The following post comes from Brandon Whittington (twitter / google plus), a soon to be graduate from Lynchburg College DPT program. He has interned under me for the past 16 weeks, a real tech geek and wants to share the following information to the physical therapy world.
As a student physical therapist I like to stay involved with advocacy in the profession of physical therapy, however, sometimes (often) I find that things like emailing legislatures and keeping up with relevant topics and upcoming meetings gets overlooked. Recently I came across this gem of an app below called the APTA Action app. The application is featured on the APTA website and is available for Android and iOS devices for download. This app really has made my ability to quickly keep up to date and take legislative action quickly and easily. I particularly like the Action Center feature, where you can take action as an APTA member or patient. The app does all the work, fills out the whole form and sends the email on your behalf with minimal work required for the user. I’m hoping for push notifications when new actions become available but for the time being, there is nothing like it to stay involved easily and quickly. Check it out, show your patients and spread the word!
Note from Harrison: Thanks for the post Brandon and great job! The limitations in getting involved with legislative action and advocacy within our field is barriers with time and access. I am guilty as most of us are! I do think this application is concise and considering we all have phones, a quick and easy way to stay up to date.
I had a female patient come into the office the other day complaining of left ankle pain following tripping on the ice the day before after leaving her home having an inversion ankle injury. She was currently being treated in our clinic for balance and hip pain, but hasn’t sought care from a medical physician for current complaint.
Upon examination, she was able to walk into the office but marked antalgic gait pattern using a standard cane (which she always uses). She acknowledged that she was able to walk immediately following the accident and feels symptoms are getting better. She had apparent swelling in the lateral/inferior aspect of the rearfoot with ecchymosis noted in this region as well (black/blue, not yellow).
Notable objective findings:
Positive Ottawa Ankle Rules with Bone Tenderness at B, but negative for other realms of the guidelines.
She also had negative provocation to moderate depth palpation to the anterior talofibular ligament and posterior calcaneofibular ligament.
Additionally, she had negative pain provocation with 128hz tuning fork at location B and ~4” above this location along fibula shaft.
My course of action was education that I did not think she had a fracture, but I could not rule it out 100%. She had a positive finding on the Guidelines and it would be best to seek out a plain film radiograph.
She sought care from PCP, had x-rays and they were negative.
Therefore, it got me thinking more about how to fine tune the specificity of the Ottawa Ankle Rules, as they only have ~32% specificity, which is very low. I would suggest the probability of an ankle fracture arriving in a physical therapy office is much lower than at an emergency room (where initial rules arose), therefore, the specificity of this test would be even lower. So, the average 13% of inversion injuries that are fractures could be more around 5-7%, even lower! Therefore, the rate of false positives would be even higher. After speaking with her, examining her walking in the clinic (more than 4 steps), the time frame from injury over 24 hours ago and her opinion that it was only a sprain—all gave me a hunch that she did not, but went with the clinical guidelines. Therefore, I did some research.
I came across this article by Dissman and Han in 2006. They examined the result of tuning fork test on the tip of the lateral malleolus and distal fibula shaft and compared it to lateral & A/P x-rays following an inversion injury.
Based on Table 3 above, the sensitivity was still at 100% but specificity increased to 61% to the tip of the lateral malleolus and 95% to the distal fibula shaft, therefore, the specificity increased 3 fold if positive tuning fork test to distal fibula shaft and two-fold to tip of lateral malleolus.
This was only a pilot study and had large confidence levels, so take what you want from it. I have seen several cases in the past where I did not think there was a fracture, the patient did not think there was a fracture, but the guidelines are unable to rule out.
So, my question to you….do you utilize all 3 aspects of evidence-based practice or rely just on the research guidelines? I know it is best practice for this case to refer out for imaging, but what about other diagnostics that are less sensitive…such as clinical instability tests and/or vertebrobasilar insufficiency?
Dissman PD, Han KH. The tuning fork test—a useful tool for improving specificity in “Ottawa positive” patients after ankle inversion injury. Emerg Med J. 2006 Oct; 23(10): 788–790.
I recently took Dr. Michael Fink’s course on MedBridge, Medical Screening and Differential Diagnosis – Systems Based Approach. This provided me 6 contact hours of medical screening and review of specific systems, which goes beyond the minimal necessary to fulfill my continuing education needs. I embrace my role as a Direct Access practitioner. Not only did I decide to take this course as a requirement, but also as a service to my patients as I’m trained in differentiating between systemic and musculoskeletal conditions.
If you are looking for a last minute Holiday gift to give out to someone this season—who may possibly be a PT, who may possibly love to learn all the time, and a gift that just keeps on giving…then check out MedBridge Education. If you enjoyed the article and want to seek out more learning opportunities, try them out for a year. Be sure to use my promo code for a special price that can’t be beat. Be sure to type in inTOUCH before you check out (in is lowercase while TOUCH is capitalized).
An article by Cote P et al in Med Care 2001 entitled, “The treatment of neck and low back pain: who seeks care? who goes where?” is quite interesting and definitely can impact our outcomes and results. You can access the abstract here
The authors performed a mail survey looking at the characteristics of individuals who seek care from healthcare professionals: medical doctors, chiropractors or both. They were looking to see if patients sought care in the previous month from a healthcare provider, which was 25%; but one particular conclusion jumped out at me:
Patients consulting chiropractors alone report fewer comorbidities and are less limited in their activities than those consulting medical doctors.
This can have many implications but the one that first comes to mind is that the patients we get from the usual referral patterns seen in the past several decades are worse off than ones who seek care from chiropractors. This can mean it will take longer to get them better and this definitely affects outcomesand results. Or, does this mean that individuals who seek chiropractic care are overall just healthier?? Do chiropractors keep them healthier and in return less comorbidities? Maybe so but I am hoping not.
I can tell you from working in a rural environment and with a population of older age and definitely more comorbidities (high blood pressure, obesity, type II diabetes mellitus); it does affect outcomes. It is more frustrating on the therapist (me) and harder to make goals. I can’t change lifestyle behaviors when all you do is sit on the couch, which in turn leads to having more comorbidites; and resulting in you seeking me for neck and back pain.
Continue to promote Direct Access and this can be another argument for its benefit in physical therapy profession. Patient can bypass the middle man.
I have written a lot over the past few years on my success with Direct Access and patients coming to see me first for musculoskeletal pain vs going through a physician referral. The literature is coming out with more and more evidence to support my (and I’m sure you other PTs) anecdotal statements.
Here are a few links from my page here. Also, check out article in the past that shows we have the knowledge to manage these patients. A recent article in Health Services Research here looked at the comparison of self-referral vs physician-referral episodes to outpatient physical therapy. If you get the opportunity, you can listen to the authors speak through APTA podcast here. I also recommend reading the APTA Media Release here as our President and others (who are more renowned in our field!) remarked on the study. I do not have access to the full article so cannot delve but so deep but I find the results very promising for our field.
Basic findings were those who self-referred had:
–fewer PT visits.
–costs the system less for services.
–overall utilization of other resources for this problem were less.
We all know this but good to have it in the literature. Quality of care, with the least cost needed, is what we are striving to provide! Don’t we want this with anything we do on a daily basis?
I educate my patients all the time in regards to not only having the knowledge to treat you (or refer out if not acting mechanically) but also availability to care in terms of time-frame is more accessible (and quicker usually) coming to me first. I will include this data now to push more cost-efficient our services are compared to the typical gatekeeper route.
Physical therapy is growing and consumers are more aware of the benefits now vs anytime in the past. We are also improving out education and post-graduate work (OCS, Fellowships, etc) to advance our knowledge even more. It is our job as clinicians to do our part to provide these results to the public, one patient at at time if need be!
This study should also help the state levels make better decisions in terms of getting Direct Access for states who do not have it, but also improve the Direct Access time-frame (i.e. Virginia can only see for 14 business days).
New York Times gives a quick overview here of back pain including data on surgery failure and side effects of medication. Basically it goes back to simple exercise, being active and most will heal on its own. We should be there for the rest.
Allen Besselink here hereoffers great insight on back pain and benefits of Direct Access to treat it. I agree with every bit.
Clinical guidelines via Annals of Internal Medicine here herefor your source on what physicians are taught. Good for new therapists out there and even for your patients.
With many PT blogs putting this video on sites promoting Direct Access, I figured I would also share with this community. I see quite a few Direct Access patients and get excellent results. Just wish more patients knew about it and more therapists implement it… Share this with your colleagues.
Also, check out VPTA’s Virginian on page 9. There is a case report utilizing Ottawa Ankle Rules through Direct Access written by myself and co-authored by David Love, PT.
Click on picture below. Hope you enjoy and continue to promote Direct Access!
I have noted Direct Access in the past through prior posts and a high supporter of the move to autonomous practice. I feel this is the right direction for the profession not only for an acceptance as qualified clinicians by the medical field, but predominantly for the patients; whom, I feel, benefit significantly from our services that are currently limited.
This can be a long discussion and can veer down many paths, but I do want to hear from others mainly concerning the success of Direct Access (or even treatment as a whole) without imaging. Even though I, you and many others (here and here) know that imaging is over-utilized, it is limiting us as a profession due to everyone wanting to get either an x-ray or MRI.
I recently wrote a post on the loss of the clinical exam here with a high number of responses so I know this is a hot topic.
Is it a type of subconscious way of feeling better inside for the individual or is this the way it has always been and will it change?
If our profession wants to advance further with autonomous practice, is getting the ability to order imaging (other than PTs in the military whom have this capability) needed to stay with the pack?
Are you comfortable treating without imaging? How much of a mechanical response to our treatment is enough to be cleared?
What are you saying to your patients if you see them under Direct Access or even referral from a physician but have not had any imaging? Or, how long do you treat under Direct Access until you decide that you, yourself, needs imaging to cover anything missed?
I recently participated with the Virginia Physical Therapy Association’s annual conference last weekend. I always get the “in” when I go to one of the state’s conferences and learn some interesting facts. The one that caught my eye the most was the lack of involvement of physical therapists in Direct Access.
I do not know the numbers for the entire country but there are only 5% of all physical therapists in the state of Virginia using Direct Access. Don’t get me wrong, I know not everyone is in an environment where this is possible but I do know more than ~200 of the ~7000 therapists in the state work in a private practice or outpatient physical therapy clinic.
I personally use it quite often and mention it to all my patients at discharge to help spread the word. I do not do this to take away individuals from seeing their primary care physicians or promote that everyone needs to see us but instead to let the public be aware of the opportunity. There is not telling how many people are in pain out there who can benefit from our services. It is also time and cost saving as found here and here.
This is still a fairly new concept to physical therapists and the profession so it can be hesitant to jump on the bandwagon. There was a huge amount of lobbying through legislation required to obtain the law and its disappointing that it hasn’t seen a larger input from therapists. If you live in Virginia, you can check out all the details here. For others, you can access through your state site or through APTA.
If you do not participate with Direct Access, what are some of the reasons that you feel keep you away from it? Is it fear of missing a critical red flag? Is it apprehension of not being reimbursed? Or, is it just lack of knowledge concerning the law?
If you do participate with Direct Access, do you find it to be successful? Have you had any problems with reimbursement? What do your patients think of the service?