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 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)
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.
