APTA American Physical Therapy Association

Studies Report Outcomes of Treating Common Back Conditions Surgically Versus Nonsurgically

Patients with sciatica who undergo early microdiskectomy surgery report faster recovery and improvement in leg pain than patients who receive prolonged conservative treatment. However, 1 year later, both groups of patients reported similar recovery results.

"Surgery Versus Prolonged Conservative Treatment for Sciatica," published in the May 31 issue of New England Journal of Medicine (NEIM), compared early microdiskectomy surgery with a strategy of prolonged conservative treatment with eventual surgery if needed. Patients who has early surgery reported faster recovery and more rapid improvement in leg pain. After 1 year, the outcomes in the two groups were similar, and 95% of the patients in both groups reported recovery.

A second study in NEIM compared surgical treatment with nonsurgical treatment, including physical therapy, of spondylolisthesis. Because of extensive patient crossover, the data were essentially nonrandomized, and as-treated analyses were performed. During 2 years of follow-up, patients treated surgically had greater improvement in pain and function than those treated nonsurgically. Patients treated nonsurgically showed moderate improvement over time.

In an accompanying NEIM editorial, "Back Surgery -- Who Needs It?", Richard A. Deyo, MD, MPH, says, "The consensus seems to be that patients who were excluded from these trials because of major motor deficits need surgery, as do some with major spine trauma. For these patients, surgery may preserve life or function. Absent major neurologic deficits, patients with herniated disks, degenerative spondyloisthesis, or spinal stenosis do not need surgery, but the appropriate surgical procedures may provide valuable pain relief. In such situations, decisions should be made jointly by well-informed patients and their physicians."

Freedom of Choice

In July, New York became the 43rd state to pass direct access legislation. The Consumer Access to Physical Therapy bill eliminates, under certain conditions, the physician referral requirement for patients who need physical therapy services. The bill passed the legislature with bipartisan support and becomes effective December 1.

Under the new law, patients can directly access the services of a licensed physical therapist for 10 visits or 30 days, whichever comes first.

"Physical therapists have been working with the state legislature to achieve direct access for patients for nearly 25 years," said James Dunleavy, PT, MS, president of the New York Physical Therapy Association in a news release. "This bill is a thoughtful piece of legislation with patient safety taking the highest priority."

You have the freedom to choose your own physical therapist. As of December 2006, residents in New York can go directly to a physical therapist without a physician's referral first.

Keep in mind that your insurance policy may require a visit to the primary care physician first or limit your access to only preferred providers.

Your physician may refer you for physical therapy that is to be provided in his or her office or to a facility in which he or she has a financial interest. If either situation is the case, insist that your physical therapy be provided by a licensed physical therapist.

• A recent major study by the Health Care Financing Administration showed that patients who received an appropriate amount of physical therapy experienced better outcomes than did those whose access to treatment was restricted by third-party payer restraints.
Shaughnessy, Schlenker, and Hittle, Home Health Care Outcomes Under Capitated and Fee-For Service Payment, Health Care Financing Review, Fall 1994

• Direct access to physical therapy results in lower patient costs. In most states, patients may obtain physical therapy directly from a licensed physical therapist. Direct access saves money for both consumers and insurers; maintains a high quality of care; encourages preventive health care; reduces the need for long-term care; does not promote overutilization; and makes physical therapy services more accessible to more people.
Mitchel J. de Lissovay G, A Comparison of Resource Use and Cost in Direct Access Versus Physican Referral Episodes of Physical Therapy, Physical Therapy, 1997

• Physical therapy is cost effective. Early physical therapy intervention prevents more costly treatment later. Hospital lengths of stay involving head injuries, strokes, and orthopedic disorders are reduced by early intervention.
Cope D, Hall K, Head Injury Rehabilitation: Benefit of Early Intervention, Archives of Physical Medicine and Rehabilitation, 1982
Hayes S. Carroll S, Early Intervention Care in the Acute Stroke Patient, Archives of Physical Medicine and Rehabilitation, 1986
Linton SJ, Hellsing A, Anderson D, A Controlled Study of the Effects of an Early Intervention on Acute Musculosketetal Pain Problems, Pain, 1993

Physical therapists treat the consequences of disease or injury by addressing impairments, functional limitations, and/or disabilities in patients. Some of the more common conditions treated by physical therapists are:

• Orthopedic conditions, such as back and neck pain and osteoporosis.
• Joint and soft-tissue injuries, such as fractures and dislocations and pre- and post-surgical conditions.
• Neurologic conditions, such as stroke, traumatic brain injury, Parkinson's disease, cerebal palsy, and multiple schlerosis.
• Connective tissue conditions, such as burns, ulcers, and wounds.
• Arthritic conditions, including osteoarthritis and rheumatoid arthritis.
• Cardiopulmonary and circulatory conditions, such as congestive heart failure and emphysema.
• Workplace injuries, such as carpal tunnel syndrome.
• Sports injuries, such as overuse injuries and trauma in recreational and professional athletes.

IMPROVING PATIENT OUTCOMES

Physical Therapy Professionals, P.C. strives to utilize the best evidence-based assessments and treatments in our practice. We continue to improve our treatment outcomes by reviewing the latest literature for recent advances, and attending continuing education seminars. We find that sharing our clinical experience amongst our staff, and with our referral sources helps to improve all lines of communication. With this in mind, we would like to highlight our treatment techniques for plantar fasciitis and heal pain.

Patients with plantar fasciitis require proper education on the nature and progression of recovery of this condition, as well as many key principles including: acute care management, proper footwear and support, controlling aggravating factors, along with proper exercise and weight loss. Unless patients are made aware of what activities worsen their condition, and they consciously reduce these activities, their condition is unlikely to improve regardless of what treatment is provided.

Both new and chronic conditions can have daily acute episodes of symptoms that require principles of acute care management. These include "relative" rest by reducing the amount of time standing and walking, as well as pacing their activity with times of nonweightbearing. Patients may benefit from use of cryotherapy in the form of ice or ice massage, contrast baths, and whirlpool. If edema present, compressive wraps or stockings may be helpful. Many patients need instruction in general footwear. Supportive shoes, or various inexpensive arch supports or orthotics are often important to control excessive pronation or over-stretching of the plantar fascia. Prolonged walking and standing, as well as standing without a show should be avoided. We educate our patients regarding supportive shoes with a solid heel counter and proper fit. They need to avoid standing barefoot, and we suggest at least a supportive sandal or slip-on style shoe at home.

Overall case management involves clinical care, as well as patient education to help control aggravating factors that may perpetuate their condition. Most patients realize that being overweight can contribute to their symptoms, however they generally choose an exercise such as walking, that involves increased weightbearing and subsequently provokes their symptoms. They need to be educated to choose exercises that involve less weightbearing such as walking in water or other water based exercises, cycling, or mat activities. The intensity, duration, and frequency of their exercise should be closely monitored in order to establish a pain free starting point and logical progression. Specific manual therapy techniques, along with these exercises help in the recovery process. Physical therapy modalities including Iontophoresis (Dexamethasone or acetic acid), ultrasound/phonophoresis, soft tissue mobilization with deep friction massage, and electrical stimulation all provide therapeutic effects. External arch taping techniques, along with nonweightbearing, specific static stretching exercises may be necessary in chronic cases.

Plantar fasciitis can be very challenging to manage, and it is encouraging that we can demonstrate improved outcomes with appropriate interventions. We appreciate your confidence and referrals, and as always, please feel free to contact our office regarding any questions, concerns, or comments that you may have.

Clinic-Based Therapy Proves Highly Beneficial

    A study published in the December issue of Physical Therapy (the journal of the American Physical Therapy Association) has found that although both clinic-based and home-based physical-therapy programs proved to be beneficial for osteoarthritis of the knee, clinic-based treatment programs, including manual therapy applied by physical therapists (PTs) combined with PT-supervised exercise, had better overall results.
    The study, conducted by Gail D. Deyle, PT, DPT, at Brooke Army Medical Center in Form Sam Houston, Texas, and colleagues, consisted of 134 patients with osteoarthritis of the knee. The patients were randomly assigned to either a clinic-based treatment group or a home-based exercise group. Patients in the clinic-based treatment group received supervised exercise, individualized manual therapy, and a home-exercise program over a 4-week period. Patients in the home-based exercise group received the same home-exercise program over the same period, reinforced at 2 weeks with a clinic visit.
    Although both groups showed significant improvement, the clinic-based treatment group had a 52% improvement rate compared with 26% from the home-based exercise group. The average distance walked in 6 minutes improved about 10% in both groups. After 4 weeks, patients in both groups participated in identical home-exercise programs, with no clinical treatment intervention. At 1 year, both groups remained improved. However, the patients in the clinic-based treatment group were less likely to take medications for their arthritis.
    The study investigators concluded that adding clinical physical therapy visits for manual therapy and supervised exercise provides greater symptom relief for patients with osteoarthritis of the knee.

Physical therapists strongly support the conclusion from the 1996 Surgeon General's Report that Americans can substantially improve their health and quality of life by including moderate-intensity physical activity for at least 30 minutes or more every day. Physical therapists treat over one million people each day who have cardiovascular disease and musculoskeletal conditions. Interventions involving exercise training and lifestyle changes are used by physical therapists to reduce the severity of the effects of cardiovascular disease and to prevent musculoskeletal injuries.