Preoperative Physical Therapy Results in 'Significant' Reduction in Postoperative Care Use for Patients Undergoing Hip or Knee Replacement
A new study has found that as few as 1 to 2 sessions of preoperative physical therapy can reduce postoperative care use by 29% for patients undergoing total hip or knee replacement, adding up to health care cost savings of more than $1,000 per individual.
Researchers in Ohio reviewed 4,733 Medicare cases involving total hip or knee replacement from a combination of 169 rural and urban hospitals with wide geographic distribution, and found that 79.7% percent of patients who did not receive preoperative physical therapy required postacute care services. That rate dropped to 54.2% for patients who received even a small number of physical therapy sessions before surgery. The study was e-published ahead of print in the Journal of Bone and Joint Surgery (abstract only available for free).
After adjusting for demographic variables and comorbidities, the study's authors estimated a 29% reduction in postoperative care use among the preoperative physical therapy group, which translated into adjusted cost reductions of $1,215 "driven largely by reduced payments for skilled nursing facility and home health agency care."
Patients with at least 1 billed encounter using CPT codes designating physical therapy evaluation or self-care/home management training were included in the preoperative group, providing they had received the service within 30 days of their surgeries.
Researchers believe that the benefit of preoperative physical therapy was derived mostly from the way it prepared patients for postoperative rehabilitation. In most instances studied, they write, preoperative physical therapy was limited to 1 or 2 sessions, which "suggests that the value of preoperative physical therapy was primarily due to patient training on postoperative assistive walking devices, planning for recovery, and managing patient expectations, and not from multiple intensive training sessions to develop strength and range of motion."
"Our study demonstrates a significant reduction in postacute care use associated with the use of physical therapy during the preoperative period for total joint replacement surgery," authors write, adding that in settings where replacement surgery has been recommended by an orthopedic surgeon, "physical therapy appears to provide value within the structure of a standardized preoperative joint replacement education and planning program in which physical therapists may play an important role."
While researchers acknowledge that more work needs to be done to pinpoint the best way to balance resource allocation between pre- and postoperative activities, they cite the current study's findings as a good first step in refining new models of care.
"As payments in health care move from a fee-for-service basis to more global payments that require some risk sharing by providers," authors write, "the ability to manage populations across the continuum to high-quality outcomes at low cost will be imperative."
It’s important to maintain exercise, especially as you age. As physical therapists, you may be seeing more active seniors looking to stay fit after injuries or orthopedic surgery.
But active seniors who are keen on keeping their bodies fit may be signing up for gym classes or doing routines that are no longer safe. Think of all those Zumba classes or senior weight training classes. Who knows if the instructors are aware of their medical conditions and past injuries.
This can lead to serious complications and even new injuries that can derail a fitness program.
Since active seniors have different exercise needs than a younger population, it might be difficult to determine what kind of program would best serve them. Can they be well-managed by a personal trainer? Or are they better off with a physical therapist? Both are needed, It’s just that they both have different roles.
The Role Of Personal Training
Personal training is a structured workout program that allows clients to exercise on a regular basis under supervision to maximize results.
The Role Of Physical Therapy
Our Physical therapists rehabilitate and educate patients who are hurt and return them to their regular routine, skillfully providing treatment plan designed to correct dysfunctional movement and return Seniors to their previous level of function, inclusive of a daily workout routine to maintain the progress they made during therapy.
Issues With Pain And Mobility
Seniors who struggle with pain, balance, and coordination, and who need rehabilitation are best suited for physical therapy.
Personal trainers are trained to help patients improve their fitness level, not heal injuries or deal with pathology. The danger in relying solely on a personal trainer is if they push a patient too far beyond their limits, there is a risk for injury. There should be a team approach, and we seeing a physical therapist when there’s an existing condition that makes exercise hard. Some preexisting conditions that need to be taken into consideration, extremity asymmetry, gout, or swelling in their knees or other joints that limits normal range of motion. This can also apply to seniors with neurological disorders like Parkinson’s.
It’s A Team Effort
Personal trainers are no replacement for physical therapists and vice versa. However, both have important roles to play in maintaining health as people age.To decide if a patient needs a personal trainer or physical therapist, take into account their fitness level, their health (if their bones or muscles are injured), and their goals (fitness or rehabilitation).When you have an injury, it's always best to see a physical therapist first. Your physical therapist will devise a treatment plan, which may include working with a qualified personal trainer or clinical exercise specialist.
There are many veins and nerves in our anatomy and many times they get affected and cause the pain. There is one major nerve called sciatic nerve that is made with tiny roots of nerves that comes from lower back area of spine. When this nerve is compressed a medical issue arises that is called sciatica. Today the majority of the people are aware of this condition and also the treatments because it is common to get affected by this condition. Physical therapy is the most remedy to relieve the apian in the patients. There are many physiotherapists who can help you out.
Physical therapy for sciatica
It is very simple to get this treatment, but it is also important that you consult a professional sciatic nerve therapist for this condition. It is important to consult one first. Professionals are going to educate the patients, which is another important thing. After that they are trained with the accurate moments. The sciatica physical therapy includes forces, manipulation of frequency like things and all this is done by the therapists in the right way. This therapy has become very popular among the patients because the oxygen amount in the blood is also increased. This increase in the blood circulation and relieves the pains to a great extend. In case patients are suffering from oxygen deprived sciatica, then this is the best for them.
More to learn
Physical therapy as you know is the best treatment to ease the sciatic nerve pain. Experts are going to tell you about several; treatment plans, exercise, stretches that these treatments are very effective and takes less time to heal the patient. Today we all are living busy lives and it s hard to get out time for regular therapy appointments. It is also going to be tiresome and exhausting. The patient must be commitment to them and follow the program step by step to get the results.
There are top notch benefits of the physical therapy and you are going to learn various types of exercises and stretches on the daily basis. You will have to follow them step by step. Therapist is having lots of experiences and they can understand your needs the better. They can eliminate pain as much as they can. If you need to heal faster than overall outcomes are going to depend upon you totally. There are doctors and therapists both available and he choice is going to depend all upon you, which you are going to choose. You must prepare a goal sheet and this is going to keep you busy and motivated.
It is possible to get rid of the sciatica and get rid of the pain. You will be able to do all the things which you love to-do. You are going to be back on your feet and will run all over. You just have to make sure that you are choosing the right therapist for your condition to get the treatment and heal faster and in the more effective way.
Many patients arrive at their first physical therapy appointment expecting to receive hot packs, ultrasound and instructions on how to complete a series of exercises. These modalities are warranted in many instances and most therapists would agree that exercise is needed to help restore muscle imbalances. However, many therapists now approach the restoration of function from a different perspective. These therapists are interested in why a muscle isn't functioning properly and view back exercise not as the driving mode of recovery but as a complement to manual therapy. They may, for instance, look to restore proper sacroiliac or lumbar joint function to treat piriformis syndrome rather then directly manipulate the piriformis muscle through exercise.
Manual physical therapy is a specialized form of physical therapy delivered with the hands as opposed to a device or machine. In manual therapy, practitioners use their hands to put pressure on muscle tissue and manipulate joints in an attempt to decrease back pain caused by muscle spasm, muscle tension, and joint dysfunction.
Manual Physical Therapy is Less Established for Back Pain Management
While all physical therapists have the option to use manual therapy in their practices, many don't spend the time or the resources to become efficient in this area of practice. Patients should be aware that it is a lesser known physical therapy technique among physicians and may not be as commonly prescribed. Also, many of the conditions that practitioners treat with manual therapy are not demonstrated with imaging or lab tests but rather during motion testing and treatment, and therefore insurance company reimbursement may be limited.
While patients may be referred for physical therapy treatment by their primary care doctor, an orthopedic surgeon, or other doctor involved in their back care, most states have direct access laws permitting patients to seek help for low back pain from a licensed physical therapist without having to seek a written referral.
Manual therapy can be helpful for the treatment of joints that lack adequate
mobility and range of motion in certain musculo-skeletal conditions. This
limitation can cause discomfort, pain, and an alteration in function, posture,
and movement. Manual physical therapy involves restoring mobility to stiff joints and reducing muscle tension in order to return the patient to more natural movement without pain. Thus, manual physical therapy may provide back pain relief both for patients with chronic back pain involving joint problems, such as sacroiliac joint dysfunction, and acute back pain from soft tissue injuries such as a back muscle strain or a pulled back ligament. Although extensive clinical studies have yet to be performed on all areas of manual therapy, limited clinical data and patient reports support the assertion that manual physical therapy can be effective in relieving back pain for certain patients.
As a group, manual physical therapy techniques are aimed at relaxing tense back muscles and restricted joints in order to decrease back pain and increase flexibility. In general, manual physical therapy techniques employ the following types of movement:
So-called arthroscopic knee surgery is becoming a less common treatment for adults with torn cartilage or painful arthritis as a growing body of evidence shows little benefit from these operations, a U.S. study suggests.
Researchers examined data on all surgeries done on patients 18 and older in Florida from 2002 to 2015, including a total of 868,482 arthroscopic knee procedures. Overall, rates of these operations declined 23 percent during the study period, with sharper decreases after 2008.
Many experts believe doctors don’t change the way they treat patients when studies show those treatments don’t work, and knee arthroscopy is often cited as an example, said study author David Howard of Emory University in Atlanta.
“There was some evidence that use of arthroscopy was declining, but this study shows that the decline was large and has been sustained,” Howard said by email. “I think patients can be reassured that doctors reacted to the evidence.”
During this operation, a surgeon makes a small incision in the knee and inserts a tiny camera called an arthroscope to view the inside of the joint, locate and diagnose the problem, and guide repairs.
While this is minimally invasive, it’s not risk-free. Patients receive anesthesia, which in any surgery may lead to complications such as allergic reactions or breathing difficulties. In addition, this specific knee procedure has the potential to damage the knee or trigger blood clots in the leg.
Multiple studies have shown that knee arthroscopy isn’t any better than non-operative treatments for conditions like arthritis, torn cartilage and knee pain, Howard notes in JAMA Internal Medicine. But evidence to date hasn’t offered a clear picture of how much doctors and patients are avoiding the operations as a result.
Between 2002 and 2015, knee arthroscopy rates in Florida declined from 449 procedures for every 100,000 adults in the population to 345 procedures for every 100,000 adults, the current study found.
Declines were steeper after 2008, when a second major trial was published that failed to detect a difference between surgery and “medical management,” which might include things like medications to ease pain or inflammation or use of heat or ice, or physical therapy.
These declines in surgery happened even as the prevalence of knee osteoarthritis among U.S. adults more than doubled from 6.6 percent in 1999 to 14.3 percent by 2014, Howard writes.
The study wasn’t a controlled experiment designed to prove what factors might have influenced any declines in these surgeries or whether or how patients might have different health outcomes as a result. And it only included data from Florida.
Still, the results suggest that doctors and patients are getting the message that these operations aren’t the best approach for wear and tear that contributes to knee pain as people age, said Andrew Carr, a researcher at the University of Oxford in the UK who wasn’t involved in the study.
“Rest and time are often very helpful,” Carr said by email. “If symptoms persist then other treatments including physiotherapy and the use of anti-inflammatory medication may be of benefit.”
There are still, however, far too many operations being done on patients who may not benefit and may be harmed instead, said Jonas Bloch Thorlund, a researcher at the University of Southern Denmark who wasn’t involved in the study.
“There is still room for improvement,” Thorlund said by email. - (Reuters Health)
Be sure you understand your diagnosis.
This sets the tone one and is the key to your Physical Therapy success because it gives you a big picture and what to expect in the weeks and months to come. Physical therapists identify movement impairments and dysfunction, so a PT diagnosis may be more detailed than your surgical or injury diagnosis or the diagnosis written on your doctor’s referral. After the initial full evaluation, the physical therapist will give you their diagnosis. That diagnosis then dictates treatment intervention and plan of care, outlining goals for therapy as well as frequency and duration of treatment. By understanding your diagnosis, it will provide insight as to why particular treatment methods are necessary and why they will be effective. That way, whether you're doing exercises at home or having manual therapy performed by your PT, you'll understand why and how your treatment works.
Ask the right questions.
Asking the right questions can help in the prevention and avoid getting that injury ever again, and much of your ability to do that depends on your therapist and how willing they are to put in that preventative work with you.
You can ask something like: "What will you teach me that will keep this from being a problem again in the future?" Your PT should not only be interested in helping get you back to full function, but also in teaching you about 'why' behind treatments, your movement, recovery, and how your overall lifestyle plays into it all.
Keep a journal.
Motivation can aid you during a long recovery process, so it's helpful to look back on how far you've come. Keep your own notes on pain levels and how you are feeling from day to day (happy, sad, motivated, discouraged, etc.). Recovery can be slow, so by having notes of how your feeling over time lets you see the progress. Seeing results also helps keep patients motivated to continue with their recovery process."
Frequency of Physical Therapy Sessions .
Most people think that the more often they see their PT for a session, the better. But this isn't always the case. Oftentimes, physical therapy referrals read two to three times per week; However, when you seek hands-on, one-on-one treatment with a physical therapist for 45 to 60 minute sessions, weekly or biweekly sessions may be more appropriate, depending on your condition. Not only will these types of sessions help you get better faster, but they'll be more cost-effective, she says. Given that you are invested in your health and healing and therefore compliant with your program, fewer sessions could actually be better than more! For those who aren't dedicated to following their program, greater frequency or duration of sessions may be necessary."
Think of your PT sessions as education, not exercise.
It’s important to remember that you're not here to work out; you're there to learn how to heal your injury and prevent it from happening again. To get the most out of your PT session, think of your session not as an exercise session, but as an educational session. “An effective physical therapist must be an effective educator. That's why learning as much as you can from your PT is critical. Take advantage of the opportunity to ask questions, because Physical Therapists often have much more time to answer basic questions than most health-care providers. A therapist may not be able to answer all your health-care questions, but can often help you seek out the appropriate answer by contacting the appropriate channels.
Ask your therapist for feedback.
Physical therapists keep track of metrics like range of motion that tell the story of progress, but many times patients don't know to ask about it. Check in with your physical therapist every few weeks or once per month to understand how you are improving quantitatively.
Be honest with your PT.
Didn't have time to do your exercises? Feeling worse than when you started PT? Tell your therapist! Physical Therapist’s appreciate their honesty. Sometimes this will alert me to other stressors in a patient's life or allow me to suggest changes. Physical therapists are trained to make recovery possible, but if they don't have all the information, it can be tough for them to make appropriate recommendations. " The more your physical Therapist knows the more they can be a resource for you.
Distracted driving can cause crashes, injuries, and even death; it's a prevalent public issue that the American Academy of Orthopaedic Surgeons (AAOS) continues to champion. But what about distracted walking? What are the consequences of pedestrians talking on the phone, texting, listening to music, or selfies.
Today, more and more people are falling down stairs, tripping over curbs and other streetscapes and, in many instances, stepping into traffic, causing cuts, bruises, sprains, fractures, even death. Alan Hilibrand, MD, chair of the AAOS Communications Cabinet reports, "The number of injuries to pedestrians using their phones has more than doubled since 2004, and surveys have shown that 60% of pedestrians are distracted by other activities while walking.
In Physical Therapy this position is known as a half lunge. There are many variations of this pose. This modified Yoga pose (Asana) is an excellent example of specific muscles lengthening and contracting around the hips.
The blue color represents muscles which are contracting and the muscles in red are lengthening. This image is shared graciously with permission from BandhaYoga from their book The Key Muscles of Hatha Yoga by Ray Long, MD. To see their amazing YogaAnatomy books, visit their website.
The muscles in blue which are contracting:
1. Left sided Triceps
2. Left sided Hamstrings
3. Left sided Iliopsoas
4. Right sided gluteus maximus
5. Right sided hamstrings
The muscles in red which are lengthening:
1. Right sided Iliopsoas
2. Right sided Quadriceps
This is a great asana posture to stretch the iliopsoas.
•Origin (1st attachment site):
Transverse process of L1-L5 and anterior ilieum
•Insertion (2nd attachment site):
Flexes the hip and trunk. Laterally flexes trunk ipsilaterally.
Involved in sit-ups.
This muscle tends to get very tight and shortened in individuals who sit a lot of the day. Most of us would benefit from regularly stretching this muscle.
Musclces that are very tight or weak can cause misalignment of joints and posture. These muscle "impairments" (such as tightness and weakness) can lead to painful movement or discomfort in certain postures. Physical Therapists (P.T.) are experts in movement and posture. By assessing the body in different positions and planes of movement, a skilled P.T. can determine which muscle imbalances exists and then take the proper steps to correct for the musculo-skeletal impairments. For instance, certain muscles are commonly shorter on one side and longer on the other, while others are stronger on one side and weaker on the other. This can set up a muscular "tug of war" between muscle groups. In the hips, there is often a complex tug of war that goes on between the iliopsoas and it's antagonist, the gluteus maximus.
There are a number of other muscle interactions as well, which will be addressed. Applying out knowledge of functional Anatomy, we gain a deep insight in how to overcome pain conditions of posture and movement.
Physical Therapists who are also trained in Yoga, such as those at Zenergy
PT, utilize their knowledge of Anatomy and Yoga to correct muscle imbalances and
postural dysfunctions using Yoga postures and techniques. There are many other ways to address muscle imbalances as well.
Future blogs will go into more detail about common muscle imbalances and how to treat them using out knowledge of Anatomy, Yoga, and Therapy.
Comments are always welcome!!
MOVE RECEIVE RELEASE STRETCH
General exercise helps relieve pain,
improve heart strength, endurance, muscular activity, coordination, mental
health, and is good for every system of the body.
Perform activities that are comfortable, listen to your body for when to
slow down. Swimming and walking and biking tend to have less impact on the
joints of the back than other activities such as jogging.
Welcome into your life what is
nourishing and life affirming. Receiving massage and bodywork has been shown to
help reduce pain and muscle tension, as well as a sense of wellbeing and joy.
Some body types find more benefit from deeper body work, whereas other’s gain
more benefit from lighter, more subtle bodywork or energy work, such as
acupuncture, therapeutic touch, or reiki. Choose a therapist/healer that you
feel very comfortable and safe. Receiving bodywork from someone who is
compassionate and sets a healing tone can make a world of difference when
receiving healing therapies.
Releasing toxicity and stress from
your life is essential to optimal health and spinal function. Fear, stress, and
anger have been associated with longer recovery. Pay attention to making
nourishing and conscious choices. Participate in activities that reduce stress,
such as meditation, mindful movement (such as t’ai chi), or relaxation
breathing. Release toxic and heavy food from your diet, as well as let go of
toxic/negative thinking. Release stressful, toxic relationship from your life is
also a good practice.
STRETCH: Daily stretching is a simple, safe and very effective
way of releasing strained and tense muscles. Yoga has been shown to be
beneficial for people suffering from back pain. The muscles and fascia store
tension from traumas, mental, emotional, and postural stress- where regular
stretching and bodywork can help relieve this built up tension. It is important
to move into postures and stretches slowly, so not to overstrain. You may need
professional guidance on safe, effective, therapeutic stretches for
Physical Therapy/ Neuro-musculo-skeletal Perspective:
This is a very common problem seen by Healers and Health Care Providers. Tension headaches commonly relate to the sub-occipital region where the vertebrae of the neck, the cranium, and the surrounding tissues come together. In anatomical terms this is known as the craniovertebral junction, which is a collective term referring to the atlas, axis, occiput, and surrounding ligaments and soft tissue.
The headaches arising from this region are also known as “Occipital Headaches” which according to many clinician’s, originate in the cervical region, especially if cervical traction decreases the headache pain. This type of headache typically has it’s origin from a structural source. In other words the structures of the neck and craviovertebral junction are strained from poor posture, overuse activities, or movements. The strain of the cervical structures can be associated with headaches.
According to the Mayo Clinic “tension headaches are the most common type of headache and yet the causes are not well understood.” With tension headaches, the muscles that supported the head, including the posterior and anterior sub-occipital muscles, deep neck flexor and extensor muscles are frequently found to be involved. Tense or constricted muscles of the neck often relate to headaches, which can be very intense and unrelenting, and often difficult to resolve. It is often throbbing, pulsating, and radiating in nature.
The sensation of pain can also relate to areas of the neck, jaw, shoulders, upper back, back of head, and refer to the frontal region of the head.
A brief overview of the anatomy involved in this area involves the following:
· Joints – Occipito-atlanto joint (O-A), Atlanto-axial joint (A-A), Mid Cervical Joints
· Ligaments – OA and AA ligaments, including Alar and Cruciform ligaments
· Muscles – Anterior Suboccipital Muscles (Rectus Capitus Anterio, Rectus Capitus Lateralis), Posteiror Suboccipitals (Rectus Capitus Posterior Major and Minor, Inferior and Superior Oblique), Splenius Capitus, Trapezius, Pectorals, and masseter.
· Nerves – Dorsal Ramus of spinal nerve C1 and C2 (Greater occipital nerve). C2 has a large cutaneous distribution and has a large dorsal root ganglion in a vulnerable location between C1 and C2. Cervical extension motions compress this region and thus Forward head posture can relate to Occipital headaches through this relationship. (ref below)
Abnormal posture has often been related to numerous musculo-skeletal and neuro-vascular impairments. In the area of postural mechanics there is a term that describes a very common position of the head and neck that relates to sub-occipital tension – known as Forward Head Posture. This position puts an abnormal load on the cervical, thoracic, and jaw regions places high amounts of stress on the muscular system. The further forward the head position, the higher the muscular force of the neck muscles must be to counteract gravity.
This posture causes excess mechanical strain on the neck region and results in a cascade of muscular and skeletal problems. As indicated above, it can relate to occipital and tension headaches due to the compression pressure that can aggravate the sensitive C2 nerves.
When working long hours at a desk or computer forward head posture often results- because the body posture will follow the eyes, usually forward, and the posture gets more and more flexed with time due to the force of gravity.
Common history and/or complaints of individual with tension headaches:
· Job that requires prolonged sitting, especially if using computer
· Recent life changes – change of job, living situation, relationship, ANY major change
· Under High amount or long duration of stress
The main clinical objective findings for tension headaches:
· Postural: FHP (Forward Head Posture) with associated increased thoracic flexion and scapular protraction. Occipito-Atlanto Backward Bending.
· Hyper tonicity and shortening of posterior sub-occipital and scapula-cervical muscles
· Tenderness to palpation of external occipital protuberance
· Taut bands and trigger points in mid belly of upper trapezius, sub-occipitals, and often upper cervical joints- especially the transverse processes.
· Restricted Active Range of motion with Chin Tuck, Cervical Forward Bending, and often Cervical Side Bending to contralateral side
· Restricted Passive Range of motion with OA forward bending and often mid cervical upglide restrictions
· Functional Limitations: Varied, often related to increased pain with looking upward, computer work, prolonged sitting, sleep disturbance
Ayurveda relates this type of headache to a Vata disturbance, related to the following qualities:
· You cannot have pain without Vata.
· The rough quality of Vata relates to muscle stiffness.
· The dry quality of vata relates to constipation, which sometimes accompanies this pain.
· You may notice these symptoms are worse during Vata times of day 2-6am and pm, and/or Vata seasons (Autumn).
· The mobile qualities of Vata relate to over-activity aggravating the skeletal, muscular, and nervous systems and cause headaches. Pain gets worse with certain movements and less if the body is at rest.
· Fear, anxiety, nervousness, stress can all aggravate Vata and relate to tension headaches.
· Typically Vata headaches are related more to the occipital region, whereas Pitta headaches will be more in the temporal region, and kapha headaches tend to be located more in the nasal/sinus regions of the head.
The treatment for these headaches varies depending on the type of health care practitioner you see. A Physical Therapist or movement specialist would certainly address ergonomics, posture, and physical restrictions with therapeutic exercises and body awareness. A stress management routine and breathing techniques would be indicated. This type of condition responds very well to manual and touch therapies – and in my estimation any treatment plan is incomplete without including it.
I will often use a combination of manual and touch therapies with great results in a short amount of time, including:
· Marma Therapy – healing points that can decrease muscles tension, stress, and pain.
The points right underneath the external occipital protuberance are considered the most influential points, called Krikitaka in Ayurveda, and well known in modern medicine for pressure relief because of the location and insertion of the posterior suboccipital muscles into the cranium.
· Manual Therapy – sub-occipital release and myofascial release techniques. These techniques can decompress to posterior joints of the neck and create more extensibility in the soft tissue.
· Yoga Therapy – there are a number of Yoga Asanas and Breathing Techniques that can offer great relief from sub-occipital tension. Alternate nostril breathing can calm the mind and Postures involving gentle neck flexion can relieve the muscular shortening and tension.
· Massage with Sesame or Vata Oil to the back of the head, scalp, and neck muscles, can help relieve the pain.
Future Blogs will give more detailed treatment approaches according to Marma and Manual Therapy principles.
Kenneth Mauck, MPT, MS Lead Physical Therapist