Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological treatment for control of pain. It has come under much scrutiny lately with the Center for Medicare Services rendering a recent decision stating that "TENS is not reasonable and necessary for the treatment of CLBP [chronic low back pain]".When reading and analyzing the existing literature for which systematic reviews show that TENS is inconclusive or ineffective, it is clear that a number of variables related to TENS application have not been considered. While many of the trials were designed with the highest of standards, recent evidence suggests that factors related to TENS application need to be considered in an assessment of efficacy. These factors include, dosing of TENS, negative interactions with long-term opioid use, the population and outcome assessed, timing of outcome measurement and comparison groups. The purpose of this perspective is to highlight and interpret recent evidence to help improve the design of clinical trials and the efficacy of TENS in the clinical setting.

U.S. military physical therapists have a proud history of providing medical care during operational deployments ranging from war to complex humanitarian emergencies. Regardless of environment austerity or intensity of hostility, U.S. military physical therapists serve as autonomous providers, evaluating and treating service members with and without physician referral. Our perspective is that the versatility of U.S. military physical therapist practice enables them to not only diagnose musculoskeletal injuries, but equally important to provide a wide range of definitive care and rehabilitation, reducing the need for costly evacuation. While war is not sport, the delivery of skilled musculoskeletal physical therapy services as close to the point of injury parallels the sports medicine model for on or near field practice. This model that mixes direct access with near immediate access enhances outcomes, reduces costs, and allows other healthcare team members to work at the highest levels of their licensure.

BACKGROUND:

The Department of Veterans Affairs (VA) and the Department of Defense (DoD) published evidence-based Guidelines (Guidelines) to standardize and improve rehabilitation of lower limb amputees, however no studies have examined the guideline impact.

OBJECTIVES:

To 1) describe the utilization of rehabilitative services in the acute care setting by persons who underwent major lower limb in the VA from 2005 to 2010; and 2) identify factors associated with receipt of rehabilitation services; and 3) examine impact of the Guidelines on service receipt.

DESIGN:

Cross-sectional study of 12,599 patients, who underwent major surgical amputation of the lower limb at a VA medical center from January 1, 2005 to December 31, 2010. Data were obtained from main and surgical inpatient datasets and the inpatient encounters files of the Veterans Health Administration databases.

METHODS:

Rehabilitation services were categorized as physical therapy (PT), occupational therapy (OT), and either (any therapy), before or after amputation. Separate multivariate logistic regressions examined impact of Guideline implementation, and identified factors associated with service receipt.

RESULTS:

Patients were 1.45 and 1.73 times as likely to receive pre-operative PT and OT, and 1.68 and 1.79 times as likely to receive post-operative PT and OT (p<0.0001) after Guideline implementation. Patients in the Northeast had the lowest likelihood of receiving pre-operative and post-operative rehabilitation services, while patients in the West had the highest likelihood. Other patient characteristics associated with service receipt were identified.

LIMITATIONS:

The sample included only Veterans who had surgeries at VA Medical Centers and cannot be generalized to Veterans with surgeries outside the VA or to non-Veteran patients and settings.

CONCLUSIONS:

Further quality improvement efforts are needed to standardize delivery of rehabilitation services for Veterans with amputations in the acute care setting.

BACKGROUND:

The Affordable Care Act of 2010 establishes American Health Benefit Exchanges. The benefit design of insurance plans in the state health insurance exchanges will be based on the structure of existing small employer sponsored plans.

OBJECTIVE:

The purpose of this study was to describe the structure of the physical therapy benefit in a typical BCBS preferred provider organization (PPO) health insurance plan available in the individual insurance market in 2011.

DESIGN:

Cross-sectional survey design.

METHODS:

Using a standard patient with a standard budget, the physical therapy benefit within 39 Blue Cross Blue Shield (BCBS) preferred provider organization plans in 2011 was studied. We first determined if physical therapy was a benefit in the plan. If so, the structure of the benefit was then described i.e., whether it was a stand-alone benefit or a part of a combined discipline benefit and if a visit or financial limit was placed on the physical therapy benefit.

RESULTS:

Physical therapy was included in all BCBS plans that were studied. Ninety-three percent of plans combined physical therapy with other disciplines into a benefit. Two in three plans placed a limit on the number of visits covered by the plan.

LIMITATIONS:

The results of the study are limited to one standard patient, one association of insurance companies, one form of insurance (a PPO) and one PPO plan in each of the 39 states that were studied.

CONCLUSIONS:

Physical therapy is a covered benefit in a typical BCBS preferred provider organization health plan. Physical therapy is most often combined with other therapy disciplines and in two-thirds of plans has a limit on the number of covered visits.

BACKGROUND:

Workplace injuries from patient handling are prevalent. with the adoption of no-lift policies, sit-to-stand transfer devices have emerged as one tool to combat injuries. However, the therapeutic value associated with sit-to-stand transfers using an assistive apparatus cannot be determined due to a lack of evidence-based data.

OBJECTIVE:

The aim of this study was to compare clinician-assisted, device-assisted, and the combination of clinician- and device-assisted sit-to-stand transfers in individuals who recently experienced a stroke.

DESIGN:

Cross-sectional, controlled laboratory study that used a repeated measures design.

METHODS:

The duration, joint kinematics and muscle activity of four sit-to-stand transfer conditions were compared for 10 stroke patients. Each patient performed four randomized sit-to-stand transfer conditions: clinician-assisted (CA), device-assisted with no patient effort (D-NE), device-assisted with patient's best effort (D-BE), and device- and clinician-assisted (D-CA).

RESULTS:

Device-assisted transfers took nearly twice as long as clinician-assisted transfers. Hip and knee joint movement patterns were similar across all conditions. Forward trunk flexion was lacking and ankle motion was restrained during device-assisted transfers. Encouragement and guidance from the clinician during device-assisted transfers led to increased lower extremity muscle activation levels.

LIMITATIONS:

One lifting device and one clinician were evaluated. Clinician effort could not be controlled.

CONCLUSIONS:

Lack of forward trunk flexion and restrained ankle movement during device-assisted transfers may dissuade clinicians from selecting this device for use as a dedicated rehabilitation tool. However, with clinician encouragement, muscle activation increased, suggesting that it is possible to safely practice transfers while challenging key leg muscles essential for standing. Future sit-to-stand devices should not only promote safety for the patient and clinician, but also encourage a movement pattern that more closely mimics normal sit-to-stand biomechanics.

BACKGROUND:

Evaluation of walking capacity and risk of falls in people with multiple sclerosis (PwMS) are often performed in rehabilitation. The Dynamic Gait Index (DGI) evaluates walking during different tasks, but the feasibility in identifying persons at risk of falls needs to be further investigated.

OBJECTIVE:

1) investigate construct validity of the DGI: known-groups, convergent, discriminant; 2) the accuracy of predicting falls and establishing a cut-off point to identify fallers.

DESIGN:

A multi-centre, cross-sectional study.

METHODS:

A convenience sample of 81 PwMS with subjective gait and balance impairment but still able to walk 100 meters (comparable with EDSS 1-6). Mean age was 49 years, 76% were women. The 25-foot Timed Walk test, Timed Up and Go test, Four Square Step Test, Timed sit-to-stand test, MS Walking scale, Multiple Sclerosis Impact Scale (MSIS), and self-reported falls during the previous two months were used for validation, establishing cut-off point for identifying fallers and to investigate predictive values.

RESULTS:

Significantly lower DGI scores (p≤0.001) was found for participants reporting falls (n=31). High sensitivity (87%) in identifying fallers was found with cut-off score ≤19. The positive predictive value was 50% and the negative predictive value 87%. The convergent validity was moderate to strong (rho=0.58-0.80), with the highest correlation coefficient found for the 25-foot Timed Walk test. Discriminant validity was shown with low correlation for the psychological subscale of the MSIS.

LIMITATIONS:

The sample included ambulatory persons participating in a randomized controlled trial investigating balance training.

CONCLUSIONS:

The DGI is a valid measure of dynamic balance during walking for ambulatory persons with MS. With the cut-off point of ≤19, sensitivity was high in identifying persons at risk of falls.

BACKGROUND:

Many factors impact student learning throughout the clinical education (CE) component of entry-level physical therapist (PT) education curricula. Physical therapist education programs (PTEPs) manage CE, yet the material and human resources required to provide CE are generally overseen by community-based physical therapy practices.

PURPOSE:

The purpose of this systematic review was to examine how the construct of quality is defined in CE literature and to determine the methodological rigor of the available evidence on quality in PT CE.

METHODS:

This study was a systematic review of English-language journals using the American Physical Therapy Association's Open Door Portal to Evidence Based Practice as the computer search engine. The search was categorized using terms for physical therapy and quality and CE pedagogy and models or roles. Summary findings were characterized by five primary themes and 14 sub-themes using a qualitative directed content analysis.

RESULTS:

Fifty-four articles were included in the study. The primary quality themes included: clinical education framework, clinical education sites, structure of clinical education, assessment in clinical education, and clinical education faculty. The methodological rigor of the studies was critically appraised using a binary system based on the McMaster appraisal tools. Scores ranged from 3-14.

LIMITATIONS:

Publication bias and outcome reporting bias may be inherent limitations to the results.

CONCLUSION:

The review found inconclusive evidence about what constitutes quality or best practice for PT CE. Five key constructs of CE were identified, that when aggregated could construe quality.

BACKGROUND:

Shared Decision Making (SDM) reduces the asymmetrical power between the therapist and patient. Patient involvement improves patient satisfaction, adherence and health outcomes and is a prerequisite for good clinical practice. The opportunities for using SDM in physical therapy have been considered previously.

OBJECTIVE:

To examine the status of SDM in physical therapy, patients' preferred level of involvement, and the agreement between therapists' perceptions and patients' preferred level of involvement.

DESIGN:

An observational study of real consultations in physical therapy.

METHODS:

In total, 237 consultations, undertaken by 13 physical therapists, were audio-recorded, and 210 records were analyzed using the OPTION (Observing Patient Involvement) instrument. Before the consultation, the patient and therapist completed the Control Preference Scale. Multilevel analysis was used to study the association between individual variables and the level of SDM. Agreement on preferences was calculated using kappa-coefficients.

RESULTS:

The mean OPTION score was 5.2 (SD=6.8) out of a total score of 100. Female therapists achieved a higher OPTION score (b=-0.86, p=0.01). In total, 36.7% of the patients wanted to share decisions, and 36.2% preferred to give their opinion before delegating the decisions. In the majority of cases, therapists believed that they had to decide. The kappacoefficient for agreement was poor at 0.062 (95% CI, -0.018 to 0.144).

LIMITATIONS:

Only 13 out of 125 therapists who were personally contacted agreed to participate.

CONCLUSION:

SDM was not applied; although patients preferred to share decisions or at least provide their opinion about the treatment, physical therapists did not often recognize this factor. The participating physical therapists still applied a paternalistic approach and lags behind in terms of theoretical developments of decision making in health care research.