Category Archives: Ortho

How Can You Improve Patient Interactions?

153570089_bb99d7108c_mHave you ever been a patient (for any provider, not just PT) and had a really great or a really bad experience?  What was the key to that experience for you?  For me, it was the interaction with the provider.  I’ve contemplated switching providers because of an interaction where I felt like a number, that my concerns were minimized and derided, and that his time was much more valuable than mine.

I received the most recent PTJ yesterday.  A few articles grabbed my attention, including “What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis” (O’Keeffee M, Cullinane P, Hurley J, et al; Phys Ther 2016; 96: 609-622).  It reminds me a lot of the PTJ article by Hush and colleagues from 2011 entitled “Patient Satisfaction with Musculoskeletal Physical Therapy Care: a Systematic Review” which is one I have my students read.

The authors identified four themes in their review: PT interpersonal and communication skills (active listening, empathy, friendliness, encouragement, confidence but not overconfidence, and non-verbal communication), PT practice skills (patient education – a big one for patients, and PT expertise and training), individualized patient centered care (individualized, and taking patient opinion and preference into consideration) and organization and environmental factors (time, flexibility).

The results aren’t all that surprising, but they bear repeating to ourselves as providers; I would argue while both articles examine this in light of musculoskeletal PT, it very likely applies across all specialties and settings. Do positive interactions enhance adherence and give better outcomes?  No evidence on this yet, but it would make sense especially for self-efficacy. I think I do pretty well in my interactions, but I think I’ll focus on my listening and patient education.  What can you work on to improve patient satisfaction and possibly their adherence and outcomes?

Photo credit: X-Factor by Pierre Metivier.


Knee osteoarthritis – treatment and pain research


On vacation last week, I came across a bunch of helpful articles and reviews on knee OA. To start, apparently runners don’t get knee OA, which goes against commonly accepted belief in the general public. For those with knee OA, for conservative treatment acupuncture does not help when combined with exercise, TENS does not help as an adjunct to education and exercise, and exercise is a staple in conservative treatment but most modalities are a placebo (for those who opt for a TKA, you can measure their progress with the KOOS).

The most interesting article I read was a review by Girbes et al about OA and central pain processing or pain central sensitization, which was followed up a few days later by this fascinating video about OA and the brain. I’m really looking forward to the opportunity to hear Lorimer Moseley at CSM.

Photo credit: IMG_8031, originally uploaded by Patty Mooney

Radiation Fibrosis, and LBP/muscle activation in gait for seniors

Two interesting articles that are not part of my required curriculum but are applicable to my recent caseload:

Radiation Fibrosis Syndrome – I can’t access this article through the UMN, but I did do a PICO question during school for reduced ROM due to radiation-induced fibrosis.  I recently had a patient with radiation fibrosis resulting in reduced ROM/ strength/ sensation – if you have had a patient undergo chemo or radiation years ago, it may be helpful to know the treatment parameters (radiation field, chemo agents used, any surgical procedures, etc) to give a better picture for past medical history and how it may direct your treatment and impact outcomes.

Low back pain and muscle activation during gait in older adults – again, I don’t have access to this article, but I’ve requested a copy.  It will be interesting to see the discussion section, given their results: “The control group participants activated their lower rectus abdomini muscles (P < .05) and right internal oblique muscles significantly more than did the LBP group (P < .05), whereas the LBP group activated their left lateral erector spinae and both lumbar multifidi sites significantly more than did the control group (P < .05).”

Spinomed orthosis in new study

I will pull the study later (I have to read a few papers about hip fractures tonight), but this looks interesting.  Apparently in a randomized trial,two spinomed braces improved trunk strength and therefor posture, and they improved quality of life (reduced pain, improved ADL’s).

recent research readings

We finally got our condo on the market – hopefully it will sell before we need to move to Minnesota (I should be licensed by June 10th, and residency starts September 1st!).  Now that the hectic time has passed, I’ve had time to read and share.

  1. Hip fracture recovery:  Kristensen M.  Factors affecting functional prognosis of patients with hip fracture.  Eur J Phys Rehabil Med. 2011 Jun;47(2):257-64.  (free text).  I have wondered why some patients do really really well after a hip fracture and others have not done as well.  This paper is a good overview of the answer to that question, and maybe a few ideas for treatment (dovetails well with the recent Cochrane review about hip fractures and rehab).
  2. More on hip fracture recovery:  The lead author on this is also an author on the recent Cochrane review, but this is free text (yeah for open access!).   Sherrington C, Tiedemann A, Cameron I.  Physical exercise after hip fracture: an evidence overview.  Eur J Phys Rehabil Med. 2011 Jun;47(2):297-307. Epub 2011 May 10.
  3. Adherence to exercise:  I had the opportunity to hear Dr. Resnick present at ExPAAC last summer – she is a great speaker and I got a lot of great ideas that I would love for my employer to implement to improve physical function in older adults in assisted living and LTC.  I haven’t had a chance to read the study itself yet (requesting a copy of the study), but according to the abstract “self-efficacy and negative outcome expectations are directly related to exercise behavior.”  We as PT’s need to be encouraging our patients’ self-efficacy and addressing outcome expectations (I love the topic of adherence – if/when I go back for a PhD, that will most likely be my focus somehow)  Resnick B, D’Adamo C.  Factors associated with exercise among older adults in a continuing care retirement community.  Rehabil Nurs. 2011 Mar-Apr;36(2):47-53, 82.
  4. Land vs. aquatic therapy for hip or knee OA:  We have a pool onsite, so when I saw the title I wanted to read further.  They found no differences between the two for outcomes, and unfortunately  the variability of the programs and the quality of the designs were not great, and they reported that the components of the programs were not described (this could be due to space limitations of the paper – word limits can hamper what you want to say which is good in that you are concise but bad because you might not be able to be as thorough).  If you ever write a case report or conduct a study, see if you can include this type of information in an appendix.  Batterham SI, Heywood S, Keating JL. Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes.  BMC Musculoskeletal Disorders 2011, 12:123doi:10.1186/1471-2474-12-123
  5. BWST vs. HEP.  For those that missed it, part of the LEAPS trial has been published with the report that there is no difference between early gait training with BWS and a progressive HEP – so don’t feel bad if you don’t have a BWS system (we don’t either). Duncan PW, Sullivan KJ, Behrman AL, Azen SP, Wu SS, Nadeau SE, Dobkin BH, Rose DK, Tilson JK, Cen S, Hayden SK; LEAPS Investigative Team.  Body-weight-supported treadmill rehabilitation after stroke.  N Engl J Med. 2011 May 26;364(21):2026-36.
  6. Urban elderly, fall reduction, and adherence:  For the residency I’ll be at Augustana in downtown Minneapolis 4 days a week.  One of the things that drew me to the program is that it is urban and there is more variety in the patient population.  When I read the title of this article I wanted to read more.  It is interesting that over half attended all the onsite sessions but only one person reported exercising at home all 12 weeks (I would be interested to see what  was the overall percentage of adherence to both), and even more interesting is that if they lived alone they were more likely to attend, but if they were depressed they were less likely to attend all the classes (I’ve requested this article, haven’t received it yet).  Stineman MG, Strumpf N, Kurichi JE, Charles J, Grisso JA, Jayadevappa R.  Attempts to reach the oldest and frailest: recruitment, adherence, and retention of urban elderly persons to a falls reduction exercise program.Gerontologist. 2011 Jun;51 Suppl 1:S59-72.

We have some changes going on at work, and I hope to have some good research and posts out of them soon – stay tuned!

fracture risk in meds, CHF/a-fib


In the past few weeks, three medications have been linked to increased risk of fractures in older adults – levothyroxine (for hypothyroidism), proton pump inhibitors (for GERD), and bisphosphonates (ironically prescribed to treat osteoporosis).

Additionally, it was reported recently in Circulation: Heart Failure that people with heart failure are at risk for vertebral fractures, with an increase when combined with a-fib.

A few thoughts with all this recent news on fractures (and seeing patients with one or more):
First, I’m glad this information is out there, and hopefully patients and their physicians and pharmacists will assess “are all these medications needed and in this dose considering the side effects?” Second, this is a reason to take a good medical history and know what your patient is taking. This segues into #3, which is the importance of weight bearing exercise which can help reduce the risk of fractures. I wish my patients and our community at large were more adherent to physical activity recommendations, but that is a research project for later.

Photo credit: Omeprazole, originally uploaded by idleman

Recent readings and news

March has been very busy between work, home, continuing education classes, and preparation for a guest lecture.  This weekend I attended NAIOMT’s Differential Diagnosis class (Part A) – three days that challenged my memory, reasoning, and abilities, and that really make me want to step up to the challenge of being a better PT.  More on that later, as Part B is in a month.

I’ve also been taking Mike Reinhold’s online Shoulder Seminar, and I have to say first that I appreciate the quality of the articles and the presentations, and second that I can go at my own pace as this week I was unable to keep up.  However, I wanted to pass on a few references of papers that he is having us read, that I thought would be good if you are interested in EBP or have questions about the shoulder:

  • Regarding EBP/EBM:
    • Cormack JC. Evidence-based practice…what is it and how do I do it? J Orthop Sports Phys Ther 32(10):484-7, 2002.  A good overview of what it is, what it is not, and how to do it.  I think I’ll review this once a year as I set out professional goals.
    • Cleland JA, Noteboom JT, Whitman JM, Allison SC.  A primer on selected aspects of evidence-based practice to questions of treatment.  Part 1: Asking questions, finding evidence, and determining validity.  J Orthop Sports Phys Ther 38:476-84, 2008.  A tough but good read.
    • Noteboom JT, Allison SC, Cleland JA, Whitman JM.  A primer on selected aspects of evidence-based practice to questions of treatment.  Part 2: Interpreting results, application to clinical practice, and self-evaluation.  J Orthop Sports Phys Ther 38:485-501, 2008.  Same as above.
  • Examination of the shoulder:
    • Malone T.  Standardized Shoulder examination – Clinical and Functional Approaches.  In Wilk KE, Reinold MM, Andrews JR, The Athlete’s Shoulder, 2nd Ed.  Elsevier, 2009.  Yes, most of my patients are not athletes, but I still benefited from the framework.
    • Wilk KE, Andrews JR, Arrigo CA.  The physical examination of the glenohumeral joint: Emphasis on the stabilizing structures.  J Orthop Sports Phys Ther 25:380-9, 1997.
    • Hegedus EJ, Goode A, Campbell S, et al.  Physical examination tests of the shoulder: A systematic review with meta-analysis of individual tests.  Br J Sports Med 42:80-92, 2008.
  • Shoulder exercise:
    • Reinold MM, Escamilla RF, Wilk KE.  Current concepts in the scientific and clinical rationale behind exercises for the glenohumeral and scapulothoracic musculature.  J Orthop Sports Phys Ther.  39:105-117, 2009.  A good overview of what shoulder exercises work best given the science and the rationale of the exercises.
    • Wilk KE, Arrigo CA, Andrews JR.  Current concepts: The stabilizing structures of the glenohumeral joint.  J Orthop Sports Phys Ther 25(6):364-79, 1997. A tough read if you are having a tough week, but given enough coffee it can be done.
    • Myers JB, Lephart SM.  The role of the sensorimotor system in the athletic shoulder.  J Athl Train 35(3):351-363, 2000. Very good article, but see above!

And in PT-related news, looks like new grads can’t pick just any date for taking the NPTE, and the neuro section has come up with recommendations for stroke outcome measures.