Becca Bartlett Spt, Sarah Berkshire Spt, Deming Haugland Spt, Evan Martina Spt, Ashlee Mcmicken Spt, Nicole Reyes Spt, Susan Scherer, Pt, Phd

Becca Bartlett SPT, Sarah Berkshire SPT, Deming Haugland SPT, Evan Martina SPT, Ashlee McMicken SPT, Nicole Reyes SPT, Susan Scherer, PT, PhD

Purpose To assess the prevalence of comorbid conditions

and cardiovascular risk status in physical therapy practice Analyze the effect of cardiovascular risk status and comorbid conditions on specific physical therapy outcomes To classify patients within the American College of Sports Medicine (ACSM) cardiovascular risk strata

Overview What is a comorbidity? Why are comorbid conditions important to physical

therapists in the clinical setting? V de Groot, 2003

Physical therapists are not using cardiovascular risk

status in the clinic 2005

Scherer, Noteboom, Flynn

ACSM Risk Stratification Positive Risk Factors Age, Family History, Cigarette Smoking, Hypertension, Obesity, Sedentary Lifestyle Negative Risk Factors High Serum HDL Cholesterol Level

Major Signs and Symptoms

ACSM, 2005

ACSM Cardiovascular Risk Strata  Low Risk

 Male ≤ 44 years of age; female ≤ 54 years of age  Asymptomatic  No more than one risk factor

 Moderate Risk

 Male ≥ 45 years of age; female ≥ 55 years of age  And/or two or more risk factors

 High Risk

 One or more signs/symptoms  Known cardiovascular, pulmonary or metabolic disease

ACSM, 2005

Hypotheses The majority of patients receiving physical

therapy would be classified into either the moderate or high cardiovascular risk stratification

High cardiovascular risk status is associated with

poor physical therapy outcomes

Comorbid Conditions: Hypertension and Smoking  Hypertension  Diagnosis: blood pressure ≥ 140/90 mmHg  Prevalence: 24% of the adult population in the United States  Effect on physical therapy outcomes

Burt, 2001 Duncan, 2003  Smoking  Prevalence

52.4 million Americans consume 800 billion cigarettes annually Brodke, 2004  Effect on physical therapy outcomes 

Comorbid Conditions: Obesity and Physical Activity  Obesity  Disease classified using Body Mass Index (BMI)  Prevalence

31% of Americans are obese ACSM, 2005  Effect on physical therapy outcomes Han, 1997 Felix, 2005  Physical Activity  Surgeon General Definition  Prevalence  Effect on physical therapy outcomes Conn, 2008 

Comorbid Conditions: Cardiovascular Disease Cardiovascular Disease (CVD) Disease Prevalence 

1 in 4 Americans have CVD American Heart Association

Effect on physical therapy outcomes

Fried, 2004 Kauppila, 2009

Comorbidity Minimum Data Set Comorbidities: ____/___ BP  Student/CI Measured  Patient Report _____ Height _____ Weight  Student/CI Measured  Patient Report Smoker:  Current  Past  Never Physical Activity:  Meets  Does not meet CVD (Patient/Family History)  CV Meds (including BP Meds) DM (Patient/Family History)  DM Meds Pulm Disease (Patient/Family History)  Pulm Disease Meds Meds for: Each group put your own meds here that you are wanting. No Comorbidities Reported  Other Conditions:

Implementation Data Collection Phase One- 20% usable data Phase Two- 75% usable data Measurement of Comorbidities Hypertension 

Brachial Blood Pressure (BP)

Smoking 

Patient Report

Obesity 

Body Mass Index (BMI)

Methods- Defining Success

Demographics table NonTraumatic knee n=39 Gender -Male -Female Obesity -Normal -Overweight -Obese Smoking -Non -Current Physical Activity -Meets -Does Not Meet Hypertension -Yes -No

Post-op ACL Post-op Shoulder

Shoulder

LBP

Foot and Ankle

n=12

n=33

n=103

n=44

n=13

Significance

.532 48.72% 48.72%

41.67% 58.33%

69.23% 30.77%

54.55% 45.45%

51.46% 47.57%

40.91% 59.09% .266

46.15% 30.77% 15.38%

33.33% 33.33% 0.00%

30.77% 38.46% 30.77%

30.30% 27.27% 33.33%

37.86% 27.18% 33.98%

27.27% 43.18% 29.55% .750

89.74% 7.69%

83.33% 16.67%

84.62% 7.69%

72.73% 15.15%

72.82% 18.45%

79.55% 18.18% .006

61.54% 10.26%

41.67% 25.00%

46.15% 46.15%

45.45% 42.42%

42.72% 56.31%

45.45% 43.18% .147

41.03% 53.85%

66.67% 33.33%

46.15% 23.08%

57.58% 33.33%

67.96% 31.08%

52.27% 40.91%

Demographics Cont…

Mean Age -St. Dev. -Range

Mean Number of Comorbidities -St. Dev. -Range Mean Length of Treatment -St. Dev. -Range

NonPost-op ACL Traumatic knee n=39 n=12

Post-op Shoulder

Shoulder

LBP

Foot and Ankle

n=13

n=33

n=103

n=44

36.90 15.84 66

34.92 13.13 41

39.54 13.70 43

50.42 18.30 72

47.22 18.82 85

37.66 16.69 66

0.41 .69 2

0.17 .39 1

0.46 .52 1

0.90 .88 3

0.78 .89 4

0.83 1.02 4

7.05 3.88 22

23.67 17.94 49

14.50 7.88 30

6.79 5.92 33

7.49 3.90 19

9.41 12.11 82

Number of Subjects

ACSM Risk Stratification by Body Region

ACSM Risk

Data Analysis Chi square analysis for differences in patient

characteristics across groups  Logistic regression for Relationship of CV risk status and success Success as measured by MCID change score and

length of treatment

Number of Subjects

ACSM Risk by Success

ACSM Risk

Discussion Most patients in the clinic had low cardiovascular

risk. Our patients were younger than reported in the literature Students were provided low risk patients,

therefore these findings do not extrapolate to others (not generalizable). Fried, 2004

Cardiovascular risk was found to not be

associated with poorer outcomes.

Summary Findings Cardiovascular risk stratification is possible in

clinical settings In adults with few comorbidities, cardiovascular risk status has no significant effect on physical therapy outcomes

Limitations Time constraints in the clinic to complete all

forms necessary Access to equipment in the clinic Unclear instructions/operational definitions Accuracy of forms Mean age of the subject population Outpatient orthopedic setting

Future Directions More in depth analysis of comorbidities effect on

outcomes Larger sample sizes needed to analyze individual comorbidities and success ACSM risk stratification in the clinic Data collection in various practice settings

References De Groot V, Beckerman H, Lankhorst G, Bouter LM. How to measure comorbidity: a critical review of available methods. J Clin Epid. 2003;56:221-229. Scherer SA, Noteboom JT, Flynn TW. Cardiovascular assessment in the orthopedic practice setting. J Orthop Sports Phys Ther. 2005;35:730-737. ACSM’s health related physical fitness assessment manual. Philadelphia: Lippincott;2005. Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the us adult population: results from the third national health and nutritional examination survey, 1988-1001. Hypertension. 1995;25:305-313. Duncan P, Studenski S, Richards L, et al. Randomized clinical trial of therapeutic exercise in subacute stroke. Stroke. 2003;34:2173-2180. Haverstock BD, Mandracchia VJ. Cigarette smokine and bone healing: implications in foot and ankle surgery. J Foot Ankle Surg. 1998:69-74. Brodke DS, Ritter SM. Nonoperative management of low back and lumbar disc degeneration. J Bone Joint Surg Am. 2004;86:1810-1818. Han TS, Schouten JSAG, Lean MEJ, Seidell JC. The prevalence of low back pain and associations with body fatness, fat distribution and height. Int J Obes. 1997;21:600-607. Felix RAL, Edward FN, Gregolin PCL, et al. Body mass as a factor in stature change. Clin Biomech. 2005;20:799-805. Conn VS, Hafdahl AR, Minor MA, Nielsen PJ. Physical activity interventions among adults with arthritis: a meta-analysis of outcomes. Semin Arthritis Rheum. 2008;37:307-316. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol. 2004;59:255-263. Kauppila, LI. Atherosclerosis and disc degeneration/low back pain – a systematic review. Eur J Vasc Endovasc Surg. 2009.

Acknowledgements Dr. Janet Houser, PhD Dr. Susan Scherer, PT, PhD Dr. Marcia Smith, PT, PhD Dr. Julie Whitman, PT, PhD Marybeth Tscherpel DPT Class of 2009

Questions