, or cartilage lesions may confound the findings of MRI as they pertain to the rotator cuff

  • There may be "no relationship between rotator cuff tear size and the inflammatory reaction responsible for the pain and disability, like low back pain is unrelated to the size of disc herniations."

What are the author's recommendations?

  • "Despite the absence of correlation between the size of the rotator cuff tears and the level of disability,MRI provides important data that may affect the management of rotator cuff lesions and should be performed before rehabilitation or surgery."

Really AJR? Let me make sure I understand. There is little to no correlation between imaging and symptoms, yet folks should go ahead and get the MRI anyway? Even before rehab? That's a hard one to swallow. In his defense of the study's author, the investigation took place in France within a socialized health care system where utilization would doubtless be far different from ours.

Regardless of the author's curious conclusion, the study is an honest representation of how limited the value of MRI can be for common musculoskeletal complaints. It also underscores the importance for physical therapists not to get too caught up in hounding the referring physician for the MRI report.

Treat the patient, not the report!

Krief, O.P. (2006). Shoulder Pain and Disability: Comparison with MR Findings. American Journal of Roentgenology, 186(5), 1234-1239. DOI: 10.2214/AJR.04.1766