New PTJ Podcast Previews June Special Issue on Infant and Child Development
In a new PTJ podcast, Editor-in-Chief Alan Jette, PT, PhD, FAPTA, interviews Jill Heathcock, PT, PhD, guest coeditor of PTJ's upcoming special issue, "Infant and Child Development: Innovations and Foundations for Rehabilitation." Heathcock is executive director of the Pediatric and Rehabilitation Laboratory (PEARL) at The Ohio State University; coeditor Jeffrey Lockman, PhD, is professor of psychology at Tulane University's Infant and Toddler Development Lab.
The idea for the issue came about during a conversation between Heathcock, who studies pediatric rehabilitation and typical infant development, and Lockman, former editor of the journal Child Development, at an Academy of Pediatric Physical Therapy conference. "Sometimes these 2 fields engage in a lot of crosstalk, but not always. The research summit was a kick-off idea of how to engage both pediatric physical therapists, or those interested in pediatric rehab broadly, and those in developmental science," says Heathcock in the podcast.
According to Heathcock, the special issue shows "how a wholistic approach is often the most successful, whether we are talking about babies with [neonatal abstinence syndrome] in the NICU or error-based learning, allowing children to really take advantage of the behaviors they show throughout the day, and then advance those through rehab or through practice. There are both low-tech and high-tech approaches that are really novel, from simulation in early infancy, to robotic prone mobility, to focusing on the parent and infant relationship."
The 3 major themes of the special issue are sensor technology and device development in pediatric rehab, approaches to measurement and assessment that use current and emerging technology, and how knowledge of perception-action can be used to support optimal infant and child development.
Some highlights include:
"Wearables for Pediatric Rehabilitation: How to Optimally Design and Utilize Products to Meet the Needs of Users"
Beth A. Smith, PT, DPT, PhD, et al
"Robot Reinforcement and Error-Based Movement Learning in Infants With and Without Cerebral Palsy"
Thubi H. A. Kolobe, PT, PhD, FAPTA, et al
"Safety and Feasibility of Transcranial Magnetic Stimulation as an Exploratory Assessment of Corticospinal Connectivity in Infants After Perinatal Brain Injury"
Samuel T. Nemanich, PhD, et al
"How Many Days Are Necessary to Represent an Infant’s Typical Daily Leg Movement Behavior Using Wearable Sensors?"
Weiyang Deng, PT, MS, et al
"Development Through the Lens of a Perception-Action-Cognition Connection: Recognizing the Need for a Paradigm Shift in Clinical Reasoning"
Mary Rahlin, PT, DHS, et al
"Embodied Cognition in Practice: Exploring Effects of a Motor-Based Problem-Solving Intervention"
Regina T. Harbourne, PT, PhD, FAPTA, et al
"A Motor Learning Paradigm Combining Technology and Associative Learning to Assess Prone Motor Learning in Infants"
Tanya Tripathi, PhD, et al
Heathcock told Jette she hopes that people will pay attention to research outside their own fields and that the special issue will "spark interdisciplinary collaboration" in research, in the clinic, and in everyday application.
Look out for the special issue on June 3.
Let's Make a Difference Together—It's Not Too Late
By Brad Thuringer, PTA
It started at APTA's Annual Conference in Boston in 2005. I was walking back to the hotel with my colleague and fellow PTA Kerry Williams. We had a late dinner and decided to stop at a fast food restaurant for ice cream.
That's when I saw a mother and her 2 kids, a brother and sister ages maybe 9 and 11, sitting at a table. There was no food in front of them—just several large bags brimming with what looked like the family's possessions. They looked bedraggled and tired.
I managed to engage them in a bit of small talk, and I mentioned that Kerry and I were planning to get ice cream. When the little boy blurted out, “That sounds good!" that was the opening I needed to convince the mom to allow me to buy the family dinner.
Things did not end there. In fact, that was just the beginning.
As we sat and visited with the family, I had noticed that the girl's cloth tennis shoes were quite worn and that the laces were tied only about halfway up because both of them had broken at some point. That image has been with me these past 14 years.
With every conference since then, our association and its members have made a difference in the city we visit through the Shoes4Kids program. With a simple gift of a new pair of athletic shoes, physical therapists, physical therapist assistants, and physical therapy students have given a child a chance to feel special.
A childhood is supposed to be magical, carefree time. However, children who live in poverty and lack adequate clothing and shoes can experience stigma, low self-esteem, ridicule and bullying—all of which can influence their self-confidence, learning, and success.
With Shoes4Kids, we do not just give a child any old pair of shoes--we give them brand-new shoes and socks, measured exactly for their feet.
Despite the instability of a child’s home life, a positive experience such as a Shoes4Kids event can help a child feel special and free. And though providing shoes and socks may seem like a small thing when compared with the challenges faced by many of these children and their families, this simple gift can have a powerful impact.
Believe me, I've seen that impact firsthand.
There was the time a dad in Baltimore solemnly and with deep appreciation shook my hand after we had given his son a new pair of basketball shoes. Memorable, too, was the joy on a young girl's face in Salt Lake City when she exclaimed, "I'm so glad I don't have to wear these anymore!" She was trying to hide from sight her old slippers, but I caught a glimpse of them. They were worn completely through.
I, too, remember a boy at a shelter in Woodbridge, Virginia, who did not want to try on his new pair of shoes because, he reluctantly confided to me, his feet smelled. I assured him that I could relate—my feet smell too, just ask my kids. He soon was fitted with a new pair of shoes that he could not wait to wear to school.
I have seen our profession do good things. But working with volunteers to help a child select new socks and fitting them perfectly with a pair of bright-colored athletic shoes—and then seeing a parent wiping tears of happiness—is powerful and something that's completely consistent with who we are as a profession.
Another Shoes4Kids drive will be held during the 2019 NEXT Conference, June 12-14 in Chicago. My hope is to have tables full of beautiful shoes, to watch the children who attend Woodlawn Community Elementary School smile and giggle when they receive our gifts, and to hear one say, “I will go running in my new shoes. I will finally be able to run faster.”
However, Shoes4Kids is short on funds to purchase the necessary shoes next month.
Can you donate $50.00 to help purchase a pair of socks and shoes to give a child an equal opportunity to have good shoes in gym, run faster, and feel just a little more confident? Although we're accepting donations of shoes and socks onsite at NEXT, you don't have to attend to participate—your monetary contributions will help us help the kids. Check out the Shoes4Kids webpage for complete information on how you can make a difference.
We've seen it over and over in our profession: we are better together, and amazing things can happen. It's time to come together again.
Brad Thuringer, PTA, is the founder of Shoes4Kids.
The Movement System: Don't Miss the Boat
By Sue Whitney, PT, DPT, ATC, PhD, FAPTA, board-certified neurologic clinical specialist
In many ways, those of us in the physical therapy profession are like the crew on a ship—a collection of individuals with many different areas of expertise, all of whom are important for keeping the ship operational and moving forward.
You could think of other health professions in the same way—each a crew member of a ship that sails as part of the health care fleet. And to be sure, we have a lot in common with other professions because we sail in the same waters.
But we also have a distinctive set of knowledge, skills, and tools that we use to optimize human movement, promote health and wellness, mitigate the progression of impairments, and to prevent additional disability. Our ship makes it possible to accomplish that goal, and being a crew member makes it easier for us to explain our unique contribution to ourselves and others.
Our ship keeps us moving forward together as we explore new horizons in practice, education, and research. But what is our ship exactly?
I say we're all crew on the SS Movement System. And now it's time to set sail. The Movement System is ready to move, and we need all hands on deck.
A quick history
Hopefully, the Movement System is a familiar term by now. But just in case, here's a little background.
In June 2013, our House of Delegates (House) adopted the following new vision for our profession: "Transforming society by optimizing movement to improve the human experience."
Along with this vision statement, the House adopted guiding principles to articulate how the profession and society will look when the vision is achieved. The first guiding principle, "identity," states the following:
"The physical therapy profession will define and promote the movement system as the foundation for optimizing movement to improve the health of society. Recognition and validation of the movement system is essential to understand the structure, function, and potential of the human body. The physical therapist will be responsible for evaluating and managing an individual's movement system across the lifespan to promote optimal development; diagnose impairments, activity limitations, and participation restrictions; and provide interventions targeted at preventing or ameliorating activity limitations and participation restrictions. The movement system is the core of physical therapist practice, education, and research."
In response to the House action, an APTA Board of Directors (Board) work group developed a 2-part definition of the movement system that was reviewed, modified, and approved by the Board.
The first part of the definition succinctly describes the movement system.
"The movement system is the term used to represent the collection of systems (cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal) that interact to move the body or its component parts."
The second part of the definition describes the relationship of the movement system to physical therapist practice.
"Human movement is a complex behavior within a specific context.
- Physical therapists provide a unique perspective on purposeful, precise, and efficient movement across the lifespan based upon the synthesis of their distinctive knowledge of the movement system and expertise in mobility and locomotion.
- Physical therapists examine and evaluate the movement system (including diagnosis and prognosis) to provide a customized and integrated plan of care to achieve the individual's goal-directed outcomes.
- Physical therapists maximize an individual's ability to engage with and respond to his or her environment using movement-related interventions to optimize functional capacity and performance."
With a definition in place, the Board next created a Movement System Task Force to begin implementing an action plan recommended by the work group to [do what]. The Movement System Task Force first convened the Movement System Summit in December 2016. At the summit, the action plan was reviewed, revised, and adopted for implementation. Since that time, information about the movement system has been presented in many sessions at national meetings and in APTA publications.
Important next steps—with your help needed
But now we've reached a critical juncture—and we need your contribution.
In the past year, 2 sub-groups of the Movement System Task Force began to address 2 specific items from the action plan: drafting a process for developing movement system diagnoses, and developing a movement system screen. These important documents are now ready for your input.
Here's what we're asking: review 2 draft movement system templates and provide your feedback by June 1. The instructions for each one, though slightly different, are easy to follow.
Movement System Diagnosis Template
Step 1: Open the online draft diagnosis template and fill in the fields to submit an example of a movement system diagnosis (examples provided within the draft template): Online Draft Movement System Diagnosis Template.
Provide feedback about the draft movement system diagnosis template.
Movement Screen Template
Step 1: Download the movement screen, a tool designed to detect movement impairments observed during functional tasks/activities that will help therapists decide which additional tests and measures to include in the patient and client examination: Draft Movement System Screen Template (.pdf). (You are not expected to fill out and submit this template.)
Provide feedback about the draft movement screen template.
Your input will help shape the future of the movement system as it becomes more widely applied across the profession.
So please, come aboard, and together let's move full steam ahead.
Sue Whitney chairs the APTA Movement System Task Force
Planning on attending the NEXT Conference and Exposition June 12-15? Be sure to check out the special Movement System presentation track.
Tell Your Patient's Story: Tips for Defensible Documentation
By Donna Diedrich, PT, DPT, and Jaclyn Warshauer, PT
As physical therapists (PTs), you've no doubt heard the saying, "The work is not done until all the paperwork is done." However, this often is easier said than done. While you're highly trained professionals who identify with a doctoring profession, you may at times struggle to effectively communicate your expertise. The challenge is multiplied when you consider the components that constitute an accurate and timely record of skilled physical therapist services, as well as the audiences it reaches such as physicians, payers, patients, and consultants if/as indicated.
Effective documentation must provide details related to the therapy episode, outlining the complex factors that necessitate skilled PT services for your patient or client. This includes specific medical necessity and skilled service interventions that require the unique skills of a physical therapist or physical therapist assistant—skills that cannot be provided by other health care providers.
When documenting your services, it helps to consider 2 questions: Why now? And why you?
Why Does This Patient Need PT Services Now?
To address" why now," consider what caused the patient visit and within what timeframe, as well as how the symptoms presented. Did Mrs Chen fall this past weekend with resulting stiffness and new-onset low back pain (LBP)? Or did she fall 3 months ago and is now experiencing exacerbation of chronic LBP secondary to arthritis that is not responding to usual care?
As you gather facts supporting the timeframe, you need to include relevant medical and psychosocial events that may be influencing the patient's presentation. For example: Is Mr Sanchez's hip replacement new or longstanding? Is he recently widowed, and was his spouse his primary caregiver? Is his current functional limitation influenced by both recent hip surgery and underlying complications from Parkinson disease?
Tell the story to relate the functional history to the current limitation of impairments. For example: "Prior to fall and hip fracture, Mrs Davis was independent in community mobility and driving, including attending church regularly with navigation up and down 12 steps without assistive devices. Her current limitations 1 week post fall surgical repair of left hip fracture with weight bearing as tolerated includes need for front-wheeled walker and contact guard to minimal assist of 1 for 25' level ground mobility, minimal assist of 1 and bilateral handrail for 2-3 step navigation and inability to drive."
Why Does This Patient Require Your Skilled PT Services?
Demonstrate the "why you" component with a thorough assessment that captures the patient's goals, uses differential diagnosis to identify the musculoskeletal and/or neurological causes integrating symptom and movement presentation, and aligns interventions with your physical therapist scope of practice. This skill needs to be evident in the written documentation of tests and measures used to rule in—or rule out—causes and how, based on evidence, you determine the most appropriate intervention intensity, exercise dosing, frequency, and duration.
It's critical to remember that "skilled" services must be complex and sophisticated enough, or the condition of the patient complex enough, that the treatment could be safely and effectively performed only by a physical therapist or a physical therapist assistant. Below is an excerpt from a denial-of-payment letter from the Centers for Medicare and Medicaid Services (CMS) (emphasis added):
The progress made does not support the need for ongoing PT. The patient could have been placed on a maintenance program with periodic assessment to determine progress. No new therapeutic techniques, compensatory strategies, or effective cueing were identified or implemented during these service dates. The documentation failed to support that the services provided were at a level of complexity and sophistication that the unique skills of a licensed therapist were necessary for their delivery.
This statement supports progress; however, it emphasizes that the physical therapist failed to justify the "why you?" component of need. Place yourself in the shoes of the reviewer as you write the progress note. Ensure you not only describe what the patient did, but clearly and succinctly communicate what you measured, analyzed, adjusted, fabricated, adapted, facilitated, and/or educated, and that it was at such a level to require your skills and expertise. Make sure to include the tests and measures you use and relative comparisons to normal values for a population similar to your patient.
Payment Is Not Necessarily Linked to Patient Progress
Remember that progress alone is not a requirement for payment. CMS reminded us via the 2013 Jimmo Settlement Agreement that payment for skilled therapy services can be medically necessary not only to restore function but to maintain it or to prevent or slow deterioration. But to justify your services, documentation must state the expertise, knowledge, clinical judgement, and decision making used that only a physical therapist can provide. This is needed whether progress is noted or your skills and analysis are required to maintain or deter decline.
Consider the following examples of documentation to support the restoration of function or maintenance of mobility:
Important, But Unskilled
Demonstrates Skill and Expertise
|Patient ambulated 50' with a wheeled walker and minimal assistance.
||Minimal assist to ambulate 50’ with front-wheeled walker. Required manual facilitation to stabilize right pelvis/hip during stance phase and verbal cueing for right toe clearance during swing phase for safe forward mobility on level surfaces.
Documentation can be daunting, but you know your patient's medical, psychosocial, and environmental story. It's up to you to paint a complete picture of the episode of care for payers.
Donna Diedrich, PT, DPT, is vice president of clinical operations at Aegis Therapies. She is a board-certified clinical specialist in geriatric physical therapy. Jaclyn Warshauer, PT, is the national director of medical review and quality services at Aegis Therapies.
For more information on this topic, visit APTA's Defensible Documentation webpage.