I believe every single PT student should do their first clinical rotation in an acute care setting. Here’s why: You see most everything a physical therapist does all in one setting:

• Orthopedics- if you work in a major hospital chances are you will work with a s/p joint replacement of some sort. Hips, knees, shoulders…you name it. It’s all there.
• Cardiopulmonary- CABG, Cath, AV valves, Respirators OH MY! You better know your sternal precautions.
• Geriatrics- Not everyone in the hospital is old, but the majority certainly are.
• Neuro- CVA, spinal cord stroke, GBS, SCI… It’s all here folks.
• Multidisciplinary learning- you are surrounded by Nurses, OT’s, Speech Pathologists, Respiratory Therapists, Dieticians, MD’s, any many other disciplines. Wonder what they all do? I’m sure your CI would love to let you spend half a day shadowing one of them.

I believe it is the perfect place to start on your first clinical because it will provide you with a nice foundation for the rest of school. You will learn patient care skills, bedside manor, and you will be able to understand where your patients are coming from. Unfortunately, this acute rotation is my last. It has been a nice summary of everything I have learned, but if I could do it all again I would most definitely choose acute care first. So, if you are wondering where you should go, find a hospital that will take you and make the most of it. I promise you will not regret it!

Written by: Jill Stein on February 15, 2011 (San Diego, California) for Medscape Medical News

A physical therapy program can effectively treat most patients who present with atraumatic full-thickness rotator cuff tears and shoulder pain, without the need for surgery, researchers announced here at the American Academy of Orthopaedic Surgeons (AAOS) 2011 Annual Meeting.

“If failure is defined as patients electing to undergo surgery, then our non-operative program is successful in over 90% of patients and the effect seems to last at least 2 years,” John E. Kuhn, MD, associate professor and chief of shoulder surgery at Vanderbilt University Medical Center in Nashville, Tennessee, and director of the Multicenter Orthopedic Outcomes Network (MOON) Shoulder Group, said.

In the United States, at least 10% of persons over age 60 years, or nearly 6 million people, will develop a rotator cuff tear.

To recognize this study, the AAOS will honor the MOON Shoulder Group with its Charles S. Neer II Clinical Science Award, which will be presented later this week on the association’s Shoulder and Elbow Specialty Day.

Prospective Cohort Study

The study included 396 patients age 18 to 100 years who had atraumatic full-thickness tears documented by magnetic resonance imaging and no other abnormality. The primary symptom was pain in most patients.

Patients were assigned to a physical therapy program that included daily postural exercises, active-assisted motion, active training of scapula muscles, and active range of motion, along with anterior and posterior shoulder stretching. They also performed thrice-weekly rotator cuff and scapula exercises. The program has been shown to be effective in patients with impingement syndrome.

Study participants also did manual mobilization exercises with assistance from a therapist.

Patients returned at 6 and 12 weeks. At this point they could decide that 1) treatment was successful and they needed no formal follow-up, 2) they had improved but would like to continue therapy with scheduled reassessment in 6 weeks, or 3) nonoperative treatment had failed and they would undergo arthroscopic rotator cuff repair.

Patients were contacted by telephone at 1 and 2 years to determine whether they had undergone surgery since their last visit.

Improvements on Multiple Outcome Measures

The analysis showed statistically significant improvement at 6 and 12 weeks for the American Shoulder and Elbow Society, Western Ontario Rotator Cuff Index, and Single Assessment Numerical Evaluation scores. P values for all measures were less than .0001 at 6 and at 12 weeks.

Six-week data indicate that fewer than 10% of patients had decided to undergo surgery.

Of patients in whom follow-up data were available for at least 2 years, only 2% had opted for surgery.

The analysis also revealed that patients who decided to undergo surgery generally made their decision within 6 to 12 weeks of starting physical therapy. In addition, patients did most of their physical therapy at home and usually made only 1 weekly visit to the physical therapist.

Dr. Kuhn said that important strengths of the study are its large size, the inclusion of patients from multiple practices nationwide, and its prospective cohort design. The results may be weakened somewhat by possible selection bias in that patients who were less likely to choose surgery were more likely to participate in a physical therapy program. Performance bias may also be a shortcoming, with some patients possibly receiving medications, acupuncture, or other pain-relieving treatments that were not examined, he added.

Finally, Dr. Kuhn emphasized that the physical therapy program alleviated pain without “doing anything to the tear.” The finding suggests that pain may be a less suitable indication for rotator cuff repair than is weakness or loss of function.

The hope is that future research will identify risk factors that can predict progression to rotator cuff tears and symptom onset and also which repaired tears are likely to fail, thereby helping surgeons decide better who is a good surgical candidate, he added.

This work was supported by the following: Arthrex Corporation Unrestricted Research Gift, NFL Charities — Medical Research Grant, National Institutes of Health grant no. 1K23 ARO5392-O1A1 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, AOSSM Career Development Award, and Pfizer-Scholars Grant in Clinical Epidemiology.

American Academy of Orthopaedic Surgeons (AAOS) 2011 Annual Meeting; Abstract #319. Presented February 15, 2011.

source [Medscape]

The National Institute of Neurological  Disorders and Stroke have given new light to the fact that patients who participate in intense physical therapy at home show the same amount of improvement compared to using expensive high tech body weight supported treadmill devices.

These researchers also demonstrate that these patients continue to improve walking ability up to a year following the initial stroke. This is yet another pat on the back for those of us in PT who work so hard with patients during the recovery. Neuroplasticity is a very slow and sometimes agonizing process for the therapist and patient. Read the full story

Another week is done up here in Canada, and boy did I learn a lot.

Let me begin by saying I love it here. I am enjoying treating patients and learning a ton along the way. One of my goals in coming here was to gain experience in manual therapy. I guess I got what I wished for because I saw about 12 shoulder patients, each of which required shoulder mobilizations, so I’m getting good practice at those.

My CI does a lot of acupuncture. In Canada, health care providers can do acupuncture as long as you get certified to do so. She is what you call a medical acupuncturist, which is different from other types of acupuncture. I have to admit, I was a bit skeptical…and I still am. We are trained to be evidence-based practitioners, and, it doesn’t seem that acupuncture is the most evidence supported treatment. One thing is for sure though, those needles seem to work, at least for most patients. Perhaps it is not hooey after all.

I also discovered this week the equivalent to medicare/medicaid here in Canada(as far as paperwork goes.) There are quite the forms that need to be filled out for Workers Compensation cases up here. It is all online, which makes it nice, but it is still time consuming for me, especially since I have limited experience filling them out. Also, motor vehicle accidents require special forms to fill out which take some time.  Otherwise, documentation is done on an 8×11 sheet of lined paper in the SOAP format, so I am getting good practice writing SOAP notes…something you just don’t really learn in the classroom.

On top of this all, we have been having fantastic weather here in southern Alberta. It is going to turn off cold next week, and I am looking forward to taking my kids trick-or-treating with costumes over their snowsuits.

See? Who wouldn’t want to live here?

A surgery is not always the best remedy in case of a knee ligament injury, reveals a novel study aimed at comparing the benefits of surgery and physical therapy in case of a knee injury.

An intense physical therapy proves as effective as a surgical operation for most of the people with a knee ligament breakage, which commonly affects athletes.

Trying rehabilitation can evade almost half of the operations done in order to repair a tear in the anterior cruciate ligament (ACL), which lies beneath the kneecap and attaches the thigh bone to the shin bone.

Treatment of “an acute ACL injury should start with structured rehabilitation rather than early ACL reconstruction,” Richard Frobell of Lund University in Sweden, whose study appears in the New England Journal of Medicine, said.

Around 200,000 ACL reconstructions worth billions of dollars are performed every year in the United States.

121 people studied

121 people aged between 18 to 35 years were studied by the researchers. None of the participants had ever been professional athletes.

After a period of 2 years, participants in the surgery group performed no better than those who received only physical therapy. Thus, without any compromise in the end results, surgery was evaded in 61 percent patients of the study group.

The participants were randomly given either a surgical treatment or rehabilitation.

However, 23 out of the 59 participants in the rehabilitation group also ended up with a surgery by the end of the study period.

Surgery group no better

After a period of two years, participants in the surgery group performed no better than those who received only physical therapy. Thus, without any compromise in the end results, surgery was evaded in 61 percent patients of the study group.

“It confirms what we have always intuitively thought and known, and that is that not all patients need their ACLs reconstructed and that the decision to perform an ACL reconstruction really needs to be individually tailored,” Levy said in a statement.

However, doctors need to be cautious as longer-term evaluations have shown that delayed ACL reconstruction in some people poses a risk of damaging other parts of the knee, and it was really hard to predict which patients will need surgery

“There’s solid evidence that people who have ACL tears and do not have reconstruction, if they go on to have frequent giving-way or instability episodes, they are at an increased risk of doing damage,” Levy said.

source [themoneytimes]

Current work with patients who have had a stroke tends to lean more toward the explicit side of motor learning. Basically giving the patient a series of directions to instruct them on how to perform a task. A recent research article from the Journal of Physical Therapy suggests a completely different approach.

The new direction that the research suggested was an implicit approach to task instructions. Simply put, you give the patient no instruction and let them figure it out in an error free environment. Implicit learning is not a new concept but it is a unique approach especially when working with patients that have decreased mental processing from a stroke. Read the full story

This is the third installment of a three part series dealing with the 3 phases of healing during soft tissue lesions. The first installment focused on guidelines for the acute phase of healing followed by a second installment focusing on the guidelines for the subacute stage of healing.

The Chronic stage of healing is the last step toward a completely healed scar over the area of the lesion and it is the stage where the scar begins to add tensile strength.

The Chronic Stage (maturation and remodeling) demonstrates no signs of an inflammatory response. Contractures may be present as well as possible areas of adhesion left over as a residual effect from the acute response. Muscle weakness may continue to exist in this stage which can limit function

Since the tissue is beginning to remodel it needs the appropriate stimulus to ensure it aligns properly with the line of force. Realignment and stimulus along with strengthening is the basis for the interventions during this phase of healing. Read the full story

I recently found this article in the New York Times. This article is a prime example why physical therapists need to always use evidence based practice. Our interventions should be grounded in research and as practitioners we should be ever vigilant in the pursuit to defend our profession. We should never use a treatment without knowing the physiological mechanisms behind it. Give use your opinion on this article and how the therapists can avoid getting slammed as “voodoo practitioners.”

I RECEIVED an e-mail message recently from an angry doctor. He’d torn his hamstring running on a beach and spent eight weeks — a total of 20 hours — in physical therapy. Then his insurer said the physical therapy was not covered.

He couldn’t understand it. The therapy cost $150 a session, and he said it was “clearly beneficial and cost-effective.” (He added, though, that after eight weeks he was not yet running again.)

Hmm. I also tore my hamstring running, but my doctor never mentioned physical therapy. Instead he referred me for platelet-rich plasma, an experimental treatment that involves having my own blood platelets injected into the torn tendon. The cost, including the radiologist’s fee, an ultrasound and the plasma injection, was $2,200.

My insurer would not pay, which made sense to me because the plasma treatment is considered experimental. It might work; then again, it might not.
Read the full story

Recovering stroke patients whose physical therapy regimen is built around Wii video games appear to improve better than patients treated with standard therapies, a new Canadian study reveals.

The finding suggests that the enormously popular virtual reality programs could move beyond fun and games into the serious business of physical rehabilitation.

“This is new technology that may potentially help patients with a stroke,” said study lead author Dr. Gustavo Saposnik, director of the Stroke Outcomes Research Unit at St. Michael’s Hospital at the University of Toronto, Canada. “We ran a pilot study to see whether this is doable, safe, and more effective than routine therapy,” he said. “And we found it was.”

The findings are scheduled for presentation Thursday at the international conference of the American Stroke Association in San Antonio, Texas.

The Wii gaming system — produced by Nintendo, which did not fund the study — allows players to physically interact in real-time with images displayed on TV screens through the use of wireless motion-detection remote controls.

To gauge the promise of a Wii-based rehabilitation program, Saposnik and his colleagues focused on 20 stroke survivors, average age 61, all of whom were recovering from mild to moderate ischemic (caused by vessel blockage) or hemorrhagic (bleeding) strokes.

The stroke survivors were randomly divided into two groups: one group assigned to standard recreational therapy for impaired arms, involving the playing of card games or the block-stacking game Jenga, and a second group assigned to Wii-based therapy, either playing virtual tennis or cooking virtually (through “Wii tennis” or “Wii Cooking Mama”).

The Wii-based therapy involved movements that mimic the arm strokes required in a tennis match or those needed for cutting potatoes, peeling onions, slicing meat and shredding cheese.

Both the recreational and Wii-based therapies were administered in eight 60-minute sessions spread over two weeks. Both regimens were launched within two months following stroke occurrence, and both were described by the researchers as “intensive.”

After two weeks, the Wii group showed greater improvements than the recreational group in the patients’ affected arms, as measured in terms of the speed and grip strength necessary for normal motor function. No evidence of safety risk was found among the Wii group.

“Basically, we found that Wii therapy produced a 30 percent better improvement than recreational therapy in the time it took for the Wii patients to execute a task, and in how well they were able to execute a task,” said Saposnik.

Saposnik said that if the apparent benefits of Wii therapy hold up to further scrutiny, the high-tech physical therapy approach could help address two paramount challenges patients face when embarking on a recovery program: time and access.

“Rehabilitation is time-consuming, which can translate into poor compliance,” he noted. “And it’s not always available to all patients, based on cost and insurance constraints. But the high-intensity, repetitive nature of Wii therapy seems to offer quick benefits, and it’s widely available. So this could prove to be very helpful.”

“However, this is just an initial step towards expanding our understanding of the potential benefit this kind of innovative, interactive approach in neuro-rehabilitation might have following a stroke,” Saposnik cautioned.

“A larger study should be completed before making recommendations,” he said. “And that is already under way.”

Dr. William Meehan, director of the Sports Concussion Clinic at Children’s Hospital Boston, said Saposnik’s early observation makes “a lot of sense.”

“In general terms, the use of computer programs with some sort of motor movement component has certainly already been shown to be of benefit in terms of helping patients regain balance control when dealing with a sports-related concussion,” he said. “So I think this whole rehabilitation approach has great promise.”

“And it is much more convenient than normal therapy, in that patients could perhaps do this kind of thing at home,” Meehan added. “But, I would say it will probably end up best being used to augment standard therapies, because you do always want an actual therapist to monitor patient progress.”

SOURCES: Gustavo Saposnik, M.D., M.Sc., director, Stroke Outcomes Research Unit, Li Ka Shing Knowledge Institute, St. Michael’s Hospital of the University of Toronto, Toronto, Canada; William Meehan, M.D., director, Sports Concussion Clinic, Division of Sports Medicine, Children’s Hospital Boston; American Stroke Association Conference, San Antonio, Texas, February 23-25, 2010
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