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 though...so 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.

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

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.

Rod