American Heart Association Prescribes Physical Therapy First

The American Heart Association recommends doctors change their approach to prescribing pain relievers for patients with or at risk for heart disease. In a scientific statement published Feb. 27, 2007 in Circulation: Journal of the American Heart Association, the heart specialists instead prescribe physical therapy first.

"We believe that some physicians have been prescribing the new COX-2 inhibitors as the first line of treatment. We are turning that around and saying that, for chronic pain in patients with known heart disease or who are at risk for heart disease, these drugs should be the last line of treatment," said Elliott M. Antman, M.D., FAHA, lead author of the American Heart Association scientific statement and professor of medicine at Harvard Medical School and Brigham and Women's Hospital.

"We advise physicians to start with non-pharmacologic treatments such as physical therapy and exercise, weight loss to reduce stress on joints, and heat or cold therapy. If the non-pharmacologic approach does not provide enough pain relief or control of symptoms, we recommend a stepped-care approach when it comes to prescribing drugs."

"This recommendation comes as no surprise to physical therapists," said Dr. Timothy Flynn from Regis University, Denver, and President of the American Academy of Orthopedic Manual Physical Therapists (AAOMPT). "Research has repeatedly shown the value of early physical therapy for patients with musculoskeletal conditions. We are glad to see that the AHA's recommendations of physical therapy as a safe and effective alternative to drugs are consistent with these findings. It only makes sense to see your physical therapist before trying drugs and surgery."

To read the AHA's scientific statement online, go to: www.americanheart.org/presenter.jhtml?identifier=3045689. For more on the benefits of physical therapy, contact your nearest physical therapist or visit the American Academy of Manual Physical Therapists at: www.aaompt.org.

APTA Recommends Yearly Visit With PT

All individuals should visit a physical therapist (PT) at least annually to promote optimal health, wellness, and fitness, as well as to slow the progression of impairments, functional limitations, and disabilities, said APTA's House of Delegates on Tuesday in adopting Annual Visit With a Physical Therapist.

Citing the increase in physical inactivity and its direct consequences -- heart disease, diabetes, obesity, and chronic disease -- the position calls for an annual visit in which the PT would use appropriate quality-of-life instruments and examination tools in conjunction with the patient's physical activity history and information on his or her current exercise regimens, nutritional intake, sleep patterns, work activities, and stress level. The annual check-up may begin simply by using the format of the "systems review" incorporated in the physical therapist examination as detailed in the Guide to Physical Therapist Practice.

The House noted that physical therapy has "tremendous potential" to reverse the trend of inactivity by helping establish age-appropriate fitness and wellness programs for life. [RC 28-07]

APTA To Pursue PT Consultation in "Welcome to Medicare" Exam

APTA will pursue initiatives with the Centers for Medicare & Medicaid Services that stress the importance of consulting with physical therapists when beneficiaries are screened related to their functional abilities (eg, fall risk, ability to perform activities of daily living, home safety) as part of the "Welcome to Medicare" physical exam.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 expanded Medicare's menu of preventive benefits by covering an initial preventive physical examination. The "Welcome to Medicare" exam enables beneficiaries to get up-to-date screenings as well as speak with their health care providers about their medical history and how to stay healthy. The exam is available for beneficiaries enrolled in Medicare Part B with effective dates on or after January 1, 2005. Beneficiaries can take advantage of the one-time-only exam within their first 6 months of Part B coverage.

It seems only natural, the House said, that a one-time PT visit is part of this program, because PTs have important roles in modifying risk factors; reviewing an individual's functional ability and level of safety; examining an individual's height, weight, blood pressure, and visual acuity; and providing education, counseling, and referral based on the results of the review. [RC 30-07]

Study Indicates Resistance Training Can Help Reverse Aging Process for Older Adults

A resistance training exercise program for healthy adults over age 65 was found to reverse aging at the cellular level in a study by McMaster University in Hamilton, Ontario, Canada; the Buck Institute for Age Research, based in Novato, California; and the Center for Genetics, Children's Hospital Oakland Research Institute, Oakland, California.

The study involved before and after analysis of gene expression profiles in tissue samples from 25 healthy older men and women who underwent 6 months of twice-weekly resistance training, compared with a similar analysis of tissue samples from 26 younger healthy men and women. Tissue samples were taken from the thigh muscle.

The gene expression profiles involved age-specific function of the mitochondria, which act as the "powerhouse" of cells. Multiple studies have suggested that mitochondrial dysfunction is involved in the loss of muscle mass and functional impairment commonly seen in older people. The study was the first to examine the gene expression profile, or the molecular "fingerprint," of aging in healthy disease-free humans.

The study participants were matched in terms of diet and exercise; none of them took medication or had diseases that can alter mitochondrial function. The 6-month resistance training was done on standard gym equipment. The twice-weekly sessions were an hour long and involved 30 contractions of each muscle group involved, similar to training sessions available at most fitness centers.

Results showed that in the older adults (average age 70), there was a decline in mitochondrial function with age. However, exercise resulted in a remarkable reversal of the genetic fingerprint back to levels similar to those seen in the younger adults (average age 26). The study also measured muscle strength based on knee flexion. Before exercise training, the older adults were 59% weaker than the younger adults, but after the training the strength of the older adults improved by about 50%, so that they were only 38% weaker than the young adults. The study results were published May 23 in the online, open-access journal PLoS One.

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 (NEJM), compared early microdiskectomy surgery with a strategy of prolonged conservative treatment with eventual surgery if needed. Patients who had 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 NEJM 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 NEJM 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 spondylolisthesis, 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."

New Exercise Campaign Calls on Physicians to Prescribe Physical Activity

The American College of Sports Medicine (ACSM) and the American Medical Association (AMA) recently launched Exercise is Medicine, a new program designed to encourage America's patients to incorporate physical activity and exercise into their daily routine and calls on physicians to prescribe exercise to their patients. Lisa L Culver, PT, DPT, MBA, represented APTA and its initiative Physical Fitness for Special Populations at the ACSM/AMA press conference.

Robert Sallis, MD, president of ACSM, noted the shift in focus in health care from treating disease to that of promoting healthy lifestyles. He called exercise a “wonder drug” and said “the costs of inactively are staggering.” He said the new program is “not just a message for physicians” but must cross specialty and disciplinary lines, calling on health and fitness professionals to “step up as resources.” He also spoke on the importance of having fitness professionals to refer patients to for exercise instruction.

Ronald Davis, MD, president of AMA, said, “…Exercise is not an option, but a necessary, active, direct way that people can maintain good health, avoid illness, improve the quality of their lives, reduce health care costs, and extend their life expectancy.” Davis suggested that exercise be viewed as a vital sign to be taken at every patient visit and tracked over time. He also addressed the need for all health care providers to become involved in exercise prescription. “Exercise makes preeminent good sense.”

In a Q&A session following the press conference, Culver applauded the breadth of Exercise is Medicine and spoke on the need for program developers to consider that patients with chronic disabilities may have a limited capacity for activity.

A link to a video of the press conference is available in the November 9, 2007, issue of PT Bulletin Online.

Physical Therapists Offer Low-Cost Solution To Increasing Health Costs

Spinal Manipulation, Exercise and Advice Offer Patients an Effective Alternative for Back Pain

Tallahassee, Florida, Feb. 14, 2008 – Health care expenditures for patients with spinal conditions are rising without an associated increase in health status, according to a February, 2008 research report appearing in the Journal of the American Medical Association. The study suggests Americans may be wasting their money for treatments as the overall proportion of people with impaired function increased from 1997-2005, despite a 65% increase in expenditures to treat spine conditions. Physical therapists offering spinal manipulation, exercise, and education can provide an effective alternative for patients with back and neck problems, often at a lower cost.

"I think the truth is we have perhaps oversold what we have to offer," said Richard A. Deyo, a physician at Oregon Health & Science University in Portland and a coauthor of the report. "All the imaging we do, all the drug treatments, all the injections, all the operations have some benefit for some patients. But I think in each of those situations we've begun using those tests or treatments more widely than science would really support."

What science does support is the effectiveness of physical therapy for affecting outcomes in patients with spinal conditions. “Research has consistently shown the value of particular physical therapy interventions for patients with back and neck problems,” said John Woolf, MS, PT, ATC in Tucson, AZ of ProActve Physical Therapy. “Specifically, spinal manipulation and exercise have repeatedly been shown to be effective in managing patients’ current pain and preventing future episodes.”

Particularly discouraging in this recent report was an increase in pharmaceutical expenditures of 171% during the study period. Treating spine pain with a chemical intervention is a reasonable option, but it does not teach the patient about the cause of the pain, nor enable the patient to understand how the pain relates to the care of their spine.

“You have drugs, you have surgery, and you have licensed health care professionals who understand the source of the pain and develop treatment plans that empower patients to heal,” explained Woolf. “The reality is that very few treatments have shown the ability to truly affect patients with spine conditions. Physical therapists make a can difference.”

These treatments include time with the patient to teach them the likely cause of the pain, hands-on therapies to mobilize the spine and exercises designed to alleviate low back pain. Woolf suggests that patients should seek out physical therapists as a first-line treatment for these conditions.

A separate study in 2006 demonstrated that patients with back pain were experiencing an increase in the rates of imaging and injections, meanwhile realizing a significant under-utilization of physical therapy.

For more on the benefits physical therapists can provide in the management of back and neck problems, contact John Woolf or visit the American Academy of Orthopaedic Manual Physical Therapists website at www.aaompt.org. AAOMPT represents physical therapists by promoting excellence in orthopaedic manual physical therapy practice, education and research.

CONTACT:
Timothy Flynn, PT, PhD
President, American Academy of Orthopaedic Manual Physical Therapists
Phone: 303-964-5137
www.aaompt.org

APTA Lets Consumers Know That Physical Therapists Offer Low-cost Solution for Spinal Conditions

When a recent study published in the Journal of the American Medical Association (JAMA) suggested that spine-related expenditures have increased without evidence of improvement, APTA issued a news release nationwide that said best evidence suggests that patients who receive physical therapy for musculoskeletal disorders, including back and neck pain, report good outcomes at a lower cost than using drugs or surgery.

APTA President R. Scott Ward, PT, PhD said, "Consumers need to know that physical therapist management is a low-cost, high-value alternative to drugs and surgery to deal with musculoskeletal pain." He added, "The judicious use of appropriate physical therapist treatment based on best evidence can improve the function of people who struggle with back and neck conditions."

Patients with chronic, disabling low back pain account for a disproportionate share of health care expenditures and workers' compensation costs, so the potential cost savings of an early, effective intervention to prevent individuals from progressing to chronic disability may be considerable.