Wednesday, December 16, 2015

Mom and Dad ready to skip rehab?; bundled payments

This week's article published in the Philly papers about knee and hip replacements ....

discussed the trends in rehabilitation after a knee or hip replacement, highlighting decisions to bypass in-patient rehabilitation after the knee or hip is replaced, incorporating the use of technology, going home the day after surgery, bypassing in patient rehab and home care.
AlterG;  mixing technology and therapy to restore function.

Discussions focus on the seemingly healthy folks that elect knee and hip replacements, leaving out a segment including perhaps your Aunt or Uncle, Mom or Dad;  folks with other co-morbidity issues that limit recovery (some doctors say up to 60% of these patients have co-morbidity problems that may require patients to go to rehab units or get home care).

Facilitating these actions is the insurance industry, as Medicare has chosen to begin "bundled payments" for  an  "episode of care", paying one source  (hospitals or accountable care organizations) one payment to take care of the entire process (including surgery, anesthesia, diagnostic studies,  in patient rehab, home care, outpatient rehab, follow up visits to surgeon, etc).

This comes fresh off the news this spring from the Hospital of Special Surgery, citing in-patient rehab is as effective as going home after surgery:

If this is the case, then why not send home all patients the next day after a knee or hip replacement?

Over the years, I clearly see Physical Therapists involvement with total hips replacements has diminished, where now only occasional hip replacements need our services.  The largest role we now play is educating, either before or after surgery, and having frank discussions about joint conservation and functional expectations.  Surgeons and their staff in general spend a shorter period of time in this arena.   PTs are educators and enablers, helping you understand limitations and expected abilities after surgery, so a few weeks of strengthening and education make a huge difference.
Conversly, Knee replacements have a larger degree of difficulties, where outpatient Physical  Therapy can have meaningful difference.  Scar tissue buildup, inflammation, and pain in most cases can be resolved quicker with skilled Physical Therapists using their hands, modalities, and a multitude of specialty equipment.  Physical Therapist are designed by education to become educators and enablers, finding opportunities to help patients with joint pain to improve their lifestyles.  A seasoned Physical Therapist is empathetic enough to understand the patients expectations and goals, has time in their day to educate, and offers solutions to restore function and performance; skills no one else in the healthcare chain offers.

Interestingly, what motivates a patient to get the surgery is loss of motion, pain, of loss of quality of life, all areas Physical Therapist are experts in.

At PTW, we are proud that outpatient Physical Therapy offers evidence driven care to help restore motion, reduce pain, and to improve quality of life, to remain part of the post operative surgical management team.

The question to ask is bundled payment strategies to reduce costs right for the other 60% of our Moms, Dads, Aunts, or Uncles?

Friday, December 11, 2015

Strains and sprains with the Fall and Winter Sport Seasons

Fall and Winter sports season is upon us.

Mark Schoettle, Doctor of PT
Athletes return to school which means a return to sports such as football, soccer, field hockey, and volleyball, basketball, and indoor tract.  Given many of these athletes will play for multiple teams including school and club teams, these athletes are at risk for overuse injuries.

Each of the above sports involves explosive dynamic movements be it sprinting, cutting, jumping, etc. If the athlete is not properly conditioned these explosive movements can lead to muscle and/or ligament sprain/strains or worse tears. Some athletes avoid the injury bug; however some, like my younger self, become afflicted and spend time on the side-lines. A minor injury can be just that, minor, if appropriately managed or can become nagging and eventually interfere with competition including within team and against opponents.

This post will highlight a common injury sustained due to overuse, poor conditioning, and previous injury. Heidersheit and colleagues, 2010 reports that high school, collegiate, and professional athletes are increasingly prone to hamstring injuries due to the sprinting demands of most sports. All of the above sports involve periods of sprinting, which increases the prevalence of hamstring strains. They reports that hamstring injuries were second only to knee sprains from 1998-2007 in a NFL player poll. The average number of days side-lined ranged between 8-25 depending on location and severity.
The Hamstring is made up of three muscles: Semi-membranosus, semi-tendinosus, and the bicep’s femoris muscles. 

Signs and symptoms of a Hamstring injury include sudden onset of posterior thigh pain followed by extreme difficulty continuing the activity due to pain. Most hamstring strains occur when the muscles are maximally stretched during terminal swing which is just prior to foot strike during sprinting (Heidersheit et al. 2010). At this point the hamstring’s role is to decelerate the limb as it prepares to contact the surface.  The most affected of the hamstring muscles is the bicep’s femoris. Pain is typically reproduced from a combination of passive knee extension and hip flexion as well as painful against a resisted knee curl or hip extension with the knee straight. Tenderness to the muscle belly and possible bruising will also be observed. 

The most common strains are grade I and II which are most commonly treated with conservative care including most importantly physical therapy. Once a hamstring injury occurs the athlete is at greater risk for recurrent strains. This places upmost importance of rehabilitation through the three phases of injury. In phase one the limb swelling is managed through icing and edema massage. Walking is limited until pain-free and without a limp. Phase two involves restoring normal ROM with progression of sub-maximal to maximal strengthening especially eccentric strengthening. This helps with proper remodeling muscle fibers. Phase three, reinstituting sport specific activity, begins once normal strength is achieved (Heidersheit et al. 2010). To achieve return to sport safely and with less risk of re-injury the athlete should then undergo return to sport functional testing carried out by a trained professional such as a licensed physical therapist.

At PTW, we have board certified physical therapists that specialize in Orthopedics and Sport injury management. We utilize the highest evidence based screening and treatment tools to successfully diagnose and treat muscle strains regardless of type or severity. Our West Norriton and Glenside locations feature the technological advance of the Alter G, zero gravity treadmill, which can be used in all phases of rehab including normalizing walking patterns and return to full pain-free sprinting. Our Lansdale location features two therapeutic pools with the benefit of maximizing muscle recovery through a controlled aquatic environment. 

At PTW we strive to exceed expectations through quicker recovery times to return to competitive play!

Do not let nagging injuries force you to miss time or play at less than your best.  Set up a free consult or initial evaluation today to begin the road to recovery! Free Alter G trials are available upon request.

Bryan C. Heiderscheit, Marc A. Sherry, Amy Silder, Elizabeth S. Chumanov, Darryl G. Thelen. Hamstring Strain Injuries: Recommendations for Diagnosis, Rehabilitation, and Injury Prevention. J Orthop Sports Phys Ther. 2010;40(2):67-81


Marc is a graduate of Temple University’s Doctorate of Physical Therapy, and a staff Physical Therapist at our West Norriton location.gree to further specialize in the field.