Posts tagged physical therapy
Does Treatment Of Trigger Points Improve Outcomes For Patients With Rotator Cuff Injury?
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Rotator cuff injuries span the spectrum from acute strains to chronic tendon pain (tendinopathy) and rotator cuff tears. Physical Therapy remains the gold standard, first line treatment for all rotator cuff injuries due to its’ cost and clinical effectiveness treating these disorders. A Physical Therapy first strategy has been reinforced by recent research demonstrating equivalent outcomes between surgery and Physical Therapy for patients with rotator cuff tears. Strength training exercises remain the most important intervention for patients due to their ability to reduce pain, heal injured tissues, and restore lost function. A recent study examined the effectiveness of adding trigger point treatments to an established Physical Therapy exercise program.

Akbaba and colleagues randomized patients with rotator cuff tears to one of two groups (J Back Musculoskelet Rehabil. 2019). Both groups received the same Physical Therapy strengthening program completed twice a week for 6 weeks, but one group also received manual soft tissue treatment of their shoulder’s trigger points. Authors assessed each patient’s pain, range of motion, function, and mental health outcomes initially and upon completion of the 6 weeks. Both groups improved pain, range of motion, function, and mental health but the addition of trigger point treatments did not improve clinical outcomes in patients with rotator cuff tears. This study highlights exercise remains the most important treatment in patients with rotator cuff injury and soft tissue interventions add little to the overall recovery of patients.

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Research Supports Physical Therapists As Primary Care Providers For Musculoskeletal Conditions
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Evidence continues to support the utilization of Physical Therapists as a first line treatment for patients with musculoskeletal conditions such as back, neck, shoulder, or knee pain. Patient self referral for Physical Therapy services or direct access has been safely utilized in our country since the late 1950s. Many large corporations and the U.S. Military utilize this model of care due to its’ clinical and cost effectiveness. Patient’s seen by a Physical Therapist first save on average $1000-1500 per episode of care. This model allows patients to access high quality care quickly after the onset of an injury avoiding lost time and money associated with delays in the traditional healthcare system.

Bornhoft and colleagues randomized patients from 3 medical clinics with musculoskeletal disorders to either a primary care physician or Physical Therapist (Ther Adv Musculoskeletal Dis. 2019). Patients were followed at 2, 12, 26, and 52 weeks after the initial consultation with a medical provider. Authors were interested in a patient’s symptoms, function, quality of life, and risk for developing chronic musculoskeletal symptoms. They found both groups of patients improved but consistently better outcomes in the group treated by Physical Therapists. The authors concluded Physical Therapists can be safely and effectively recommended as an alternative management pathway for patients with musculoskeletal conditions.

Physical Therapy Offers Equivalent Outcomes To Surgery For Carpal Tunnel
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Carpal tunnel syndrome or the entrapment of the medial nerve at the wrist is a condition leading to pain, numbness, and pins and needles sensations along the palm side of thumb, index, and middle fingers. If the entrapment continues weakness can be experienced in the wrist and hand. Contributing factors include loss of nerve and wrist mobility, muscle imbalance, and work ergonomics. Although surgery remains a common intervention, previous research has shown no difference in long term outcomes between surgery and Physical Therapy for patients with carpal tunnel surgery (Fenandez de las Penas et al. J Pain. 2015.). A recent research study compared the cost of these Physical Therapy interventions for patients with carpal tunnel syndrome.

Journal of Orthopedic and Sports Physical Therapy published a recent article on the cost effectiveness of either Physical Therapy or surgery for the treatment of carpal tunnel (Fernandez de las Penas et al. 2018). Authors randomized 118 patients with carpal tunnel to either a surgical intervention or Physical Therapy consisting of 3 sessions of manual therapy, nerve mobilizations, and home exercises. As expected, patients in the surgical group required greater numbers of additional treatments, days lost from work, and greater costs compared to patients in the Physical Therapy group. In addition, this study supported previous research findings on equivalent outcomes found between surgery and conservative care treatments for patients with carpal tunnel.

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Q and A with Dr. Thomas McPoil, PT, PhD, FAPTA on his Career, the Physical Therapy Profession, and the Management of the Foot and Ankle
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1.     You have experienced an illustrious and diverse career in research, education and clinical work. What is the secret to your success in all of these disciplines?

I have been very blessed to have such a great career in physical therapy – I firmly believe that the reason for any of the success that I have had is directly related to the tremendous personal and professional mentors I have had throughout my career.  On a personal note my father and mother and most importantly, my wife and my daughters, who have always been so supportive and understanding of my desire to be the best clinician, teacher, and researcher I could strive to be – even at the expense of time I could have been spending with them.  From a professional standpoint, there have been so many mentors and colleagues who have influenced my development as a clinician, teacher and researcher.  While it would be impossible to name all of these individuals, I need to recognize Harry Bergtholdt, PT, MS and Drs. Gary Hunt, Harry Knecht, Mark Cornwall, Dale Schuit, and Bill Vicenzino.  Each of these individuals as well as so many others have had a profound effect on me throughout my career. 

2.     You have witnessed many changes in the field of physical therapy. What are some good changes, what are some bad changes, and where do you see the profession going?

The accomplishments our profession has made since I started practicing physical therapy are nothing short of phenomenal!  At the time I completed my certificate in physical therapy at Children’s Hospital of Los Angeles in 1973, positions for new graduates in the Los Angeles area were extremely difficult to find.  At that time, 80% of all physical therapists worked in either hospitals or nursing homes.  In my first staff PT position, I served in a technical role as a physical therapist under the direction of a physiatrist.  Every morning I would go the PT department located in the basement of hospital and get my treatment orders from the physiatrist – the typical prescription for patients with neck and back conditions was ultrasound, followed by hot packs, and then 15 minutes of massage.  At the completion of the treatment, I did William’s Flexion Exercises with the patient on the treatment table.  I remember getting a stern lecture from the chief physical therapist when I was silly enough to attempt to do some closed-chain exercises with a patient based on my athletic training experiences in college – he told me it was not appropriate to have the patient exercise while standing.  Needless to say it was depressing and there were several times when I thought about leaving physical therapy and going back to athletic training.  I was fortunate enough to accept physical therapy position in the U.S. Public Health Service in 1976 which was a major turning point in my career.  In the Public Health Service, I was able to work with some outstanding physical therapists and was finally able to independently examine and treat a patient without physician direction.  To think that today our students now obtain an exceptional education and are granted a doctoral degree, physical therapist can practice in a variety of specialty areas in multiple practice environments, and we have achieved the ability to practice autonomously with patients having direct access to our services is remarkable.  These are definitely great changes!

Unfortunately, the physical therapy profession is still fighting for recognition in both the health care arena and society as THE primary care provider for neuromusculoskeletal conditions.  In my opinion, there is no other health care profession that has the knowledge and training to serve in this important health care role.  The other critical issues facing the profession is 1) the ongoing struggle to improve the system of payment for physical therapy services and 2) the high cost of obtaining a Doctor of Physical Therapy degree.  After teaching physical therapy students at both the undergraduate and graduate level for 36 years, I am also convinced that certain critical clinical skills including obtaining the history and appropriate decision making based on subjective and objective findings are difficult, if not impossible, to teach in the current model of academic and clinical entry-level education.  The ability to acquire these skills requires structured clinical mentorship that occurs during direct patient care that is provided with quality residency/fellowship training.  Some of the issues for entry-level students considering a physical therapy residency or fellowship is student loan debt and salaries not commensurate with advanced clinical specialization.  In addition, there are not enough residencies or fellowships positions for every entry-level graduate.  That being said, the profession needs to strongly consider reducing the length of entry-level education programs to 2 and ½ years as well as promote the path to residency or fellowship as the norm for entering the practice of physical therapy.  To do so, the profession also needs to do all that is possible to accelerate the development of residencies and fellowships.  

3.     You are world renown in research surrounding the ankle and foot. What first got you interested in specializing in that area?

As a student athletic trainer in college, I was always assigned to the cross-country and track and field teams.  As a result I had to deal with many foot and ankle injuries and I enjoyed treating these injuries that even though I did not have the necessary knowledge to adequately manage the injuries.  As I noted in question #2, my first assignment as a physical therapist in the U.S. Public Health Service (PHS) was the PHS hospital located in Staten Island, New York.  Many of the patients referred to physical therapy were diabetic and were admitted for foot plantar ulcerations that eventually lead to a lower extremity amputation.  While I enjoyed working with these patient’s as the physical therapist was responsible for fabricating the temporary protheses as well as gait training, it also was apparent that we needed to do something to help prevent the development of plantar ulcerations as a result of diabetic neuropathy.  A senior PHS physical therapist Joe Reed who had tremendous expertise in foot orthotics and footwear would visit the hospital and help us make cushioned insoles and sandals for these patients.  So Joe was the first physical therapist to get me started making orthotics.  In 1978, I accepted my second assignment at the U.S. Public Health Service Hospital located in Carville, Louisiana which was also known as the National Hansen’s Disease Center.  The lay term for Hansen’s Disease is leprosy.  Patient’s with leprosy have the same neuropathic issues as the diabetic patient even though the disease process is different.  It was also at Carville, that I was first introduced to the Podiatric Model by a podiatrist who had studied with Dr. Merton Root one of the founders of the podiatric model.  During the three years I was at Carville, I spent at least 50% of my time making foot orthoses or footwear modifications.  At the same time, I was pursuing my master’s degree in athletic training at Louisiana State University and would make foot orthoses for the intercollegiate athletes.  As a result of these experiences, when I left the U.S. Public Health Service in 1981 to join a private practice in Joliet, Illinois, I knew that I wanted to continue to specialize in the foot and ankle for the rest of my physical therapy career.

4.     There is research validating the use of custom fitted orthotics and their benefit for patient function. What is your current stance on these findings? Have your thoughts changed over the years of studying this topic?

This is very interesting and complex question.  Before discussing the “evidence” it would be best to define what is a custom fitted foot orthotic.  When I first started teaching continuing education courses on the foot and ankle in the early 1980’s, a custom foot orthosis would be defined as a device that was fabricated on a mold of the patient’s foot that was obtained using a slipper cast with the patient positioned in subtalar joint neutral position as per the podiatric model.  Unfortunately, there are two issues with this method.  First, since the typical prescription for podiatric model orthotic device is fabricated with a firm material such as polypropylene, if the polypropylene was molded to the mold of the patient’s foot obtained in subtalar joint neutral position, the orthosis would cause medial arch (navicular) pain during weight bearing.  To allow the use of firm material in the fabrication of the orthosis, the mold of the patient’s feet obtained from a neutral position plaster slipper cast are modified using “arch fill” so that the podiatric model foot orthosis is comfortable to wear.  The typical amount of arch fill reduces the height of the medial longitudinal arch by 50%.  As a result, when a patient stands on a pair of podiatric style foot orthoses, they will undergo pronation depending on the amount of arch fill selected on the prescription form.  So this leads to the question – how custom-fitted is this type of foot orthoses?  Other foot orthotic manufacturers will have the clinician use a foam box to obtain a mold of the patient’s foot rather than a plaster slipper cast.  However, in a study we did in 1989 which compared two non-weight bearing plaster slipper cast techniques to the foam box method, the foot mold obtained using the foam box was markedly different in comparison to the non-weight bearing casting methods.  Second, the examination methods and foot orthosis theory based on the podiatric model were shown to have no validity and poor reliability over 20 years ago.  The most current research on this topic published in 2017 by Jarvis et al in the Journal of Foot and Ankle Research concluded that: 1) the examination protocol advocated by the podiatric model no longer provides a suitable basis for professional practice, 2) clinicians should stop using subtalar joint neutral position as part of the clinical examination and as a means of defining foot deformities associated with the podiatric model, and 3) their results question the relevance of the podiatric model as basis for prescribing foot orthoses.  More importantly as pre-fabricated foot orthoses have developed over the past decade, many of these pre-fabricated foot orthoses can be “customized” to provide both increased contact with the plantar surface of the foot through heat molding as well as with wedging or posting.  The major disadvantage with pre-fabricated foot orthoses, in comparison a polypropylene podiatric model device, is the durability.  Since EVA foams are used to fabricate many pre-fabricated foot orthoses, they tend to “wear-out” at a faster rate than polypropylene.  To determine if durability is an issue, it is important to look at the clinical evidence for foot orthosis effectiveness.  There is evidence to support the use of custom fitted foot orthoses for individuals with rheumatoid arthritis, neuropathic diabetic ulcerations, and forefoot conditions such as metatarsalgia, hallux limitus/rigidis, and Morton’s toe.  For conditions commonly referred to physical therapy including plantar heel pain, commonly diagnosed as plantar fasciitis, excessive pronation (however that is defined!), and anterior knee pain best current evidence supports the use of foot orthoses in reducing pain and improving function for up to 12-weeks with no difference in outcomes between customized versus pre-fabricated foot orthoses.  Optimal treatment for these conditions requires a multi-modal approach with the short-term use of foot orthoses to provide pain reduction and increased functional levels.  So at this point in my career for the majority of patients I see, the use of a pre-fabricated or custom foot orthoses provides similar outcomes as long as the pre-fabricated foot orthoses selected for the patient can be modified.  So the choice – custom versus pre-fabricated – should be based on which device is most cost effective for the patient.  The important point here is that for most patients, the use of foot orthoses is only one component of the overall management program – it can never be viewed by the patient or the clinician as the “centerpiece” of the treatment plan.  

5.     You are entering into a new season of life as you retire from your position from Regis University. What are your plans going forward? What do the next 5 years look like for Dr. Tom McPoil?

I still have several professional things I am working on over the next year including some guest lectures at meetings as well as the 50th McMillan Lecture next June at the APTA NEXT Conference.  I want to get back to playing some golf and I just started playing pickleball.  I played squash for a number of years when we lived in Flagstaff, Arizona, but was never able to get back to playing since moving to Denver.  I have always enjoyed playing tennis, racquetball, and squash, so I am looking forward to learning the game of pickleball.  I also started volunteering 8 hours per week at the SAME Café in Denver as part my commitment to the Ignatian Volunteer Corp.  Of course, I want to spend more time with my wife, our two daughter’s families and our five grandchildren.  So I think I will have plenty to do to keep me busy over the next 5 years.  As I said at the start, I have had a very blessed 45-year career as a physical therapist!  I am looking forward to the next chapter in my life.   

Physical Therapy Supported As First Line Treatment For Meniscal Tears
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Meniscal tears are a common knee diagnosis and can occur either traumatically or gradually over time. This latter type of meniscal tear, degenerative, was previously treated with arthroscopic surgery and post operative physical therapy but more recent research has changed our practice patterns with this patient population. Specifically, research shows no benefit of surgery over placebo surgery or surgery over conservative care including Physical Therapy. The equivalent outcomes of arthroscopic surgery and Physical Therapy has let many medical groups to advocate against the use of surgery for this condition.

A recent article in the Journal of the American Medical Association supports these previous findings on the management of patients with meniscal tears (van de Graaf et al. 2018). Three hundred twenty one (321) patients were randomized to either a knee arthroscopic menisectomy (meniscal tear removal) or Physical Therapy consisting of 16 sessions over 8 weeks. These sessions primarily consisted of strengthening exercises of the lower quarter. Authors found Physical Therapy was equivalent to surgery for improving knee function at 2 year follow up and stated Physical Therapy may be considered as an alternate to surgery for patients with meniscal tears. Although some patients may eventually require surgery the vast majority of patients will benefit from Physical Therapy first for their meniscal tears.

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Should I choose PT or surgery for my hip impingement or labral tear?
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The labrum is a dense connective and fibrocartilage tissue lining the socket of the hip joint.  It functions to deepen the hip socket and improve stability and weight bearing during functional activities.  The labrum is highly innervated on top and front portions of the joint and often refers to the front of the hip when symptomatic.  Labral tear diagnosis is on the rise due to more surgeons being trained in hip arthroscopic surgery and increased utilization of MRI scans.  Experts note caution is warranted when interpreting these findings because up to 68% of pain free individuals will have a labral tear after MRI testing.

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Hip labral tears  and femoral acetabular impingement are common diagnoses among < 40 year old patients especially those involved in rotational sports such as hockey and tennis.  As stated previously, many of the positive MRI findings are also present in pain free athletes.  Researchers are still determining which of these findings indicate pathology vs. a natural adaptation to the sport similar to what we see in pitcher's shoulders. 

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Physical Therapy treatments including manual therapy and exercise are very effective for both hip impingement and labral tears.  Goals of treatment include pain reduction and improving patient function including return to sport and activity.  Interventions are designed to increase space and avoid abnormal contact at the hip joint.  Most importantly, patients are trained to re establish hip strength and coordination to allow a safe return to sport without the classic hip pinch or catch.  Two studies have compared the effectiveness of Physical Therapy to surgical interventions and both have found significant patient improvement, but no significant differences between groups.  Thus, patients are encouraged to utilize Physical Therapy first for their hip symptoms.  Early Physical Therapy may also help identify patients who require surgical intervention after conservative treatment.  

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