Physical Therapy in the Prevention and Treatment of Osteoporosis

Osteoporosis might not have the public spotlight like many other widespread diseases, but it’s a serious problem for over 75 million people in the U.S., Europe, and Japan.

The International Osteoporosis Foundation states that one in three women and one in five men over the age of 50 will experience osteoporotic fractures – so why don’t preventative measures and treatments get more attention?

Based on the number of individuals affected by this serious disease, there should be an equally large demand for information, supplements, treatment options, and physical therapy and exercise regimens.

But because osteoporosis is a silent disease, only those who are suffering from its worst complications are aware of it. Fortunately, physical therapy can help treat some of these complications – and it can also help to prevent osteoporosis.

Although it’s not the first form of treatment that tends to pop into someone’s head when the word “osteoporosis” is spoken, it’s highly effective and has been proven to be one of the best courses of action against the disease.

How Physical Therapy Fights Osteoporosis

For those who already have the disease or are at risk for developing it, physical therapy is often a recommended form of treatment – and it can even be practiced on patients who have sustained fractures.

A patient’s road to beating or managing osteoporosis begins with a thorough evaluation, enabling the physical therapist to identify an individual’s activity limits. This is based on a close study of the patient’s bodily movements that shows imbalances, restrictions, and both what the patient is capable of doing and what is obviously beyond his or her limits. The physical therapist then takes this information into consideration while drawing up a customized program for the patient.

Physical Therapy Program Components

A patient’s physical therapy program might be comprised of prescribed exercises, pain management through heat and ice, massage and manual therapy, bone-strengthening activities like tai chi and yoga, and other types of weight-bearing exercise.

There are several important components of exercise in physical therapy because osteoporosis can be a delicate disease to treat.

Exercises should be weight-bearing to build bone mass and strengthen bone-supporting muscles, but this type of exercise alone can be detrimental to someone who’s already experiencing the fragility caused by osteoporosis. To counter this, physical therapists employ exercises that teach patients about body balance, mechanics, and posture – these types of exercises ease the stress on bones to reduce the risk of new fractures.

Good balance and posture are also essential to preventing falls, which are the cause of many fractures. Exercises that promote flexibility (such as yoga and tai chi) and working to improve patients’ gaits are additional concerns that physical therapists include in each exercise program.

Consultation and Patient Responsibility

Finally, physical therapists consult with their osteoporosis patients to identify potentially harmful activities at home or at work.

Many patients struggle with fear of sustaining fractures and limit their daily activity more than they need to. Physical therapists can help these patients to gradually build activity back into their lives by showing them which types of activity are healthy and what might be considered risky activity. Patients may even be reluctant to practice exercises at home because of their fear, but it’s important to follow the physical therapist’s instructions to the letter.

Even with the most successful physical therapy program, patients are ultimately responsible for practicing the prescribed exercises at home and avoiding any activity that might increase their risk of osteoporotic complications.

Patients can also supplement their physical therapy treatment plans by increasing calcium, vitamin D, and vitamin K intake – all of these contribute to the process of building or maintaining bone mass. When combined with the appropriate forms of weight-bearing exercise, supplements like these can promote optimum bone mass growth, which is an important part of treating and preventing osteoporotic complications.

Bio: Maria Rainier is a freelance writer and blog junkie. She is currently a resident blogger at First in Education, where recently she's been researching different physical therapy assistant schools and blogging about student life. In her spare time, she enjoys square-foot gardening, swimming, and avoiding her laptop.

Why I Couldn't Participate in the DOTPA Pilot Study

I can't use the DOTPA self-reports for care planning and goal setting in my outpatient physical therapy clinic.

The 17-page evaluation and the 16-page discharge note are not intended to be a part of your patient's clinical record. You are not expected to make clinical decisions based on the data recorded.

I can't use the AM-PAC (from which DOTPA is derived) without paying the license fee. The folks at Research Triangle International (RTI) offered to see if the AM-PAC was available, in the full, commercial version, for data collection - but, it was not.

I am not alone. Researchers associated with the RTI project have objected, on scientific grounds, that the DOTPA project...

"...developed a proposal that demonstrated a scientifically deficient and naïve review of existing instruments available for patients receiving outpatient therapies."

Specifically, the researchers charged, the DOTPA tool is less...

"...sensitive to change (than competing measures) and since payment might be based on these measures, it is essential to have the most sensitive measure for the clinicians to gain the most reimbursement when warranted."

I can't ask my therapists to perform "double entry" for several reasons:

1. My profit margins not sufficient to support the administrative burden.
2. Studies of paper-based and computerized Clinical Decision Support systems show that "double entry" is a major source of system failure.
3. My patients would object.
4. Pen-and-paper measures are a step backwards in this era of computerization, automation and electronic decision support tools.

Our Medicare Compliance plan is based on the following:

• data-driven decisions
• setting quantitative goals
• knowing when minimal change occurs to demonstrate progress
• knowing, based on quantitative progress scores, when to apply the -kx modifier for patients eligible to exceed the $1,860 PT/SLP cap

Using the DOTPA tool would not only have imposed expensive and time-consuming burden on my therapists but my physical therapy notes would have become LESS COMPLIANT for Medicare.

Who can use the DOTPA tool?

Interesting story.

I invited a friend and a peer to listen in and share notes on my phone line to the original RTI conference call on August 19th, 2010.

She was using, at that time, NO outcome measures - for her the DOTPA project was a step in the right direction.

Can You Put a Number on Physical Therapy?

One of the most popular Simpsons episodes ever - MoneyBART - succinctly describes the struggle between intuitive and algorithmic decision making in physical therapy.

(video length 2min 50sec.)


This struggle, catapulted to prominence in 2002 with the publication of Flynn's manipulation rule, is not unique to physical therapists.

Physicians, too, resist the influence of decision rules and adhere poorly to clinical practice guidelines.

Physical therapists share some commonalities with physicians in that we overestimate our ability to access medical knowledge relevant to the patient, to screen for low-frequency events and to apply effective treatments while mitigating the use of ineffective treatments.

MoneyBART captures what I think is one of the drivers for the low utilization of evidence-based decision rules (including treatment-based classification). This driver is captured in the struggle between Lisa and Bart.

Lisa argues for numbers and statistics - the "brains" of the algorithmic, "computer logic" behind treatment based classification - while Bart argues for his "gut" - the intuitive, naturalistic basis for pattern matching traditionally employed by physical therapists.

Plot synopsis: Lisa becomes the manager of Bart's Little League baseball team even though she doesn't know anything about baseball ("Go kick a field goal, Bart!").

To learn about baseball, Lisa turns to a team of statisticians who meet to discuss sabremetrics at Moe's Tavern. Using this brand of statistical baseball analysis, Lisa begins winning games and Bart complains that she has taken the fun out of the game. Bart gets kicked off the team after disobeying Lisa's instructions to walk off a pitch and hits a home run, winning the game.

Lisa eventually makes the city championship and she asks Bart to come back because she needs Bart to pinch run from first base. He agrees to help but again disobeys her management and tries to steal all the way home. As Bart makes his move, Lisa calculates the odds as being vastly against him but, instead of being mad, comes to love the thrill and excitement of the game. Bart is tagged out at home, losing the game and the championship, but Lisa thanks him for showing her how to love baseball as a game.

In fairness, I've made some simplifying assumptions that physicians and physical therapists resist clinical decision support (CDS) because of personal factors ("It takes the fun out of the game") when, in fact, clinicians are professionals who may resist the "top-down" management of complex doctor-patient interactions they perceive as limiting.

Physicians typically not trained, incented or supported for using evidence-based decision rules. The rational response, then, is not to use them.

But, we do have good evidence that safety and efficiency, from high-quality impact studies, are both improved when algorithmic decision making replaces intuition.

Does that take the "fun" out of the game?

Medicine isn't Little League so, if we're going to play, let's play to win.

Leverage Points

Physical therapists can "leverage" their expertise to spot opportunities that physician may miss. This takes training, experience and an attention to detail - attributes that many physical therapists possess in abundance.

Here's how "leverage" works in the physical therapy clinic...

Betty Love came to my physical therapy clinic last week with a referral from her orthopedic surgeon for rehabilitation after her right total knee replacement.

Betty is...

• two weeks post-op
• walks with a four-point walker
• has some swelling
• redness and
• incisional tenderness.

Betty has high expectations, is willing to work hard and a good listener.

Betty is a satisfied physical therapy patient from a prior episode of lower back pain about one year ago.

Betty filled out some questionnaires in the waiting room at her first visit:

• Fear Avoidance Beliefs (FABQ)
• Knee Injury and Osteoarthritis Outcome Score (KOOS)

Tests similar to these are routinely filled out by patients at Medical Arts Rehabilitation, Inc. for care planning and goal setting.

When asked, Betty indicated that she would NEVER consider kneeling on her operated knee even though her surgeon chose a prosthetic that allows kneeling (Oxford PKR by Biomet).

Betty stated that she had not knelt for many years before her surgery and why would she want to kneel after her surgery?

A study by Jenkins published in September 2008 in the Physical Therapy Journal revealed that patients will NOT spontaneously learn to kneel after partial knee replacement (PKR) unless trained to do do.

After PKR, without training, the patients who could NOT kneel increased from 28% of patients to 34% of patients!

Joint replacement surgery actually made these patients MORE disabled!

Physical therapists can improve other activity limitations (eg: heavy household chores, getting up off of the floor, etc.) by training kneeling.

Patients do NOT Value Kneeling

Like Betty, many patients in physical therapy have voluntarily restricted their daily activities due to pain, fear-of-pain, low endurance, depression or lifestyle.

In the 2003 study detailing the KOOS scale, researchers found that over 90% of patients wanted improvements in Pain, Symptoms, ADLs, and Quality of life after surgery while only 51% of patients reported that improvements in squatting, kneeling, turning and twisting were very important.

Can Kneeling Predict Future Risk?

Ganz, Bao, Shekelle and Rubenstein describe a "quantitative approach" to falls risk assessment that provides the probability shift associated with many physical findings such as the following:

Physical Exam Test	+ Likelihood Ratio	Estimated Probability Shift
Inability to do 1x Chair Raise w/o arms	4.3	+25%
Inability to do 1x Chair Raise less than 10sec.	2.3	+15%
Inability to do Tandem Standing for 10sec.	2.0	+15%
History of falls in the last month	3.8	+25%
Osteoarthritis of the knees	2.0	+15%
Slower Gait over 10m.	2.0	+15%

Positive physical examination tests for faller status are sensitive but not specific, that is, they don't accurately predict non-faller status. Although kneeling has not been studied may other common physical therapy interventions have been studied. This table illustrates how a positive test (eg: disability) is more predictive than a negative test.

Gary Klein, PhD describes leverage points that only experts recognize as opportunities to intervene while the outcome is uncertain, undetermined or unlikely (p.116 Sources of Power).

Experts recognize a need as well as a sense of how the problem can be solved. Leverage points are important because experts can apply their skill to effect change early in the course of care, at less cost and with better outcomes.



Physical therapists can prevent patients like Betty Love from falling down, becoming institutionalized, experiencing chronic disability and pain by recognizing "leverage points" that non-experts like physicians, patients and family members do not recognize.

Physical therapists will need to have the courage to challenge patients values, physicians expectations and payers' "rules".

But, I'm optimistic since courage is something physical therapists have in abundance.

New Veteran Administration Study Positive on Physical Therapy Rehabilitation

A recent meta-analysis of Veterans' Administration (VA) care compared with non-VA care found the VA performed better on process measures but about the same on patient outcomes.

Rehabilitation fared well in the Systematic Review: Comparison of the Quality of Medical Care in Veterans Affairs and Non-Veterans Affairs Settings. One of the 36 studies that passed the final cut looked at rehabilitation outcomes and assessed 60 post-stroke patients, finding good outcomes:

"...Stroke patients receiving rehabilitation in VA settings were discharged with better functional outcomes..."

Limitations of the study reported in the media were the use of self-report measures of outcome, typically questionnaires or patient interview.

Many newer data indicate that reliability of self report is superior to more traditional "objective" data but older clinicians, some physicians, politicians and the lay public may have difficulty understanding why the Oswestry Disablement Index returns "harder" data than a lumbar x-ray in the assessment of lower back pain:

"PROs are often not included in routine clinical care or quality improvement activities because some clinicians believe that PROs are not "objective" measures or that they lack precision for measuring individual patients." - Darren DeWalt, MD

Another criticism was the age of the studies - most dated from the Clinton administration and one study was from 1991.

The VA performed well on process measures such as issuing the right medication at the right time to the right patient. The VA's performance on patient outcomes, however, was not so good:

"Studies that used accepted process of care measures and intermediate outcomes measures, such as control of blood pressure or hemoglobin A1c, for quality measurements almost always found VA performed better than non-VA comparison groups.

Studies looking at risk-adjusted outcomes generally have found no differences between VA and non-VA care, with some reports of better outcomes in VA and a few reports of worse outcomes in VA, compared to non-VA care."

The media seem perplexed by these results but most physical therapists will recognize that health care, as a determinant of health, accounts only for about 10% of the causes of death and disability:

Veteran's Administration outcomes are a hot topic right now because of their own public relations campaign over the last fifteen years promoting their investment in Electronic Medical Records (EMR) and automated Clinical Decision Support (CDS) technology.

This meta-analysis may be seen by some as a testimony to the effectiveness of that investment.

“This report is strong evidence of the advancements VA continues to make in improving health care over the past 15 years,” said Secretary of Veterans Affairs Eric K. Shinseki.

“The systems and quality-improvement measures VA actively uses are second to none, and the results speak for themselves.”

Some of the reasons proposed for the VA's superior performance in processes of care include the following:

• integration of health care settings
• use of performance measures with an accountability framework
• disease-management practices and electronic medical record or health information technology.

Physical Therapy Price Innovators Hated by Everyone

$68 visits for physical therapy in Michigan have some private practice physical therapists hoping Theramatrix loses its fight to treat Ford and Chrysler workers with Blue Cross Blue Shield (BCBS) of Michigan.

The Justice Department, however, views BCBS actions with hospitals to keep competitors from seeing the Ford and Chrysler workers by charging up to 40% for the same treatments, like physical therapy, as anti-competitive.

Is it hard to tell who to root for?

On the one hand, TheraMatrix Physical Therapy, Inc. has organized a provider network to compete against the monopolistic Blue Cross franchise and bring prices down to $68 per PT visit.

Isn't that the goal? To bring healthcare costs down so employers can offer affordable coverage eventually to everyone?

On the other hand, Michigan private practice PT owners are openly hoping for TheraMatrix to loose its battle and, ultimately, its revenue stream and go out of business.

$68 per visit, according to some PT thought leaders, is insufficient revenue per visit to run a private practice.

I would agree - under our present system with many hidden costs, compliance and administrative burdens, malpractice risks and increasing healthcare labor costs.

My costs here in Florida are about $68 per visit. We used to take United Insurance which is like giving every patient with that insurance a $20 after each treatment session.

However, physical therapy is flourishing around the world - in countries that DO NOT HAVE our hidden (and non-hidden) compliance costs.

Physical Therapists in Spain have full direct access, charge about $35 per visit and collect cash.

Oh, and by the way, private practices are flourishing with brand new clinics every time I go and visit. Spanish physical therapists also don't face competition from physicians.

Low payments are a problem in American healthcare because current owners of capital need those payments to meet expenses, including profit.

What gets missed in this discussion, however, is that the hidden costs of compliance is what is preventing innovation and lower costs.

TheraMatrix has produced innovation pricing and put itself in a head-to-head confrontation with everyone in Michigan: BCBS, hospitals and PT private practices.

What if, instead of innovative pricing we had innovative service delivery? Things like...

1. distance therapy by e-mail reimbursed
2. video home exercises
3. mixed home and clinic based therapy from a single provider
4. therapist deciding medical necessity instead of the physician
5. no need for the physician signature on the plan of care
6. therapist deciding of appropriate delegation to support staff (including PTA and non-licensed staff).
7. simple, inexpensive standards for outcomes measurement
8. benchmarks for progress according to these standards

Many of these concepts currently exist but they are NOT part of our service delivery model, especially under Medicare.

The problem, then, is that our current system rewards ONLY price innovation and not service delivery innovation.

It's not rocket science - the only way to innovate on price is DOWN and the innovators, like TheraMatrix, are hated by everyone.

Standards in Physical Therapy

This question came up from an interested reader and I'm re-posting it here to provide a forum for discussion. Let me know if you have any other questions along these lines...

Dear Tim,

"Are there specific standard functional levels for post acute cure patients in deciding what level of care is optimal for these patients:

• In Patient Rehab
• SNF
• HH
• Hospice
• Outpatient Service?

I do understand there are multiple considerations in this decision making process as well as the payer coverage and patient/family desires/considerations... however I wondered if there were standards available.

I would appreciate any insight into the deliveries of care."

Thank you,
NM

Dear NM,

You've brought up a great point: Are there standards for post-acute care for physical therapy patients? My experience is in outpatient delivery but these suggestions should be applicable to any ambulatory, post-acute setting.

Your question is rather broad so I'll take the liberty of addressing a specific portion - should we change over the course of care or discharge functional status?

This issue, incidentally, also begs the question of how to assess baseline status, medical necessity for physical therapy and progress in an expected time frame required for Medicare reimbursement.

At this time, a lot of work is being done assessing change over the course of care: you can do this work yourself using validated change scores like MCID or MDC for patient self-report (eg: ODI, LEFS, NDI...) and performance scales like Step Test, 10' Gait Velocity, et al.

You can also pay to have it done for you by groups like FOTO, AM-PAC or even DOTPA (you pay with your time).

Is there a standard for discharge function?

Not really.

Lots of groups have published age-and-gender matched norms for their tests (eg: Cybex, MedX and even tests like Single Leg Support) but these just give averages.

"Averaging stamps out diversity, reducing anything to its simplest terms.
In so doing, we run the risk of oversimplifying, of forgetting the variations around the average" - Kaiser Fung

To determine your optimal level of care you'll need to delve into your physical therapy evidence base (or pay to have it done for you). It's not that hard, in fact, the hardest part is just getting started.

This article discusses some of the predictors of function for shoulder patients, depending on how you assess outcome.

Read...
Prognosis in Soft Tissue Disorders of the Shoulder: Predicting Both Change in Disability and Level of Disability After Treatment

Nancy Garland, physical therapy advocate, wins 20th District in Ohio

Democrat Nancy Garland won her hotly contested seat Tuesday November 2nd for her second term in Ohio's 20th legislative district.



At a recent national meeting of physical therapists Nancy said that her race was being watched closely by national leaders on both sides of the political spectrum. Ohio is an important state for both parties since it will figure prominently in the 2012 presidential campaign.

According to the Columbus Dispatch...

"House Democrats tried to use a 2-1 money advantage to hold back the GOP wave.
The national party and a handful of independent groups also pumped millions into legislative races on behalf of Democrats."

I met Nancy Garland, JD at the APTA State Government Affairs meeting in Portland, Oregon from September 26th-28th, 2010.

Nancy presented her ideas on running for public office in a very practical, "here's-how-it-affects-you" manner for physical therapists who might consider running for public office.

The rehabilitation community needs people like Nancy, former CEO of the Ohio state chapter, in public office. Many other professions have their advocates in state legislatures: chiropractors, orthopedic surgeons, attorneys and land developers.

Physical therapists also need advocates in politics.  Nancy is not a physical therapist but, before becoming an Ohio state legislator in 2008, she ran her state physical therapists' association for seven years.

Nancy is also a clinical assistant professor at The Ohio State University School of Allied Medical Professions where she teaches Health Policy in the physical therapy doctoral program.

Nancy has passed many health care related bills while working as the State Representative for Ohio's 20th District. Furthermore, her actions in her first term improved opportunities for physical therapists and their patients:

• Fixed the educational funding system that was unconstitutional and have begun the educational reform needed to prepare Ohio students for the 21st century
• Expanded health care to more Ohio citizens
• Passed legislation to require insurance companies to cover treatment of Autism-Spectrum Disorders

Nancy is known as the "The Listening Legislator" and has held numerous town hall meetings, coffees, and community meetings to hear the concerns of the citizens of the 20th District.

Nancy's statements on healthcare are consistent with physical therapists' goals and issues:

"I want to create an environment where citizens have access to primary care while also focusing on prevention and wellness."

Congratulations on your win, Nancy!

Frequently Asked Questions about Treatment Based Classification (TBC)

Can I substitute mobilization for thrust manipulation?

No.

High-velocity “thrust” movement has been shown to be an important component of the treatment in the lumbar manipulation decision rule. Treatment with lumbar mobilization was shown NOT to result in better outcomes (Hancock et al).

The same logic applies to manipulation for anterior knee pain although that rule is still in the derivation stage.

No direct comparison of mobilization vs. manipulation has been performed for thoracic manipulation. The thoracic manipulation rule has been subjected to a broad validation study that showed improved functional outcomes in the manipulation + exercise group over the exercise-only group.

Further, the thoracic manipulation rule was NOT shown to predict response to treatment better than subjects manipulated without the rule.

Therefore, the authors concluded that ALL patients with neck pain without red flags for pathology should be manipulated.

Are TBC groups mutually exclusive?

That is, are all members of the lumbar manipulation group also NOT in the lumbar stabilization group? Conceptually, exclusivity is important in designing treatment groups for study. However, clinical reality belies this notion.

Manipulation and stabilization appear to be non-compatible, even contradictory, approaches to an episode of spinal care. Anecdotal reports affirm that many patients, once managed acutely with manipulation, qualify for stabilization training in the long run.

Zimny acknowledges that strict categories actually lower the percentage of patients who can be classified at all.

Are TBC groups exhaustive?

Have researchers identified all possible patient groups?

There is an uncertain benefit in trying to classify EVERY possible group when the cost and effort of rule development outweigh the possible benefits.

Hart discusses the possibility of a prediction rule that might imply the necessity for modality use in a small, well-defined cohort of patients.

Childs describes “general conditioning” as perhaps the largest cohort of patients that would benefit from physical therapy intervention. With education and possibly amended state licensing laws a rule defining this group could be applied to pre-symptomatic patients for screening and risk assessment.

What conditions are appropriate for Treatment Based Classification (TBC)?

High-volume conditions with vague indications for treatment (eg: LBP) or no consensus on treatment (eg: neck pain) are candidates for the full, four levels of rule development.

Conditions for which there is general consensus on treatment (eg: ankle sprain) may not be appropriate for full-scale rule development.

Is TBC “cookbook” medicine?

To professionals trained in a culture of naturalistic and intuitive decision making an algorithmic approach where treatment decisions are supported by “likelihood ratios” may initially seem threatening.

But, TBC algorithms can be used initially for the “heavy lifting” in developing the Plan of Care with Frequency, Duration and Expected Outcome boilerplate outputs that allow physical therapists to concentrate their time and attention on face-to-face interaction with the patient rather than tedious, narrative notes.

Expert decision makers in many disparate fields use naturalistic decision making for their common tasks.

Likewise expert decision makers also use sophisticated tools, like TBC algorithms and decision rules, that speed up complex jobs.

“A tool is a trick I use twice.” – George Polya

McGee notes that the need to establish accurate pre-test probabilities, used extensively in epidemiologic testing, requires knowing many patient characteristics in far greater detail than is possible without sophisticated data collection tools and analysis.

Finally, the father of SOAP notes decries memory-based systems in medicine that hold doctors and physical therapists accountable for perfect recall and processing of medical information:

“We use probabilities in decision making in direct proportion to our ignorance…of the situation.” - Lawrence Weed, MD

How can TBC improve Medicare compliance?

1. TBC decision rules provide an evidence-based plan of care (frequency, duration and expected outcome) within the first 15 minutes of the evaluation.
2. TBC allows physical therapists to concentrate on the value exchange - the face-to-face interaction that typifies a physical therapist interaction.
3. When you are in your office, reading a chart, writing a note or pecking at your computer you are NOT giving value to the patient.
4. TBC can establish medical necessity for physical therapy.
5. Since most TBC decision rules use self-report questionnaires as outcome measures they can create a culture of outcomes measurement in your physical therapist workforce.
6. TBC requires a probabilistic mindset – a way of thinking that accounts for risk factors, baseline factors and outcomes that will come to define skilled physical therapy decision making.
7. TBC is a tool that creates autonomy in your physical therapist workforce. When you can describe your patient characteristics that predict outcome better than the referring physician can describe you become a resource for that physician.