Research on preventative care?

[BiffTheFlashRogers]

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Sidenote: in previous threads I have had discussions regarding the challenges a PT would face seeking reimbursement for preventative care and performance training. For this thread, I'd like to request that discussions focuses on research. Thanks!

Does anyone know of any research looking at the effects of preventative physical therapy care or performance training for healthy individuals? I know the APTA is in favor of involving yearly musculoskeletal checkups for patients, and that some PTs working with athletes are becoming more involved with screenings and functional training for athletes.

To me it seems obvious that such interventions would be useful, but now I am on the hunt for research to support this. I had a discussion with a classmate who, like me, has expressed interest in dedicating time to working with people preventatively. However, my classmate had a recent meeting with a professor who basically said that there is zero evidence that supports preventative care for athletes or really any population for injury prevention or performance optimization, and essentially said to not waste our time with it.

That feels a little ridiculous to me, but I can't seem to find any research one way or the other on the subject. That being said, research isn't everything...thoughts?

 

[jesspt]

Sidenote: in previous threads I have had discussions regarding the challenges a PT would face seeking reimbursement for preventative care and performance training. For this thread, I'd like to request that discussions focuses on research. Thanks!

Does anyone know of any research looking at the effects of preventative physical therapy care or performance training for healthy individuals? I know the APTA is in favor of involving yearly musculoskeletal checkups for patients, and that some PTs working with athletes are becoming more involved with screenings and functional training for athletes.

To me it seems obvious that such interventions would be useful, but now I am on the hunt for research to support this. I had a discussion with a classmate who, like me, has expressed interest in dedicating time to working with people preventatively. However, my classmate had a recent meeting with a professor who basically said that there is zero evidence that supports preventative care for athletes or really any population for injury prevention or performance optimization, and essentially said to not waste our time with it.

That feels a little ridiculous to me, but I can't seem to find any research one way or the other on the subject. That being said, research isn't everything...thoughts?

Nope. Not everything. But a pretty important component of evidence-informed practice. I'd go so far to say that it's impossible to employ evidence-informed practice without .....evidence.

I agree with your professor for the most part.

 

[BiffTheFlashRogers]

I guess I phrased that horribly at the end, so I apologize for that. I recognize and understand the importance of using evidence in practice. The purpose of this post is to try to find research on this subject, which I am of course doing through other means but wanted to see if anybody on here knew of anything. At the very least, I am looking for discussion on the subject that is not centered around reimbursement challenges.

Much of PT, especially in outpatient practice where I plan on working after graduation, is based on the idea that by getting people stronger and optimizing their capacity for movement, we can decrease pain, decrease the likelihood for re-injury, and/or optimize function.

Besides challenges stemming from reimbursements from insurance companies, is there any reason why physical therapists could not apply these same principles to relatively healthy/currently symptom free individuals to decrease the likelihood of musculoskeletal injuries occurring and/or optimize function?

 

[BiffTheFlashRogers]

Adding some clarification to what I mean when I talk about preventative care/prehab/performance training, taken from a post I made elsewhere:

The APTA is pushing the idea of regular musculoskeletal "check-ups." Many people go see their GP once a year or go see their dentist once or twice per year to simply touch base and catch the early signs of medical/dental issues before they get out of hand. Wouldn't it make sense for PTs to offer the same sort of opportunity for patients, where they can come in for a general musculoskeletal screening? Patients can present concerns or minor issues that arose during the year for the PT to examine. Or, the PT can simply go through a typical full screening, looking for ROM or strength limitations and address them via therex prescription. Additionally, functional tests could be administered. For example, older adults who are at risk for falls can come in and have their balance assessed and based on the results be provided with therex ideas or encouraged to schedule regular PT visits if appropriate. There are really a ton of different directions that you could go with this. If this could become the norm (which is a lot easier said than done but it has to start somewhere), it could be huge for PTs, patients, and the healthcare industry. If we can catch problems early on and treat them conservatively, it would give us more patients, potentially save our patients pain and money and optimize their function, and save the healthcare industry money in the long term. Healthcare vs sick care.

Performance training would be similar. I'll frame it from my viewpoint as a runner. The vast, vast majority of runners (65-80%) report being injured during a given year. That is absurd, for an activity that should be fairly natural. Musculoskeletal injuries are tremendously common in all sorts of other athletes as well, obviously. Particularly on the recreational, but also on the high school and even collegiate level, people do not have an understanding of how to strength train, cross train, or how to perform basic body maintenance (stretching, recovery and the like) to become better all around athletes and optimize their performance and decrease their risk of injury.

At this point, many people I speak to jump in and ask why wouldn't these people just go to a personal trainer. From my viewpoint, and the viewpoint of one of my favorite professors, we as PTs should NOT pass these patients/clients on the personal trainers. Physical therapists are supposed to be THE MOVEMENT EXPERTS. Physical therapists should be the TOP OPTION for people looking to move better, get stronger, and be healthier. If you're like me and are working on earning or already have earned your CSCS, you're even further ahead of the game. Working with high level patients to optimize their function should be just as much in our wheelhouse as working with older adults to return them to functional activities! So, performance training could be as simple as patients coming in for a full PT eval and bring their concerns or past injury history up during the initial discussion. From there, the PT could again identify ROM or strength impairments and address them as appropriate. In my opinion, there is NO REASON why we as PTs should have to wait until people are injured before we get them moving better.

I hope that makes sense. Let me know your thoughts!

 

[DPT'17]

@BiffTheFlashRogers I appreciate your push to discuss research and more clinically applicable topics on this forum as I think it could be beneficial especially to us young clinicians in guiding our interpretation of current research.

I disagree with your professor and the poster above that there is no research regarding or supporting injury prevention interventions especially within athletic populations. I am finishing my last year of PT school but have previously worked as an ATC, CSCS and so I have been interested in the topic for a while. Unfortunately, I will agree that there is not a wealth of high quality research available on injury prevention efforts. I don't think that means we can't find any clinical utility or meaningfulness in the studies that have been performed, they just have to be interpreted with caution. The highest quality studies which have been performed in athletic populations typically concern dynamic warm-up programs or plyometrics within an exercise conditioning program and more common diagnoses like ACL sprains or MTSS. However, there are a variety of topics which have been examined for their effects on injury prevention including foam rolling, massage, ice immersion/cold therapy, stretching, balance training, the list goes on.

Below are a few review articles I was able to access again quickly from my bookmarks but let me know if you need additional help identifying resources. The references within those articles should serve as a decent starting point for identifying further studies.

Rössler R, Donath L, Verhagen E, Junge A, Schweizer T, Faude O. Exercise-based injury prevention in child and adolescent sport: a systematic review and meta-analysis. Sports Med. 2014;44(12):1733-48. https://www-ncbi-nlm-nih-gov.proxygw.wrlc.org/pubmed/25129698

Bizzini M, Dvorak J. FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide-a narrative review. Br J Sports Med. 2015;49(9):577-9. https://www-ncbi-nlm-nih-gov.proxygw.wrlc.org/pubmed/25878073

Yeung SS, Yeung EW, Gillespie LD. Interventions for preventing lower limb soft-tissue running injuries. Cochrane Database Syst Rev. 2011;(7):CD001256. https://www.ncbi.nlm.nih.gov/pubmed/21735382.

 

[BiffTheFlashRogers]

@BiffTheFlashRogers I appreciate your push to discuss research and more clinically applicable topics on this forum as I think it could be beneficial especially to us young clinicians in guiding our interpretation of current research.

I disagree with your professor and the poster above that there is no research regarding or supporting injury prevention interventions especially within athletic populations. I am finishing my last year of PT school but have previously worked as an ATC, CSCS and so I have been interested in the topic for a while. Unfortunately, I will agree that there is not a wealth of high quality research available on injury prevention efforts. I don't think that means we can't find any clinical utility or meaningfulness in the studies that have been performed, they just have to be interpreted with caution. The highest quality studies which have been performed in athletic populations typically concern dynamic warm-up programs or plyometrics within an exercise conditioning program and more common diagnoses like ACL sprains or MTSS. However, there are a variety of topics which have been examined for their effects on injury prevention including foam rolling, massage, ice immersion/cold therapy, stretching, balance training, the list goes on.

Below are a few review articles I was able to access again quickly from my bookmarks but let me know if you need additional help identifying resources. The references within those articles should serve as a decent starting point for identifying further studies.

Rössler R, Donath L, Verhagen E, Junge A, Schweizer T, Faude O. Exercise-based injury prevention in child and adolescent sport: a systematic review and meta-analysis. Sports Med. 2014;44(12):1733-48. https://www-ncbi-nlm-nih-gov.proxygw.wrlc.org/pubmed/25129698

Bizzini M, Dvorak J. FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide-a narrative review. Br J Sports Med. 2015;49(9):577-9. https://www-ncbi-nlm-nih-gov.proxygw.wrlc.org/pubmed/25878073

Yeung SS, Yeung EW, Gillespie LD. Interventions for preventing lower limb soft-tissue running injuries. Cochrane Database Syst Rev. 2011;(7):CD001256. https://www.ncbi.nlm.nih.gov/pubmed/21735382.

Thank you so much for your feedback and for providing the resources. I'll report back after diving into everything over the next few days.

 

[jesspt]

@BiffTheFlashRogers I appreciate your push to discuss research and more clinically applicable topics on this forum as I think it could be beneficial especially to us young clinicians in guiding our interpretation of current research.

I disagree with your professor and the poster above that there is no research regarding or supporting injury prevention interventions especially within athletic populations. I am finishing my last year of PT school but have previously worked as an ATC, CSCS and so I have been interested in the topic for a while. Unfortunately, I will agree that there is not a wealth of high quality research available on injury prevention efforts. I don't think that means we can't find any clinical utility or meaningfulness in the studies that have been performed, they just have to be interpreted with caution. The highest quality studies which have been performed in athletic populations typically concern dynamic warm-up programs or plyometrics within an exercise conditioning program and more common diagnoses like ACL sprains or MTSS. However, there are a variety of topics which have been examined for their effects on injury prevention including foam rolling, massage, ice immersion/cold therapy, stretching, balance training, the list goes on.

Below are a few review articles I was able to access again quickly from my bookmarks but let me know if you need additional help identifying resources. The references within those articles should serve as a decent starting point for identifying further studies.

Rössler R, Donath L, Verhagen E, Junge A, Schweizer T, Faude O. Exercise-based injury prevention in child and adolescent sport: a systematic review and meta-analysis. Sports Med. 2014;44(12):1733-48. https://www-ncbi-nlm-nih-gov.proxygw.wrlc.org/pubmed/25129698

Bizzini M, Dvorak J. FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide-a narrative review. Br J Sports Med. 2015;49(9):577-9. https://www-ncbi-nlm-nih-gov.proxygw.wrlc.org/pubmed/25878073

Yeung SS, Yeung EW, Gillespie LD. Interventions for preventing lower limb soft-tissue running injuries. Cochrane Database Syst Rev. 2011;(7):CD001256. https://www.ncbi.nlm.nih.gov/pubmed/21735382.

You're correct - there is good evidence on the preventative effects of the 11+ training program on ACL tears in soccer players. I'm not aware of any studies that have looked at its use outside of the young soccer player demographic, so one would need to determine if the results of the research are generalizable to their patient population.

Here's the conclusion statement of the last article you provided - "Overall, the evidence base for the effectiveness of interventions to reduce soft-tissue injury after intensive running is very weak, with few trials at low risk of bias. More well-designed and reported RCTs are needed that test interventions in recreational and competitive runners." I'm not sure that I could tell my patients who are marathon runners, in good conscience, that I can provide interventions that will help them prevent injury.

Here's the situation as I see it:
If you treat a lot of young soccer players, I think you can offer them a training program which will significantly reduce their risk of incurring an ACL tear.
If you treat NFL or Div. 1 American Football players, I think you have some data that indicates you can predict who is more likely to suffer an in-season injury.
The other research that I am aware of seems to be hot garbage for the most part, but, in full disclosure, injury prevention isn't a big focus of mine.
A PT could offer a product of either injury prevention, performance enhancement, etc. but at the moment, it is only a product and not an evidence supported treatment/intervention.

 

[jesspt]

Thank you so much for your feedback and for providing the resources. I'll report back after diving into everything over the next few days.

You may want to take a look at http://smsmf.org/ - they are a group that has done considerable work looking at injury prevention in sports and helped to develop the 11+ program.

 

[imagodei20]

Adding some clarification to what I mean when I talk about preventative care/prehab/performance training, taken from a post I made elsewhere:

The APTA is pushing the idea of regular musculoskeletal "check-ups." Many people go see their GP once a year or go see their dentist once or twice per year to simply touch base and catch the early signs of medical/dental issues before they get out of hand. Wouldn't it make sense for PTs to offer the same sort of opportunity for patients, where they can come in for a general musculoskeletal screening? Patients can present concerns or minor issues that arose during the year for the PT to examine. Or, the PT can simply go through a typical full screening, looking for ROM or strength limitations and address them via therex prescription. Additionally, functional tests could be administered. For example, older adults who are at risk for falls can come in and have their balance assessed and based on the results be provided with therex ideas or encouraged to schedule regular PT visits if appropriate. There are really a ton of different directions that you could go with this. If this could become the norm (which is a lot easier said than done but it has to start somewhere), it could be huge for PTs, patients, and the healthcare industry. If we can catch problems early on and treat them conservatively, it would give us more patients, potentially save our patients pain and money and optimize their function, and save the healthcare industry money in the long term. Healthcare vs sick care.

Performance training would be similar. I'll frame it from my viewpoint as a runner. The vast, vast majority of runners (65-80%) report being injured during a given year. That is absurd, for an activity that should be fairly natural. Musculoskeletal injuries are tremendously common in all sorts of other athletes as well, obviously. Particularly on the recreational, but also on the high school and even collegiate level, people do not have an understanding of how to strength train, cross train, or how to perform basic body maintenance (stretching, recovery and the like) to become better all around athletes and optimize their performance and decrease their risk of injury.

At this point, many people I speak to jump in and ask why wouldn't these people just go to a personal trainer. From my viewpoint, and the viewpoint of one of my favorite professors, we as PTs should NOT pass these patients/clients on the personal trainers. Physical therapists are supposed to be THE MOVEMENT EXPERTS. Physical therapists should be the TOP OPTION for people looking to move better, get stronger, and be healthier. If you're like me and are working on earning or already have earned your CSCS, you're even further ahead of the game. Working with high level patients to optimize their function should be just as much in our wheelhouse as working with older adults to return them to functional activities! So, performance training could be as simple as patients coming in for a full PT eval and bring their concerns or past injury history up during the initial discussion. From there, the PT could again identify ROM or strength impairments and address them as appropriate. In my opinion, there is NO REASON why we as PTs should have to wait until people are injured before we get them moving better.

I hope that makes sense. Let me know your thoughts!

Never stop doing what you are doing, I am applying to PT schools now but your vision for prehab is amazingly well thought out. I really really hope this becomes a yearly full body checkup/strength assessment/movement analysis, etc. No matter what archaic PT's tell you, I think you should fight for this 100% it is a game changing idea to me at least. Definitely the direction I want the field to go.

 

[jesspt]

Never stop doing what you are doing, I am applying to PT schools now but your vision for prehab is amazingly well thought out. I really really hope this becomes a yearly full body checkup/strength assessment/movement analysis, etc. No matter what archaic PT's tell you, I think you should fight for this 100% it is a game changing idea to me at least. Definitely the direction I want the field to go.

Well, I hope your admissions essay is phrased better than your post above.

If you're fortunate enough to get accepted you'll probably learn about appraising the evidence and letting it guide your practice, rather than to just "never stop doing what you are doing."

I am old and archaic. The evidence I use to support my care is not.

 

[Fiveoboy11]

Never stop doing what you are doing, I am applying to PT schools now but your vision for prehab is amazingly well thought out. I really really hope this becomes a yearly full body checkup/strength assessment/movement analysis, etc. No matter what archaic PT's tell you, I think you should fight for this 100% it is a game changing idea to me at least. Definitely the direction I want the field to go.

Will you please apply to chiropractic school instead?

 

[BiffTheFlashRogers]

Never stop doing what you are doing, I am applying to PT schools now but your vision for prehab is amazingly well thought out. I really really hope this becomes a yearly full body checkup/strength assessment/movement analysis, etc. No matter what archaic PT's tell you, I think you should fight for this 100% it is a game changing idea to me at least. Definitely the direction I want the field to go.

Thanks for the kind words, but at this point in time it is just a vision. I'm definitely going to put some work in on the idea, though. And word to the wise, be careful knocking experienced PTs, especially in broad strokes. There are many, many awesome experienced PTs out there, just like there are many not so great experienced PTs out there. Same goes for the range of quality amongst new grads. Experienced PTs aren't entirely close minded as a group. @jesspt shared a perfectly reasonable perspective.

@jesspt and @DPT'17 - I'm still working on reading through the information shared and will get back to you in detail hopefully within the next week.

Will you please apply to chiropractic school instead?

Play nice.


Side note: I'm currently working on designing a research study to investigate the efficacy of the system I initially posted about. If there isn't much research on a topic you want to learn about, might as well make the research yourself.

 

[imagodei20]

Well, I hope your admissions essay is phrased better than your post above.

If you're fortunate enough to get accepted you'll probably learn about appraising the evidence and letting it guide your practice, rather than to just "never stop doing what you are doing."

I am old and archaic. The evidence I use to support my care is not.

Yea, I spent a bit more than 30 seconds writing my admissions essay, fortunately, so no problems there! Thanks for the concern for my future Jess~ 😉