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Physio findings - Intensive care

In our regular column on research that’s relevant to physiotherapists, Janet Wright looks at the latest clinical findings.

Early rehabilitation cuts costs and  improves outcomes

Starting physiotherapy in intensive care units (ICUs) saves money as well as helping patients make a better recovery, American researchers have reported.

Their new study shows it could save hospitals up to $3.7 million (£2.3 million) a year.

‘The evidence is growing that providing early physical and occupational therapy for intensive-care patients – even when they are on life support – leads to better outcomes,’ says senior author Dale M. Needham, a critical-care specialist at Johns Hopkins University School of Medicine in Baltimore.

Patients are stronger and more able to care for themselves when they are discharged.’

However, says Dr Needham, administrators in US hospitals have been slow to support early-rehab programmes because they were worried about the cost.

Physiotherapists and occupational therapists started an early-rehab programme in Johns Hopkins adult ICU in 2008, which cost the hospital $358,000.

But within a year, the average length of stay in intensive care had dropped from six-and-a-half to five days.

The same patients spent less time in the wards they moved on to, and left hospital earlier. From then on, the programme was saving Johns Hopkins more than $800,000 a year.   

The research team, from Johns Hopkins hospital and medical school, published data with records from the hospital’s own early-rehabilitation programme.

They created a financial model for adult ICUs of various sizes, covering different lengths of stay and ranging from conservative to best-case scenarios.

Of the 24 scenarios they developed, 20 showed that the early-start programmes saved money.

In the others, the cost was small compared with the ‘substantial’ improvement in patient outcomes, say the authors.

The financial projections, per year, ranged from a cost of $87,000 to savings of more than $3.7 million.

‘Our study shows that a relatively low investment up front can produce a significant overall reduction in the cost of hospital care for these patients,’ Dr Needham says. ‘Such programmes are an example of how we can save money and improve care at the same time.’
Lord RK et al. ICU Early physical rehabilitation programs Critical Care Medicine 2013; 1, doi:10.1097 CCM.0b0 13e3182711de2

Arthritis

Rub that chronic pain away
Putting anti-inflammatory products on a sore spot is known to relieve pain. But although many people with chronic musculoskeletal conditions such as arthritis use these products – topical non-steroidal anti-inflammatory drugs (NSAIDs) – there is little guidance about their safety or efficacy in long-term use.  

‘One of the problems has been that older clinical studies were generally short, lasting four weeks or less, and short-duration studies are not regarded as adequate in ongoing painful conditions,’ say the authors of a Cochrane review.

Sheena Derry of the University of Oxford and colleagues reviewed 34 randomised double-blind trials with 7688 participants.

All the trials tested NSAIDs in the form of cream, gel, solution or patch against oral drugs or a placebo, or both.

The trials had at least 10 people in each treatment arm and lasted two to 10 weeks.

‘Topical NSAIDs can provide good levels of pain relief,’ the authors conclude.

As NSAIDs are more commonly taken by mouth, the team also compared oral and topical drugs for side effects.

They found the topical NSAIDs as helpful as oral drugs, and both were significantly more effective than placebo.

But while oral drugs can cause gastrointestinal side effects, the topical versions caused no more than placebo.

Topical diclofenac was particularly effective for hand and knee arthritis. Topical NSAIDs caused more local side effects, said the team, but these were mainly mild skin reactions.
Derry S et al. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database of Systematic Reviews 2012; doi:10.1002/14651858.CD007400.pub2

Back pain

Don’t change the disc yet
Disc replacement can ease the chronic lower-back pain caused by disc degeneration.

But a new report from the Cochrane Collaboration suggests that the improvements, though statistically significant, may not as yet outweigh the risks.

Researchers did a systematic literature review and found seven randomised controlled trials comparing total disc replacement with other interventions (usually fusion surgery), and following patients for two years afterwards.

‘Total disc replacement seems to be effective in treating low back pain in selected patients, and in the short term is at least equivalent to fusion surgery,’ say the authors.

However, they add, the studies didn’t assess related factors, such as degeneration of facet joints or neighbouring discs.

‘We think that harm and complications may occur after some years,’ the authors conclude, warning against bringing this operation into widespread use yet.
Jacobs WCH et al. Total disc replacement for chronic discogenic low back pain: A Cochrane review.
Spine 2013; 38, 24-36, doi:10.1097/BRS.0b013e31 82741b21

Comments & Conclusions

Exercise, sleep and mindfulness training can work with drug treatment to alleviate generalised anxiety disorder, which is common but is often overlooked in primary care and can lead to major depression, say researchers.
Hoge EA et al. BMJ 2012; 345, doi:10.1136/bmj.e7500

Learning weight-maintenance skills such as self-regulatory habits before going on a diet can help keep weight off, a study of 267 obese middle-aged women has found.

Those who followed a ‘stability skills’ course before dieting lost the same amount of weight as those who did the diet before the course – but regained much less weight during the following year.
Kiernan M et al. Journal of Consulting and Clinical Psychology 2012; doi:10.1037/a0030544

Three hours a week of bone-building sport (on foot and at high intensity, such as football or netball) reduces teenagers’ risk of osteoporosis in later life, say researchers.
Gracia-Marco L et al. BMC Public Health 2012; 12: 971, doi:10.1186/1471-2458-12-971

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