Saturday, March 14, 2015

Don't worry, therapists...

I was doing a series of talks- on stroke recovery, natch- in Georgia last week. Someone brought up a concern about my talk that I also heard last time I did a series of talks. Here's a paraphrasing of that concern:

"You're saying that a lot of what we do in the clinic is shown to be ineffective in research. Payers (insurance/Medicare/Medicaid) are going to hear about this and then... I'm afraid we're going to get paid less and have fewer treatment options."

And I laughed. On the inside because out loud would have been rude. But: How silly! To think that insurance companies are listening to researchers about what is and is not effective! Insurance cares about shareholders and Medi"care" cares about keeping costs as low as possible. One thing they care little about: the science.

Therapists, fret not. Things that research indicates are ineffective are still paid for. Consider splinting. These are the rigid pieces of plastic that keep a joint in a certain position.  They are believed to reduce muscle shortening in patients that posture in a flexed potion.

So people like this:
Get one of these...


Governmental clinical guidelines suggest splints don't work, and may make things worse. Its usually stated like this....
For stroke survivors at risk of or who have developed contractures and are undergoing comprehensive rehabilitation, the routine use of splints or prolonged positioning of muscles in a lengthened position is NOT recommended.

Is splinting paid for. Let's put it this way.
So relax therapists. Don't worry, they're not listening to researchers!

And not only will they pay for stuff that does not seem to work, they won't pay for stuff that does work yay!

Take constraint induced therapy (CIT). We've known for a while that is particularly effective for some stroke survivors. In fact, CIT shows up on every set of clinical guidelines in the English speaking world. Here for example, are the clinical guidelines for OT in Australia. Open it, and search (Ctrl+F) for the word "constraint."

Is CIT paid for? No. There is not even a "code" for it (a code is the numbers used to bill for a particular treatment). 
"stroke recovery expert"

8 comments:

Rebecca Dutton said...

If researchers would study the effect of resting splints on pain I think they would find different result. See my post "Are Resting Splints a Waste of Money?" http://homeafterstroke.blogspot.com/2014/05/are-resting-hand-splints-waste-of-money.html

Peter G Levine said...

Pain has been looked at and you may be right! If you need the reference, let me know. In the meantime, this is what the research suggests...

Hand splinting does not improve motor function or reduce contractures in the upper extremity

Hand splints do not reduce spasticity nor prevent contracture.

There is strong (Level 1a) evidence that hand splinting does not improve impairment or reduce disability.

All this, however, does not mean your experience is not contrary.

Rebecca Dutton said...

Do you know of any research on the SaeboStretch resting splint? I have been using one for years and swear by it. The splint is designed to bend when high muscle tone kicks in This helps my wrist flexors relax so the splint can return to its original position.

Peter G Levine said...

I'll bet a million there are no studies. Contact saebo to make sure. But I think that the 'flex is the nextgen of splinting. My entry was about rigid splints. Thanks for your input, RD!

John Short said...

When I stretch or lie down my fingers become completely stretched. I must be lucky. spasticity only kicks in after I stand up and do stuff.

Elizabeth, John, Jack, and Luke said...

I wish we could just move towards an entirely cash pay system. Patients would pay for therapy that actually works...I bet it would more affordable with better outcomes!

anonymous said...

I found the reference on google scholar, but they want $54 to access the study for 24 hours! My husband has a Neuro-IFRAH rigid arm and hand brace that he's supposed to wear for 6 hours/day per his OT. It does not appear to improve motor function nor to reduce contractures. However, it's difficult to question these therapists or explain a rationale for doing something different without referencing the research.

Peter G Levine said...

Hi Anonymous,

You may be over thinking the debate. Where does all quality peer reviewed research end up? PubMed. What does it say when you put Neuro-IFRAH in the search box? "No items found." If you simply want to find free research that concludes when ALL the research is evaluated, splints do little, email me and I'll help you out!

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