Football Season and Injury Prevention

Credit: aa7ae – http://www.flickr.com/photos/87241965@N00/

With high school football season beginning, it’s important to become aware of injury risks with this sport.  Football injuries are most commonly related to trauma.  Unlike a sport like baseball where the most common injuries are over-use related.  Concussions, knee injuries, and injuries to the shoulder are seen frequently.

How do you reduce this risk?  First, talk to your child’s coach and observe a practice or two.  Collisions are what lead to the most injuries.  By reducing how much contact occurs in practice, and reducing the speed of the collision (by practicing “half speed” or greatly reducing the distance between the colliding players), it is possible to mitigate risk.

Be wary of “old school” coaches that use the philosophy that football players need to be toughened-up with practices dominated by hitting.  Especially tackling drills where kids are lined up yards from each other for a big running start.

For more information on football injury prevention, click on the link below or contact Harris Physical therapy on FaceBook or via email with any questions.

Stop Sport Injuries.org

Direct Access to Physical Therapists Saves Money

ALEXANDRIA, VA, October 13, 2011 — A new study suggesting that “the role of the physician gatekeeper in regard to physical therapy may be unnecessary in many cases” could have significant implications for the US health care system, says the American Physical Therapy Association (APTA).

The study, published ahead of print September 23 in the journal Health Services Research (HSR), reviewed 62,707 episodes of physical therapy using non-Medicare claims data from a Midwest insurer over a 5-year period. Patients who visited a physical therapist directly for outpatient care (27%) had fewer visits and lower overall costs on average than those who were referred by a physician, while maintaining continuity of care within the overall medical system and showing no difference in health care use in the 60 days after the physical therapy episode.

The study is noteworthy because services delivered by physical therapists account for “a significant portion” of outpatient care costs in the United States, according to the study, and some health insurance plans require a physician referral for reimbursement of these services. In addition, although 46 states and the District of Columbia now allow some form of direct access to physical therapists for treatment/intervention, some of them nonetheless impose restrictions if patients have not been referred by a physician.

“Physical therapists have long known that direct access to our services is safe and effective,” said APTA President R. Scott Ward, PT, PhD. “The elimination of referral requirements and other restrictions has been a priority of APTA for decades. This study provides further evidence that direct access to physical therapists could go a long way toward helping to make health care more affordable and accessible for all. We encourage researchers and insurers to continue to further investigate this important issue that could have a profound impact on patient care.”

“When patients choose direct access to a physical therapist, it does not mean the end of collaboration with their physician, nor does it diminish continuity of care,” added Thomas DiAngelis, PT, DPT, president of APTA’s Private Practice Section. “We believe the results of this study will support our efforts to work with legislators and physician groups to establish policies that reduce unnecessary regulations, improve access, and build models of delivery that best serve the patient and the health care system. Although this study focused on direct access, it is not about the provider. It is about the patient. It means better opportunities to provide the proper care to those who need it, when they need it.”

Led by Jane Pendergast, PhD, professor of biostatistics and director of the Center for Public Health Studies at the University of Iowa, the study retrospectively analyzed 5 years (2003-2007) of private health insurance claims data from a Midwest insurer on beneficiaries aged 18-64 in Iowa and South Dakota. A total of nearly 63,000 outpatient physical therapy episodes of care were analyzed – more than 45,000 were classified as physician-referred and more than 17,000 were classified as “self-referred” to physical therapists. Physical therapy episodes began with the initial physical therapist evaluation and ended on the last date of services before 60 days of no further visits. Episodes were classified as physician-referred if the patient had a physician claim from a reasonable referral source in the 30 days before the start of physical therapy. Researchers found that self-referred patients had fewer physical therapy visits (86% of physician-referred) and lower allowable amounts ($0.87 for every $1.00 of physician-referred) during the episode of care, after adjusting for age, gender, diagnosis, illness severity, and calendar year. In addition, overall related health care use – or care related to the problem for which physical therapy was received, but not physical therapy treatment – was lower in the self-referred group after adjustment. Examples of this type of care might include physician services or diagnostic testing. Potential differences in functional status and outcomes of care were not addressed.

“Health care use did not increase in the self-referred group, nor was continuity of care hindered,” the researchers write. “The self-referred patients were still in contact with physicians during and after physical therapy. Concerns about patient safety, missed diagnoses, and continuity of care for individuals who self-refer may be overstated.”

According to Rick Gawenda, PT, president of APTA’s Section on Health Policy and Administration, the study should cause insurers and policymakers to rethink the physician gatekeeper concept when it comes to physical therapist services. “Evidence shows that, in the case of physical therapy, the physician gatekeeper model is doing exactly the opposite of what it was originally designed to do; it does not reduce ineffective and duplicate care nor reduce health care costs,” says Gawenda. “It’s time to end the physician referral requirement in every state, and it’s time for all payers to embrace direct access to physical therapists.”

Earlier research has supported direct access to physical therapists, but the new HSR study is the most comprehensive to date. A 1994 study analyzed 4 years of Blue Cross Blue Shield of Maryland claims data and found that total paid claims for physician referral episodes to physical therapists were 2.2 times higher than the paid claims for direct access episodes. In addition, physician referral episodes were 65% longer in duration than direct access episodes and generated 67% more physical therapy claims and 60% more office visits. The HSR study looked at a far more extensive number of episodes than the previous study, and also controlled for illness severity and other factors that could have affected the patients’ outcomes.

“In summary,” the researchers write, “our findings do not support the assertion that self-referral leads to overuse of care or discontinuity in care, based on a very large population of individuals in a common private health insurance plan with no requirement for PT [physical therapy] referral or prohibition on patient self-referral. We consistently found lower use in the self-referral group, after adjusting for key demographic variables, diagnosis group, and case mix. We also found that individuals in both groups were similarly engaged with the medical care system during their course of care and afterwards.”

 

 

Reference
1. Pendergast J, Kliethermes SA, Freburger JK, Duffy PA. A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy. Health Services Research. Published ahead of print September 23, 2011. DOI: 10.1111/j.1475-6773.2011.01324.x

Understand How Pain Works

Most of us are taught early on that pain is a direct result of tissue harm or damage.  While this view works well for most situation (eg, pain with a muscle pull or pain with a paper cut), it is incorrect and can lead to sub optimal or even harmful treatments when this paradigm is strictly followed.

Our friends in the southern hemisphere have put together a fantastic 5 minute video about pain but also ideas on how one can better manage pain:

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Experts Warn About Elbow Injury in Little Leaguers

ALEXANDRIA, VA, August 2, 2011 — Talented, young baseball players from around the world are gearing up for the 65th Little League Baseball World Series, August 18-28 in South Williamsport, Pennsylvania. While the focus is on winning, the game-plan for many coaches and parents also aims to protect players from a painful injury caused by excessive throwing known as Little League Elbow or Pitcher’s Elbow. The American Physical Therapy Association (APTA) warns that millions of little leaguers are putting themselves at risk for injury in their attempt to throw the fastest and farthest.

“It has been estimated that 2.2 million children between the ages of 4 and 16 are participating in baseball annually,” said APTA member Kevin Wilk, PT, DPT, a leading authority in sports injury rehabilitation. “Kids between the ages of 9 and 14 who throw breaking balls, pitch in showcases to display their skills and fundamentals, or, more importantly, pitch too frequently without adequate rest, are the most vulnerable to injury.”

Little League Elbow is a chronic inflammation of the growth plate on the elbow joint, which manifests itself as pain and swelling inside the elbow. Approximately 50% of little leaguers ages 9 to 14 will experience elbow pain.[i] Pitchers in this same age group who pitch more than 100 innings a year experience a 3 to 4 times greater risk of elbow or shoulder injury.[ii] Those who continue to pitch through the pain can eventually cause the growth plate to separate from the joint, requiring surgery to re-attach it.

Routinely players will go from a game in one league to a practice or game in another league and pitch on back-to-back days. If coaches on both teams are unaware of the fact that the pitcher just pitched for another league, there will be a misrepresentation of league pitch counts and a subsequent increase to one’s risk for injury.

APTA member Mike Mullaney, PT, DPT, an expert on throwing injuries said, “It is up to the player and the player’s parents to monitor pitch count, understand the designated pitch counts for their age group, and respect them.”

These risk factors contribute to elbow pain in youth baseball players:

  • Age. Youth baseball players are at greater risk because their elbow joint (bones, growth plates, and ligaments) are not fully developed and are more susceptible to overuse injuries.
  • Pitching too many games.The number of games pitched should be carefully monitored and follow the league’s pitch count rules (.pdf). If pain occurs before the pitch count limit is reached, then the player should stop immediately. Rotating pitchers during games is a good idea to ensure adequate rest is given to each pitcher.
  • Curveballs and breaking pitches. Both of these types of pitches appear to put more stress on the growth plate than other types of pitches.
  • Improper mechanics. Proper throwing mechanics decreases forces on the elbow joint.

Physical therapists, as experts in restoring and improving motion in people’s lives, can help players prevent overuse injuries by educating them on proper throwing mechanics and through preventative programs that focus on stretching and strengthening the arm. Wilk recommends a combination of good mechanics, being physically fit, not being fatigued when you throw, adhering to pitch count guidelines, and not playing the positions of pitcher and catcher for a team to decrease one’s risk. Mullaney added that a strengthening program focused on the posterior shoulder may also minimize risk.[iii]

In March 2011, the American Sports Medicine Institute, where Wilk is the director of rehabilitative research, updated its “Position Statement on Youth Baseball Pitchers,” which includes 10 recommendations for preventing injuries in youth baseball pitchers:

For more information about Little League Elbow and how a physical therapist can help prevent or treat the condition, click here.

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New Activity Recommendations for Those With Type II Diabetes

The American Diabetes Association and the American College of Sports Medicine have jointly published updated guidelines for physical activity for those with type II diabetes. The last set of Recommendations were published in 2000 and these new recommendations incorporate the new research since then.

Highlights include:

  • At least 2.5 total hours of moderate to vigorous aerobic activity a week.
  • Brisk walking may be vigorous for sedentary individuals.
  • At least 3 days of exercise per week with no more than 2 days between exercise sessions.
  • Resistance training should also be included.
  • For many, SUPERVISED exercise should be provided initially.

This paper points out that much research has shown that aerobic and resistance exercise has a separate and additive affect on blood glucose transportation.  This is no small finding.

While I am not advocating that Physical Therapists become front line clinicians in the fight on Diabetes, many – if not the majority in some regions – patients coming to see us have Diabetes.  This is a perfect time to educate and incorporate into a home program (if appropriate) ways for them to better manage their diabetes.  We should not look past this opportunity to help.

Would enjoy hearing anyone’s experience with diabetes and exercise.

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2010 EIM Elevator Pitch Winner!

The fine folks over at Evidence In Motion have announced their 2010 winner of the Elevator Pitch Contest.  This year’s winner is Amy Lee from Oklahoma.  Congratulations and great video.

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Power Balance Wrist Band – Just More Snake Oil?

I’m sure many of you – just like me – thought from the beginning “of course it doesn’t work”.  I want to make some points and hope to get us to think on a bigger picture scale beyond that of Power Balance and the great marketing job the owner’s have done.

1.  Claims are supported only by testimonials.

2.  Explanation of why it works: “Power Balance is based on the idea of optimizing the body’s natural energy flow…”

Have we heard this similar theme anywhere else?  Lets take a look -

  • Reiki (www.reiki.org): “Reiki heals by flowing through the affected parts of the energy field and charging them with positive energy…”
  • Acupuncture (www.acupuncture.com): “Acupuncture works to “re-program” and restore normal functions by stimulating certain points on the meridians in order to free up the Chi energy…”
  • Energy Medicine (www.energymed.org): “…heal the body by activating its natural healing energies; you also heal the body by restoring energies that have become weak, disturbed, or out of balance…”

3.  Response to real studies that show product/treatment makes no difference beyond placebo – “Power Balance has lived and thrived in the ultimate testing environment, the real world…” (quote from ESPN OTL segment).

Again, this theme has been put forth in other “alternative” medicine/treatment camps:

  • Homeopathy (www.homeopathic.org): “…difficult medical discipline to master because it is based on the pure observation of nature, and the strict application of a natural law.”
  • Acupuncture (www.medicalacupuncture.org): “…The conventional Western medical model, by treating specific and “objective” diagnoses, can easily design studies which permit statistical inferences about the benefits of an intervention…This approach is in contrast to traditional acupuncture models where an individual, not a diagnosis, is treated.”

As consumers and/or healthcare providers, we face a mounting surge of similar claims.  While it may be easy to shrug off products that grow out of great marketing, we must also be aware of some of the possible holes in treatments we must decide to recommend or provide for our clients.

Think critically and avoid what are – in my opinion – common marketing strategies that are re-manufactured over and over.

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Degenerative Rotator Cuff Tears

Full Thickness Tear

A group of radiologist set out to document where, how, and why of degenerative rotator cuff tears.  Their findings were recently published in the Journal of Bone & Joint Surgery.  They presented some interesting findings:

  • Full thickness tears tended to be mostly small with only a small majority being classified as “massive”.  Also, partial thickness tear width and length were generally smaller than full thickness tears.
  • Full thickness tears location were found right next to the biceps tendon but partial thickness tears were found in the tendon at the junction of the supraspinatus and infraspinatus.  This suggests a back to front tear pattern.
  • There is a significance between the biceps tendon and the location of the tear, but what that is is unknown at this time.

It’s important to note that these findings were on a population of people with asymptomatic rotator cuff tears.  Therefore the pathogenesis described in the study won’t necessarily translate to those with symptomatic or traumatic rotator cuff tears.

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How To Spot Woo – A Short Read on Evaluating “Alternative” Medicine Claims

After many question from my patients and the general public regarding “alternative” treatments (e.g. magnets, craniosacral, dietary supplements, etc) I decided to sit down and write up an educational handout to summarize how to approach evaluating treatment options. This includes treatments in so called “Alternative Medicine” and main-stream medicine alike.
I am very concerned that many alternative treatments are blatant attempts to take advantage of persons in desperate situations. Such as end-stage cancer and progressive disease processes like arthritis.

Below are some ideas on how to approach decisions about “new” therapies to allow you to maximize your potential gains and to protect your money from those offering up only a big handful of woo.


EVALUATING INTERNET MEDICAL ADVICE

Jason Harris, PT, DPT

Our modern internet has opened the door to a vast arena of medical advice and information. With this information, it is important to critically evaluate the information and the author’s credibility. How does one pick between credible and worthless? It can be hard, but I will outline a few rules for judging the value of the information you are reading.

I suggest you look for “Red Flags” while researching medical information on the internet. In medicine “Red Flags” are signs and/or symptoms that warrant immediate attention as they indicate a potential life threatening situation. I will use the term to indicate immediate problems with information that is being evaluated.

“RED FLAGS”:

1. Any site that use the terms “alternative”, “holistic”, “integrative”, “natural”, and/or “miraculous” (Barrett). The vast majority of websites using these terms should replace them with “unproven” and/or “ineffective”. They also tend to push Herbs, vitamins and supplements. Do not trust a salesman to tell you the whole and complete truth. Their job is to sell you the product.

2. Claim large effect on symptoms with out side-effects. Causing a large change in body function (or dysfunction) has a cascading effect that leads to known side-effects and occasionally adverse reactions. No side effect most often indicates such low doses as to have no real effect.

3. Claim that a treatment can cure multiple problems/pathologies. Nothing can, or ever will, cure your shoulder pain and colic.

4. Claim that everyone will experience the same positive results. Humans are not all the same. Disease processes are complex and include multiple organ systems to varying degrees. Due to this, you cannot expect all to respond the same way or to the same degree. This is why well run clinical trials are essential. Which brings us to the next point…

5. The use of testimonials as sole proof that treatment works. A positive experience one person has cannot be generalized to anyone else. This is a complex topic as we rely on recommendations and advice from our neighbors to function efficiently in society and these salesmen attempt to take advantage of this.

6. Person is touted as a “Guru” with many impressive sounding “credentials”. Often claims are made that your problems can only be cured by the seller. Often it is because of some procedure or test named after them that only they can do. In the end, only they can do it because there has been no published research to support or refute it’s ability to do what it is purported to do.

7. Must buy to see results. Any reputable treatment/product should have peer-reviewed published literature that shows it can do what it claims. You should never have to first buy something to know or experience how it works.

Medical information from the internet must be reviewed wisely and used as a supplement to the advice a trusted healthcare professional has given you. When in doubt, bring the information you have found to your MD, DO, or PT and discuss it with them. These “red flags” are a good start to filtering out the majority of bad from the good.
Works Cited Barrett, M.D., Stephen. ” How to Spot a “Quacky” Web Site.” 06 September 2006. Quackwatch. 7 July 2007 .

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CHOOSE BACK SURGERY AT YOUR OWN RISK

Tallahassee, Florida, April 9, 2010 – Patients with low back pain from spinal stenosis are increasingly being exposed to dangerous surgeries. The Journal of the American Medical Association (JAMA) has just reported an alarming increase in complex spinal surgery for lumbar spinal stenosis.  In just five years, from 2002 to 2007, the number of complex fusion surgeries to treat lumbar (low back) spinal stenosis soared from a rate of 1.3 per 100,000 to 19.9 per 100,000. The study showed that life-threatening complications occurred in 5.6% of patients having complex spinal fusions. Patients who had complex fusions had longer hospitalizations, higher rates of re-hospitalization, and three times the rate of serious complications such as heart attack and stroke. These surgeries continue despite little medical consensus on whether or not these procedures are helpful or should even be used in the management of lumbar spinal stenosis.

“This study supports what we have been seeing in our clinics for years,” said Dr. Bob Rowe, President of the American Academy of Orthopedic Manual Physical Therapists (AAOMPT).  “Older adults are seeking care from physical therapists following significant back surgeries and they frequently have problems that weren’t there prior to surgery and yet they still have back and leg pain.  We hope this finally sounds the alarm and stops the madness that is going on in surgical spine care.”  Dr. Rowe cautions that patients should be aware that these surgeries are extremely risky and put your life in danger and that you may not be any better off after the procedure.”  

Fortunately there is good news for healthcare consumers as a previous randomized clinical trial demonstrated that patients with Lumbar Spinal Stenosis report significant improvement after physical therapy, with the greatest gains occurring in patients who received manual physical therapy, exercise, and a progressive body-weight supported treadmill walking program. Rowe noted that, “it just make sense to try physical therapy first, which is a low cost, low risk, and most importantly effective treatment for chronic low back pain due to lumbar spinal stenosis.”  Consumers should actively seek care from a qualified physical therapist for their low back complaints.

For more on the benefits physical therapists can provide in the management of back and neck problems, contact your nearest physical therapist or visit the American Academy of Orthopaedic Manual Physical Therapists website at www.aaompt.org, to find a fellowship trained manual physical therapist in your area AAOMPT represents physical therapists by promoting excellence in orthopaedic manual physical therapy practice, education and research., you can go directly to: http://www.aaompt.org/directory/fellowSearch.cfm

For more information on managing lumbar spinal stenosis go to: http://tinyurl.com/stenosisRCT

Jason L. Harris, PT, DPT

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