Monday, September 25, 2017

A Better Way to Mobilize the Median Nerve

If you get good results from Neurodynamic Mobilizations, but perform the normal wrist or elbow oscillations, try these variations. You should treat and mobilize the entire neural container. The AIGS concept states that the site of tethered and sensitized peripheral nerve is not often the symptomatic site. Review that concept and much more with Butler's best text for clinicians The Sensitive Nervous System

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A Better Way to Mobilize the Median Nerve

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Sunday, September 24, 2017

The association between sleep quality, low back pain and disability: A prospective study in routine practice.

The objective of this study was to estimate the association between sleep quality (SQ) and improvements in low back pain (LBP) and disability, among patients treated for LBP in routine practice. This prospective cohort study included 461 subacute and chronic LBP patients treated in 11 specialized centres, 14 primary care centres and eight physical therapy practices across 12 Spanish regions. LBP, leg pain, disability, catastrophizing, depression and SQ were assessed through validated questionnaires upon recruitment and 3 months later. Logistic regression models were developed to assess: (1) the association between the baseline score for SQ and improvements in LBP and disability at 3 months, and (2) the association between improvement in SQ and improvements in LBP and disability during the follow-up period.

Seventy-three per cent of patients were subacute. Median scores at baseline were four points for both pain and disability, as assessed with a visual analog scale and the Roland-Morris Questionnaire, respectively. Regression models showed (OR [95% CI]) that baseline SQ was not associated with improvements in LBP (0.99 [0.94; 1.06]) or in disability (0.99 [0.93; 1.05]), although associations existed between ‘improvement in SQ’ and ‘improvement in LBP’ (4.34 [2.21; 8.51]), and ‘improvement in SQ’ and ‘improvement in disability’ (4.60 [2.29; 9.27]).

Improvement in SQ is associated with improvements in LBP and in disability at 3-month follow-up, suggesting that they may reflect or be influenced by common factors. However, baseline SQ does not predict improvements in pain or disability. In clinical practice, sleep quality, low back pain and disability are associated. However, sleep quality at baseline does not predict improvement in pain and disability.

Feeling stiffness in the back: a protective perceptual inference in chronic back pain

Does feeling back stiffness actually reflect having a stiff back? This research interrogates the long-held question of what informs our subjective experiences of bodily state. The authors propose a new hypothesis: feelings of back stiffness are a protective perceptual construct, rather than reflecting biomechanical properties of the back. This has far-reaching implications for treatment of pain/stiffness but also for our understanding of bodily feelings.

Over three experiements they challenge the prevailing view by showing that feeling stiff does not relate to objective spinal measures of stiffness and objective back stiffness does not differ between those who report feeling stiff and those who do not. Rather, those who report feeling stiff exhibit self-protective responses: they significantly overestimate force applied to their spine, yet are better at detecting changes in this force than those who do not report feeling stiff. This perceptual error can be manipulated: providing auditory input in synchrony to forces applied to the spine modulates prediction accuracy in both groups, without altering actual stiffness, demonstrating that feeling stiff is a multisensory perceptual inference consistent with protection.

Together, this presents a compelling argument against the prevailing view that feeling stiff is an isomorphic marker of the biomechanical characteristics of the back.

Facilitatory and inhibitory pain mechanisms are altered in patients with carpal tunnel syndrome

Preliminary evidence from studies using quantitative sensory testing suggests the presence of central mechanisms in patients with carpal tunnel syndrome (CTS) as apparent by widespread hyperalgesia. Hallmarks of central mechanisms after nerve injuries include nociceptive facilitation and reduced endogenous pain inhibition. Methods to study nociceptive facilitation in CTS so far have been limited to quantitative sensory testing and the integrity of endogenous inhibition remains unexamined. The aim of this study was therefore to investigate changes in facilitatory and inhibitory processing in patients with CTS by studying hypersensitivity following experimentally induced pain (facilitatory mechanisms) and the efficacy of conditioned pain modulation (CPM, inhibitory mechanisms). Twenty-five patients with mild to moderate CTS and 25 age and sex matched control participants without CTS were recruited. Increased pain facilitation was evaluated via injection of hypertonic saline into the upper trapezius. Altered pain inhibition through CPM was investigated through cold water immersion of the foot as the conditioning stimulus and pressure pain threshold over the thenar and hypothenar eminence bilaterally as the test stimulus.

The results demonstrated that patients with CTS showed a greater duration (p = 0.047), intensity (p = 0.044) and area (p = 0.012) of pain in response to experimentally induced pain in the upper trapezius and impaired CPM compared to the control participants (p = 0.006). Although typically considered to be driven by peripheral mechanisms, these findings indicate that CTS demonstrates characteristics of altered central processing with increased pain facilitation and reduced endogenous pain inhibition.

Saturday, September 23, 2017

Capitalizing on Cash-Pay: 5 Strategies for Out-of-Network Success

As reimbursements continue to decline, more and more physical therapists are looking outside the traditional third-payer reimbursement model to buoy their business and provide better care for their patients. But, forging an unfamiliar course can be challenging—if not outright daunting. Luckily, there are pioneers—like Jarod Carter, PT, DPT, MTC—who are already leading the way to out-of-network success. So, all we need to do is follow in their footsteps and heed their lessons learned. To that end, here are five strategies to help you capitalize on cash-pay:

1. Recognize the state of things.

Reimbursements have been declining steadily for a while now, and as a result, it’s becoming increasingly tough for healthcare professionals to provide quality care and earn enough money to make a profit. Plus, with the proliferation of high-deductible health plans, patients are financially responsible for a larger portion of the cost of their care—and many don’t fully understand this. Thus, providers are having to step in to educate patients about the specifics of their plans—something most would argue is the responsibility of the insurance carrier—in order to ensure payment from those patients. And patient collections can be difficult, especially if the education piece isn’t handled properly. Providers who are unable to collect patient payments—for any reason—run the risk of having to eat the patient’s portion of the cost, which many clinics simply can’t afford to do. In other words, playing the third-party payer game may no longer be a sustainable business option for many practices, which is why many providers are opting out.

2. Do your research.

In some regions, a 100% cash-based practice may not be possible, as the necessary demand does not exist. So, please do your research—and speak with a healthcare attorney in your area—before making any changes to your current business model. That being said, adopting a hybrid model—that is, remaining in-network with some insurance companies and opting out of others—or simply adding cash-pay wellness services to your repertoire can work almost anywhere. In fact, the rise of HDHPs has actually helped pave the way for this type of business structure, because patients are becoming accustomed to paying for at least some of their care out-of-pocket. In this way, the lines between patient and consumer are beginning to blur, so many patients are evaluating the value of the care they receive much more closely. Providers who can not only provide value, but also prove that value objectively via outcomes data, are in a particularly good position.

3. Explore your options.

You can certainly provide skilled physical therapy treatment to generate a cash-based revenue stream, but that’s far from your only option. In fact, I recommend you give some thought to what kinds of health and wellness services your clients really want—and will pay for. Here are some examples of cash-pay services to get you started:

  • Continuing education classes for PTs or physical trainers
  • Public classes (e.g., anatomy, nutrition, stretching, or injury prevention)
  • Fitness training (e.g., medically oriented gym memberships, yoga, cycling, or Pilates)
  • Alternative wellness (e.g., Reiki, Ayurveda, acupuncture, or traditional Chinese medicine)

And by no means do you need to be the one providing all these services yourself. In some scenarios, it may behoove you to partner with a non-therapy provider in order to better serve your patients and boost your bottom line. No matter what services you decide to offer, be sure you’re providing value that’s commensurate with what you’re charging.

4. Get the word out.

While physicians may not refer as many patients to out-of-network practices as in-network ones, it’s still crucial to retain those relationships and develop ones with new, non-physician referral sources at the same time. Ultimately, your referrers are placing their reputation in your hands when they send patients your way.  So, if you’re the best therapist for the job—and you have the data to back that up—you’ll see referrals, whether you’re in-network or not. Plus, now that direct access is available to some degree in all 50 states, you can market your services directly to patients and take on the role of a care coordinator—referring patients out to other providers and building relationships of reciprocity. When it comes to marketing strategies, be sure to cover all your bases: word-of-mouth, social media, and lead generation. You may even want to adopt a patient relationship management system that can help you engage and re-engage your patients.

5. Speak confidently about being out-of-network—and your pricing.

Prospective patients will inevitably ask whether you accept their insurance, and depending on their comfort level with out-of-network providers, they may hesitate to give you a shot. So, as Dr. Carter advises, don’t jump into the money conversation right off the bat. Instead, get your soon-to-be patients talking about their pain, injury, or condition and how it’s restricting their quality of life. From there, you’ll be able to discuss exactly how you can help—and how being out-of-network affords you the flexibility to really focus on providing them with the best possible care. Once you’ve connected in that way, you can broach the pricing discussion—confidently, because you already know your value, right?—and explain what it means to work with an out-of-network provider (i.e., patients may be able to request reimbursements from their insurance companies, and depending on the terms of a specific insurance plan, working with you may even cost those patients less than they’d pay to see an in-network provider). If you’re not the one handling these phone calls yourself, Dr. Carter recommends ensuring that your entire staff is so certain “of your value that they would be willing to pay for your services themselves.”

Dr. Carter and I recently hosted an entire webinar on this subject titled, “Cashing in on Private Pay: The PT’s Guide to Going Out-of-Network.” If you haven’t already listened to the recording, I recommend doing so here. You’ll learn even more about capitalizing on cash-pay, including how to:

  • Remain compliant with Medicare patients.
  • Price your services legally.
  • Maintain defensible documentation (yes, even cash-pay therapists need to do this).
  • Format invoices so your patients can request reimbursement from their insurance company.
  • Start a cash-pay clinic or transition an existing clinic.

As the healthcare landscape continues to evolve, there’s more opportunity in cash-pay than ever before. And taking advantage of that opportunity may just be your ticket to ensuring financial success in the long term—regardless of whatever additional changes come down the pike.

Effects of Femoral Rotational Taping on Dynamic Postural Stability in Female Patients With Patellofemoral Pain.

The aim of this study was to investigate the effects of femoral rotational taping on task performance, dynamic postural control, and pain during the Star Excursion Balance Test (SEBT) in patients with patellofemoral pain (PFP) compared to healthy controls. Twenty-four female participants (16 with PFP, 8 controls) took part in the study and were divided into a PFP and SEBT groups with no tapeing, sham taping or femoral rotational taping. The maximum anterior excursion distance, 3-dimensional hip and knee kinematics of the stance leg, and pain score (VAS) during SEBT were recorded. The coefficients of variance (CV) of kinematic data gathered from electromagnetic sensors on pelvis and femur were calculated to represent segmental stability.

When performing the SEBT in the anterior direction, application of femoral rotational taping increased maximum excursion distance (65.57% vs 66.15% leg length, P = 0.027), decreased hip adduction excursion (47.6 vs 32.1 degrees, P = 0.010), and pain (3.34 vs 2.38, P = 0.040) in the PFP group. Femoral rotational taping also improved the medial-lateral (7.1 vs 4.6, P = 0.015) and proximal-distal stability (7.5 vs 4.5, P = 0.020) of the pelvis, and medial-lateral stability (7.2 vs 6.1, P = 0.009) of the femur. The results support the use of femoral rotational taping for improving dynamic postural control and reducing pain during SEBT. Femoral rotational taping could be used in the management of young female patients with PFP.

Friday, September 22, 2017

Elite Distance Runners: A 45-Year Follow-Up.

The present longitudinal study assessed cardiorespiratory capacity and running economy of Olympic athletes over several decades to measure changes in fitness in an elite group during aging. Twenty-six male runners training for the 1968 Olympics were recruited. Heart rate, VO2max, ventilation, and running economy were measured in 1968, 1993, and 2013. In 2013, 22 of the original runners participated: three passed away between 1993 and 2013, and one declined to participate.

The mean (+/-SD) maximum heart rate (bpm) was 178+/-10.6 in 1968, 176+/-13.1 in 1993, and 168+/-16.4 in 2013 with a difference from the predicted maximum heart rates in 1968 and 2013 (both P<.001). The mean (+/-SD) VO2max (mL•min-1•kg-1) was 78+/-3.1 in 1968, 57+/-6.7 in 1993, and 42+/-8.9 in 2013. VO2max based on the original body weight (mL•min-1•kg-1) in 1993 and 2013 were 65+/-6.0 and 47+/-8.1, respectively, which were higher than the measured VO2max values at those times (both P<.001). VEmax (L•min-1) was 177+/-13.1 in 1968, 150+/-24.9 in 1993, and 118+/-22.5 in 2013; and declined at each time (all P<.001). The decline in VEmax predicted (P<.001) the decline in VO2max (R2 for 1993 = .500; R2 for 2013 = .567). Running economy (mL•kg-1•km-1) was 196+/-7.0 in 1968, 205+/-16.5 in 1993, and 240+/-27.0 in 2013; and was greater in 2013 than in 1993 and 1968 (both P<=.001).

The data suggested that higher initial fitness in younger years contributed to higher fitness with aging despite an expected age-related drop in fitness. Also, older adults could maintain high levels of cardiorespiratory fitness as they age. Expectations for fitness during aging should be more robust, especially since higher fitness could bolster quality of life.