Transcript Document

Using PTNow at the Point of Care:
How Can PTNow Help Translate
Clinical Practice Guidelines, Tests,
and Validated Outcome Measures
for Busy Clinicians?
Tara Jo Manal, PT, DPT, OCS, SCS, Paul Mintken PT,
DPT, OCS, FAAOMPT
Jette (2003)
• 488 APTA members most agreed
– evidence-based practice was necessary,
– that literature was helpful in their practices and
– the quality of patient care was better when evidence was used,
• BUT
– 17% read fewer than 2 articles per month and
– 25% stated they use literature in their clinical decision making less than
twice per month.2
• FURTHER
– PTs reported decreased confidence in literature search and appraisal
skills and
– lack of time to use evidence in practice.2
• SO
– Translating evidence into practice is vital to improve patient outcomes
and decrease discrepancies in health care.
Multi-Tool for Practitioners
• Translation tool
Translating research to practice
• Implementation tool
Helping clinicians apply evidence in
patient care
• Collaboration tool
Discuss evidence and share strategies
when evidence is lacking
PTNow in a Nutshell
Clinical Summaries
– Achilles Tendinitis
– ACL Injury
– Benign Paroxysmal Positional
Vertigo (BPPV)
– Cerebral Palsy
– Chronic Obstructive
Pulmonary Disease (COPD)
– Critical Illness: Managing
Patients in the ICU
– Down Syndrome
– Fall Risk in Communitydwelling Elderly
– Muscular Dystrophy:
Duchenne and Becker
– Parkinson Disease
– Spinal Cord Injury
– Total Knee Arthroplasty
• Coming Soon:
– Asthma
– Multiple Sclerosis
– Mobility Impairments in
Dementia
– Urinary Incontinence
• Coming in 2015
– Concussion
– Ankle Sprains
– Breast Cancer/Lymphedema
– Spinal Cord Injury
– More!
Applying Evidence in Best
Practice Begins With
Understanding the Value of
Various Tests and Measures
Why Do I Choose a Measure in My
Clinical Practice?
• To help me, as a clinician, see the effect of my
treatment
– Am I getting the results I should?
– Am I clinically effective?
• How do I compare with what’s been published?
– I want to monitor and review progress in an
objective manner.
– I want to use a measure to help motivate my
patient.
What Makes a Good Test/Measure?
• A test must be reliable within and between testers,
and give the same result at different times
• Each time a test/measure is performed we must
understand how the results of the test compare
with the truth.
• This is determined by comparing the test results
with a measure of the truth.
• So—how do we do this?
Standard Error of Measurement
• Describes the range (+/-) within which a
patient’s true score might fit within a given
test.
• Example:
– SEM for knee flexion goniometry is 3.5
degrees
– Measured range is 120 degrees
– The variation of the true/actual ROM would be
between 116.5 and 123.5 degrees
Differences
• Minimal Clinically Important Difference (MCID)
– The smallest change in scores that patients perceive as
important
– Similar to the concept of CLINICAL SIGNIFICANCE
• Minimal Detectable Change (MDC)
– Commonly expressed as MDC90 or MDC95
– An index of the reliability of an outcome measure
– Similar to the concept of STATISTICAL SIGNIFICANCE
• MDC90: Minimum change at 90% confidence
– The amount of change in scores required to be 90%
confident that it is beyond measurement error
Responsiveness
• Does the outcome detect changes over time that matter
to the patient?
• Ability of outcome to detect small, but clinically
important differences
• Ceiling & Floor Effects
– Ceiling: When the task is too easy, and all patients
perform at or near perfect, you have a ceiling effect.
– Floor: When the task is too hard and everyone
performs at the worst possible level.
EXAMPLE: Achilles Tendinopathy
Your patient is a 26-year-old
male who was running and
heard/felt a “pop” in his left
Achilles tendon 3 days ago. He
has been able to walk on it with
a pronounced limp. There is
substantial swelling and
discoloration in the posterior
heel.
What is the “likelihood” this patient
ruptured the Achilles tendon?
Let’s go to PTNow:
• Clinical tools
• Search by practice
area
• Search by body
part
• Search by ICF
domain
– Thompson Test
Thompson Test
• In a retrospective study of 174 patients over 13
years with unilateral tears in which surgery was the
reference or “gold” standard
–
–
–
–
Sensitivity: 0.96
Specificity: 0.98
+LR=48.00
-LR=0.04
So is this a good test for screening
for Achilles Tendon rupture?
• Link to video
• So if this test is negative, does the patient have a
rupture? Not Likely!
Next Question:
Does this patient have Achilles tendinopathy?
Let’s go to PTNow:
• Clinical summary
• Achilles tendinopathy
• Search clinical tools
– Achilles Tendon
Palpation
– Arc Sign
– Royal London Test
Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB. Clinical diagnosis
of Achilles tendinopathy with tendinosis. Clin J Sport Med. 2003;13:11-15.
Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB. Clinical diagnosis of Achilles tendinopathy with tendinosis. Clin J Sport Med.
2003;13:11-15.
Examination & Diagnosis*
• Moderate evidence supports use of a group of signs
–
–
–
–
Achilles tendon palpation test
Decreased PF strength and endurance
Arc sign
Royal London Hospital test
• Strong evidence to incorporate validated functional
outcome measures before and after intervention
– Victorian Institute of Sport Assessment (VISA-A)
– The Foot and Ankle Ability Measure (FAAM)
• Moderate evidence to analyze walking ability, stair
decent, unilateral heel raise, single limb hop, and
participation in recreational activities
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Intervention*
Intervention
Prognosis
• Conservative care 6 to 12 weeks duration: significant
decreases in pain with the maintenance of long-term
function without reinjury.
• Prognosis in the more sedentary population is not as
encouraging.
• Conservative management may be unsuccessful in as
much as 24% to 49% of patients.
• Surgery (eg, excision of fibrotic adhesions, removal of
degenerated nodules, longitudinal incisions to restore
vascularity) is a favorable option after 4 to 6 months of
failed conservative measures.
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Medical Management
•
Extracorporeal Shockwave Therapy (ESWT): A series of 2 or 3 high-energy pulses
per second to promote healing through neovascularization. Research on
effectiveness limited and conflicting. ESWT is not FDA-approved for this purpose.
•
Local Corticosteroid Injection: Used to decrease acute inflammation, pain, and
promote function and activity. May decrease tensile strength.
•
Sclerosing Injection (Polidocanol): Used to manage the more chronic, midsubstance form of Achilles tendinopathy, especially when less invasive strategies
have failed; decreases pain via the analgesic effects of the medication and reducing
high-flow areas within the tendon.
•
Oral Nonsteroidal Anti-inflammatory Drugs (NSAIDs): Used as an adjunct to other
treatments to control pain and inflammation. Side effects are common. Should be
used with consideration of comorbidities, especially in the older population.
•
Surgical Intervention: Percutaneous tenotomy and open removal of the tendon
pathology. Used when conservative management fails and functional decline
continues. Prognosis based on the extent of remaining tendon structure. If condition
progresses to the point of tendon rupture, primary Achilles tendon repair is
performed.
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Total Knee Arthroplasty
Clinical Implications of PCL Sacrificing: Posterior tibial translation or
anterior femoral translation engage the cam and post mechanism.
Is Your Patient’s Rehab on Track?
Your patient is asking if they can return to…
Doubles Tennis? Basketball?
…after discharge from rehabilitation
A patient comes in 3 years after TKA and is
complaining of instability and pain in the knee….
Your patient had a revision TKA, they seem to be
lagging behind your typical milestones….
Can You Learn Something New…
Percent of New Information
100
50
0
Surgical
Procedure
Post Op
Complications
Can you take it with you?
Activity Exam
Tennis after
discharge?
N=9
Fall Risk in the Elderly
Who Should Be Screened for Fall Risk?
http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html
Fall Risk Factors
• Depression
• Dizziness or orthostatic
hypotension
• Functional limitations or
limitations in activities of daily
living (ADL)
• Disabilities
• Age >80 years old
• Female
• Low body mass index
• Urinary incontinence
• Cognitive impairment
Fall Risk: 8% risk for 1 factor; • Arthritis
78% risk for 4 or more factors • Diabetes
• Pain
• Previous falls (RR=1.9–6.6)
• Balance impairments
(RR=1.2–2.4)
• Decreased muscle strength
(RR=2.2–2.6)
• Vision impairment
(RR=1.5–2.3)
• >4 medications or
psychoactive medications
(RR=1.1–2.4)
• Gait impairment (RR=1.2–2.2)
Strength Assessment:
Major Muscle Groups
Chair Rise Test or other
functional LE test
Mobility:
•
•
•
Walking speed
<1.0m/s= Risk
MDC .1m/s and .2 m/s
including health status
Functional Tests for Balance
•
Single-leg stance. People who
cannot stand on 1 foot for at
least 5 seconds are at
significantly greater risk of
injurious falls than those who
can stand for longer than 5
seconds.
•
Timed chair rise. The inability
to perform the chair rise test
more than doubles the risk of
falling in high-risk older adults.
•
30-second chair rise. The
number of sit-to-stand rises
performed in 30 seconds.
People should be able to
perform above the cutoff for their
age and gender.
Otago Home Prevention Program
PTNow helps answer your
questions!
How have you used
PTNow?