Posts in Physical Therapy
Increased Risk of ACL Re Injury Among NSAID Users

In our previous posts we have detailed the risk factors for ACL injury and the effectiveness of Physical Therapy to reduce this risk especially among adolescents.  A percentage of athletes who return to sport will re injure their ACL leading to further surgeries and Physical Therapy.  A delayed return to sport allows the athlete more time to resolve muscle imbalances and coordination impairments leading to decreased re injury risk.  As we learn more about these athletes who re injure their ACL reconstructions we will have a better idea of how to prevent the injuries.

A recent large study in the The American Journal of Sports Medicine reviewed patient charts who underwent an ACL reconstruction surgery in the US Military over a 7 year period (Pullen et al. 2016).  Over 17,000 procedures were performed over this time period and 587 soldiers underwent revision surgery (3.6%).  The median time to re injury among these individuals was 500 days.  Athletes at greater risk of re injury included younger, active duty soldiers who took anti inflammatory medication during the perioperative period.  This study also identifies the potential harm of taking anti inflammatories during rehabilitation for ACL repair.

Arthroscopic Surgery for Knee Pain

Last year over 500,000 thousand arthroscopic knee surgeries (scopes) were performed in the Unites States making it one of the most common orthopedic surgical procedures.  In a previous post we highlighted some of the evidence behind this surgery showing it is not superior to a sham or placebo surgery for degenerative meniscal tears.  In addition, many literature reviews and analyses have shown the procedure offers little to benefit to patients with knee pain (Thorlund et al. BMJ. 2015).  

A recent article in the British Medical Journal compared Physical Therapy exercises to surgery for middle aged patients with degenerative medial meniscal tears (Kise et al. 2016).  The authors found no difference in self reported knee function at long term follow up, but reported greater strength and muscle performance in the exercise group.  Patients with knee pain are encouraged to utilize Physical Therapy over surgery for painful knee conditions.   

Individualized Physical Therapy Saves Money Compared to Usual Care for Low Back Pain
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As healthcare costs continue to rise, all stakeholders (patients, providers, and payers) are looking for ways to reduce costs associated with common conditions.  In our field, we see patients given generic, one size fits all exercise programs for common conditions including low back pain.  Our previous post highlights the limitations of this approach including providing incorrect, inadequate, and sometimes harmful exercises to patients without a proper Physical Therapy examination first.  In addition, patients provided these incomplete, generic exercise programs will often spend additional healthcare resources in the coming months looking for relief of their symptoms.  

A recent research article in the journal Spine compared the effectiveness of individualized Physical Therapy services to guideline based advice for patients with low back pain. (Hahne et al. 2016).  300 patients were randomized to one of the two groups then were followed for 1 year to determine the effectiveness and cost of each treatment group.  Patients treated with Physical Therapy reported higher levels of health benefits at a lower cost than the guidelines group.  Specifically, patients missed fewer work days at a savings of close to $2,000 per worker.  This study adds to the existing data on the importance of individualized Physical Therapy for patients with low back pain.  

Strength Training to Failure
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A common question we receive in clinic is how many repetitions should I perform of this strengthening exercise?  Clearly, enough repetitions are needed under a given load to promote beneficial changes within the tissues for improvements in both healing and performance.  Ranges of repetitions range from < 5, 8-12 reps, and >15 reps depending on the intended goals of the exercise and the patient/client's capability.  Another repetition goal gaining popularity is performing the exercise until muscle fatigue/failure regardless of the number of repetitions.  The biggest limitation of this training is sacrificing intensity (amount of weight) in order to perform a high number of repetitions.  A study recently compared the effects of training until failure with higher intensity exercises.  

Looney and colleagues had healthy volunteers squat with 50, 70, and 90% of their maximum squat strength (J Strength Conditioning Research. 2016).  Athletes were assessed for muscle activation during these exercises to determine which level of resistance and repetitions produced the most beneficial environment for strength gains and muscle growth.  The authors results were consistent with the previous literature indicating intensity (higher weights) is more effective than training to fatigue (higher repetitions) for muscle performance.  Athletes and clients are encouraged to pick a repetition range consistent with their goals and to lift a weight which leads to fatigue (only 1-2 good reps left at end of the set) within that repetition range.  '

To learn more on how strength training can improve your health and performance contact your local Physical Therapist.  

PT Visits in Physician Owned Practices Comes at a Cost
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Patients have a choice for where they attend Physical Therapy even if directed to a single PT practice by their physician. Unfortunately, physician owned physical therapy practices, either on or off site, are on the rise around the country and referrals are being driven to these practices due to financial incentives. These practices often utilize less qualified personnel (aides, technicians) to deliver PT services at a higher cost than independently owned practices. In addition, research shows these practices utilize a higher percentage of passive modalities (ultrasound) inconsistent with current medical research guidelines.

A recent article highlights the importance of choice when patients select a Physical Therapist after knee surgery.  Mitchell and colleagues researched Medicare data on 3,771 total knee replacements performed between 2007 and 2009 (Health Services Research. 2016).  Researchers divided these patients into three groups based on where they attended Physical Therapy and the financial relationship between the Physical Therapy clinic and the physician.  

1. 709 patients received PT a a clinic where there was a financial connection with the physician  

2. 2215 patients received PT at a clinic where there was no financial relationship             

3. 847 patients received PT at a clinic with an independent provider, but referring physician had a financial interest

The researchers found patients who received Physical Therapy at a physician owned clinic were seen for twice as many visits and received less individualized care.  Authors also noted a decrease in intensity at the physician owned clinics likely responsible for the longer plan of care.  Intensity was described as the amount of individualized interventions designed to improve range of motion, strength, and endurance.  These results are consistent with prior research demonstrating the key financial and quality differences between physician owned and non physician owned Physical Therapy practices.   

Patients are advised to research into the ownership of their Physical Therapy clinic and choose a Physical Therapist who can deliver the most effective and efficient interventions possible.   

  

Does One Size Fit All in Physical Therapy?
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In our fast paced, instant gratification world we want solutions to our problems the same day as their arrival.  This is no different in low back pain, a common, costly condition affecting over 90% of adults.  Patient's hurting from low back pain symptoms often turn to the internet, friends, or their primary care physician for quick solutions to their problem.  Although low back pain is common, the reasons behind the pain are multifactorial in nature limiting the effectiveness of a one size fits all approach.  Thus, patients seeking advice online, from friends, or their physician may be given an inappropriate or ineffective treatment plan leading to lost time, lost employment and money.  In the past, clinical guidelines on low back pain have been created by medical and government agencies in an attempt to help guide decision making for all patients with low back pain.  Not surprisingly, research has shown the limitation of this one size fits all approach with lower costs and improved outcomes observed with Physical Therapy compared to guidelines.  

A more recent article in British Journal of Sports Medicine was published to compare the outcomes between general advice and patient specific Physical Therapy treatments (Ford et al. 2016).  200 patients with low back pain, less than 6 months in nature, were randomized to either an education group or to 10 sessions of Physical Therapy interventions including manual therapy and exercise.  Consistent with prior research a patient specific plan of care showed better outcomes at 10, 26, and 52 weeks compared with an education only approach.  

This article adds to the existing literature indicating the importance of early, patient specific Physical Therapy treatment compared to advice or a wait and see approach.  To learn more on how Physical Therapy can help get accelerate your recovery from low back pain contact a local Physical Therapist.