Issue 41 King Crab Edition - Pushing the Profession, What Do You Think of Imaging, Pelvic Floor, SNF Algorithms, and A Bladder Review

This week, did you hear that North Dakota just started allowing PTs to order diagnostic imaging? Oh yeah! That’s three states down, 47 (and one District) to go. For those marking your scratch-off wall maps, the three that allow it are Wisconsin, Utah, and North Dakota. On the back of that news, we’ve got papers discussing how to push PT forward through the next century, how PTs feel about X-rays, and more. Enjoy!

Push the Profession with Diagnostic Labels

The Gist - This piece, from an eminent physical therapist at Washington University of St. Louis, isn’t a research paper, but rather an argument. This former APTA Board member wants to push the profession forward and believes that new diagnostic labels are the way. She argues that the profession has emphasized treatment over diagnosis and what we do over what we know. She thinks it’s time to exert what we know and change the world’s perception of PT by diagnosing and treating out own, physical therapy-specific conditions. To do this, diagnostic labels are the key.

I know, I know, this all seems esoteric and not important to your daily practice, but it is. Diagnostic labels help the profession gain recognition “because they clearly indicate an understanding of the dysfunction causing the patient’s functional problem, whether it is a musculoskeletal dysfunction, the disordered motor control of a neurological pathology, or a cardiopulmonary pathology.” By giving patients PT-specific labels, we grab a foothold on the medical landscape and exert ourselves as profession in the eyes of patients and society.

Tell Me More - This is a very interesting piece that I know some people will vehemently debate. The author is calling for cultural change and that’s tough to do. She’s arguing that diagnostics are a primary role of the doctoring profession and that we need PT labels like the DSM has introduced for psychology and psychiatry. In her mind, “A diagnosis would focus on the collection of deficits systematically observed during the performance of tasks and measured during tests of body structure and function. A label for that condition would reflect a summation of the problem using known movement-related terms… The label also provides the direction for treatment by indicating the movement to be modified to reduce or eliminate the symptoms.”

Look, if you’ve made it this far, you should go read the piece. It’s longer, at 13 pages, but easy to read and well worth it. This is someone who’s trying to imagine a better future for PT and should be heard out, whether you agree or disagree with her methods. Give it 20 minutes of your time.

I’ll read it. Great! It’s available for APTA members here.

How do you feel about diagnostic imaging?

The Gist - This piece isn’t dissimilar to the last, discussing the future of physical therapy in diagnostic imaging. To do that, we need to know how PTs feel about their ability to order imaging. Well, we’ve got it, and they feel pretty good. Young PTs feel especially good about it. And this is good news, since PTs can order X-rays, CTs, and MRIs in North Dakota, Wisconsin, and Utah and recommend them in Colorado, Maryland, and Washington, DC. A recent study recently showed that PTs are better at suggesting imaging than physicians, ordering imaging in a way that’s approved by radiologic guidelines 91% of the time when physicians were only in the 80s. Go us! Over 90% of PTs feel comfortable ordering MRIs or X-rays which is also great news.

Tell Me More - Again, I know, why does this matter? This is how we gain more power to order imaging, by demonstrating that we can do it competently. Just last week, North Dakota law started allowing PTs to order imaging and studies like this can be really helpful in pushing that out to more states. It is legal to recommend that physicians order imaging in all states and legal to directly order it in three. Important info for any PT engaged in advocacy throughout the country. Lastly, military PTs have been able to order diagnostic imaging since 1972 and this has reduced costs and over treatment in that arena. Hopefully we’ll get this throughout the US soon.

I’ll read that paper. Sweet! Here ya go.

The Algorithm for Your SNF

The Gist - The team behind this research came up with a simple algorithm to determine SNF length of stay after hip fracture surgery. The goal is to reduce SNF stays and lead to cost savings for healthcare systems. The algorithm was based on ambulation ability. If they could walk unassisted, the algorithm recommended 7 days. One person assist was 14, and two person was 21. They gave this information to the rehab specialists and the patients in the participating SNFs who then set those marks as discharge goals and compared their results to SNFs who didn’t follow the protocol. And wouldn’t you know it?! It helped! Patients in participating SNFs safely discharged to home an average of 8 days sooner (23 vs. 31) with no increase in adverse events. Cool!

Tell Me More - I know that even their average discharge date was well behind the longest time given by the algorithm, but having a more rapid goal for discharge did indeed help bring it about. The researchers plan to refine the algorithm to better fit real-world conditions, but the concept seems to be well-founded. Since this was performed in a single participating SNF, the study is limited in its generalizability and the concept as a whole needs more work, so this isn’t finished research, but it’s a potentially interesting way to reduce healthcare costs and get people home faster.

I want to read the whole thing. Have at it mate. Open access too.

How to fix an overactive bladder? We’re not sure.

The Gist - In only our second piece form the Journal of Women’s Health Physical Therapy, we’re looking at a review of pelvic floor muscle training and urgency control strategies. The researchers put a bunch of papers through their paces in this short but sweet review. Overall, we find this: lots of interventions for overactive bladder work. We’re not sure which is best.

The researchers assessed pelvic floor muscle training, cognitive training, mindfulness-based stress reduction, electrical stimulation, and more. Across the board, just about all of them worked pretty well and we don’t know which is best yet. Good news! But not great news.

Tell Me More - The takeaway is that we need more work in this field, with the researchers leaving this note in the discussion section:

The most compelling result of this review is that current evidence leaves so many unanswered questions, such as the following: What PFMT training program is most effective for women with OAB? Does it differ for women with OAB with UUI versus OAB without UUI? Is distraction the best cognitive approach to controlling urgency, or would patients have better results by de-emphasizing distraction and instead focusing on mindful awareness of bladder sensation? When are additional modalities such as electrical stimulation warranted, if at all? Strong studies examining these questions are needed to guide physical therapy intervention.

Right now, we have a few techniques that are effective, but a lot more to learn.

I’d like to check out the paper. Good choice.

That’s our week! Hope you enjoyed this slightly off edition of PT Crab. It was a bit different than our regular content, but still full of elements important to the profession. As always, feel free to respond to let me know what you think, I’m all ears.

Cheers,

Luke