Choose Wisely

In this month’s edition of JOSPT the APTA published their “Top Five Choosing Wisely” recommendations. Apparently, releasing a top 5 choosing wisely recommendation is a new trend with over 60 medical related societies and 15 consumer related groups producing these lists. For example :
American Academy of Orthopaedic Surgeons:

  • Avoid performing routine post-operative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty.
  • Don’t use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief
  • Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.
  • Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.
  • Don’t use post-operative splinting of the wrist after carpal tunnel release for long-term relief.

American Academy of Physical Medicine and Rehabilitation

  • Don’t order repeat epidural steroid injections without evaluating the individual’s response to previous injections.choose-1-red-pill-or-blue-pill.preview
  • Don’t order an EMG for low back pain unless there is leg pain or sciatica.
  • Don’t prescribe bed rest for acute localized back pain without completing an evaluation.
  • Don’t order an imaging study for back pain without performing a thorough physical examination.
  • Don’t prescribe opiates in acute disabling low back pain before evaluation and a trial of other alternatives is considered.

American College of Occupational and Environmental Medicine

  • Don’t prescribe opioids for treatment of chronic or acute pain for workers who perform safety-sensitive jobs such as operating motor vehicles, forklifts, cranes or other heavy equipment.
  • Don’t initially obtain X-rays for injured workers with acute non-specific low back pain.
  • Don’t order low back X-rays as part of a routine preplacement medical examination.
  • Don’t routinely order X-ray for diagnosis of plantar fasciitis/heel pain in employees who stand or walk at work.
  • Don’t routinely order sleep studies (polysomnogram) to screen for/diagnose sleep disorders in workers suffering from chronic fatigue/insomnia.

The JOSPT article describes a 6 step (rounds) process that was used to create the list. Essentially a group of experts used consensus and evidence to narrow the list down to 9 items. Those 9 items were then sent out to APTA members and they were asked to vote for their top 5. I think all 9 of these are important so I included them below.

Votes %
Don’t use passive physical agents except when necessary to facilitate participation in an active treatment program.  1770 72.7
Don’t routinely prescribe underdosed strength training programs for older adults. Instead, match the frequency, intensity, and duration of exercise to the individual’s abilities and goals 1695 69.7
Don’t recommend bed rest following diagnosis of acute deep vein thrombosis (DVT) after the initiation of anticoagulation therapy unless significant medical concerns are present.  1371 56.4
Don’t use continuous passive motion machines for thepostoperative management of patients following uncomplicated total knee replacement.  1295 53.2
Don’t use whirlpool for wound management. 1197 49.2
Don’t use overhead pulleys in the treatment of hemiplegic upper extremities after stroke unless care is taken to ensure appropriate patient shoulder girdle alignment and function during the treatment 1193 49
Don’t use ultrasound to reduce swelling, promote joint healing, or achieve long-term pain relief for musculoskeletal conditions 1114 45.8
Don’t prescribe exercise or progressive physical activity regimens to patients without monitoring heart rate and blood pressure 958 39.4
Don’t useHomans sign to evaluate patients suspected of deep vein thrombosis (DVT).  817 33.6

As a profession we often get caught up in new fancy trends like dry needling, ASTM, Kineseo tape yet we don’t even do the basics well. Imagine how much better our profession would be if we could get all PTs to follow these top 5 (or all 9) comments. Even just the first 2 would make a huge difference in our profession.

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  • In conversation with my Physical Therapy colleagues discussing the recommendations, I am disappointed in some of their response. They complain and abdicate the responsibility saying “Physical Therapist are not responsible for managing deep vein thrombosis; Physical Therapist are not responsible for ordering use of continuous passive motion machines; Physical Therapist are not responsible for ordering whirlpool for wound management”. Apparently, their mind-set continues to be we follow orders of Physician, and their attitude is far from seeking autonomous practice.
    The price of greatness is responsibility – Winston Churchill.

    Damien Howell January 7, 2015 6:30 pm Reply
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