1. 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

2. 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.

3. 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

4. PTNow in a Nutshell

5. 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 Community- dwelling 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!

6. Applying Evidence in Best Practice Begins With Understanding the Value of Various Tests and Measures

7. 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.

8. 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?

9. 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

10. 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

11. 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.

12. 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.

13. 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 TestThompson Test

15. 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 Link to video So if this test is negative, does the patient have a rupture? Not Likely! So is this a good test for screening for Achilles Tendon rupture?

16. 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.

18. 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 18

19. Intervention*

20. Intervention

21. 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. 21

22. 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, mid- substance 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. 22

23. Total Knee Arthroplasty

25. Clinical Implications of PCL Sacrificing: Posterior tibial translation or anterior femoral translation engage the cam and post mechanism.

28. Is Your Patient’s Rehab on Track?

29. Your patient is asking if they can return to… Doubles Tennis? Basketball? …after discharge from rehabilitation

30. 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….

31. Can You Learn Something New… N=9 Can you take it with you?

32. Fall Risk in the Elderly

33. Who Should Be Screened for Fall Risk? http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html

34. Fall Risk Factors 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) 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 Arthritis Diabetes Pain Fall Risk: 8% risk for 1 factor; 78% risk for 4 or more factors

35. Strength Assessment: Major Muscle Groups Chair Rise Test or other functional LE test 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 Mobility: Walking speed <1.0m/s= Risk MDC.1m/s and.2 m/s including health status

36. 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.

39. Otago Home Prevention Program

42. PTNow helps answer your questions!

43. How have you used PTNow?