Feature CSM 2017 Coverage In her introductory remarks to the American Board of Physical Therapy Specialties ceremony for newly certified clinical specialists, the traditional opener to the Combined Sections Meeting (CSM), APTA President Sharon Dunn, PT, PhD, announced that CSM 2017 would be the largest ever. She asked, "Is this the new norm? Tens of thousands of our colleagues attending every year. We're turning a corner. More of us want to attend because of what happens when we come together. We are seeing further evidence of the transforming profession that is physical therapy." By APTA Staff | May 2017 We Imagined. We Discovered. We Grew. In her introductory remarks to the American Board of Physical Therapy Specialties ceremony for newly certified clinical specialists, the traditional opener to the Combined Sections Meeting (CSM), APTA President Sharon Dunn, PT, PhD, announced that CSM 2017 would be the largest ever. She asked, "Is this the new norm? Tens of thousands of our colleagues attending every year. We're turning a corner. More of us want to attend because of what happens when we come together. We are seeing further evidence of the transforming profession that is physical therapy." Whether you were among the more than 14,000 participants and want a refresh of the experience, or you couldn't attend and want to see what you missed, here are highlights from PT in Motion's coverage of CSM 2017. Cerasoli Lecturer Challenges "Sunk Cost Fallacies" Warning that he "likes to poke the bear," Chad Cook, PT, PhD, MBA, challenged his audience to reconsider their views on physical therapist (PT) school admissions, accreditation standards, and metrics of success. Delivering the Pauline Cerasoli Lecture on February 18, Cook addressed "the sunk cost fallacy"—a business concept in which investments in resources continue to be made—often irrationally—because resources already have been committed to the project or venture. One sunk cost fallacy Cook identified was "continued reliance on cognitive ability-focused admission processes that don't appreciate the full breadth of intelligence." Cook polled the attendees with this scenario: Lisa and Jane apply to your program. Lisa is African-American; Jane is Caucasian. Lisa has a 3.45 GPA; Jane has a 3.6 GPA. All other factors are unremarkable. Who would you choose? The Cerasoli audience voted 61%-39% to choose Lisa. Cook noted that CAPTE data indicate that there's no difference in pass rates when a GPA is 3.45 or higher. He also commented that US Census data indicate that whites are overrepresented in the physical therapist workforce (79.2%) when compared with the total US workforce (75.2%) and the entire US population (72.4%). He referred to Gardner's Theory of Multiple Intelligences, noting that standardized admissions tests typically measure only 2 of the 9 intelligences—linguistic and logical abilities—while failing to measure skills that are more determinative of a PT's success, including kinesthetic and interpersonal abilities. Admissions procedures, Cook said, should focus more on the strengths of the applicants and less on factors unrelated to whether an applicant will become an excellent PT. Another sunk cost fallacy was "reliance on success metrics that are too easily obtained and not reflective of what professional success may actually be." He said 2 primary purposes of DPT education are to optimally train PT learners (1) to be excellent PTs and (2) to contribute to the profession as a whole. Citing several studies, Cook said the traits that best predict positive professional performance include emotional/social intelligence and grit/resilience. He urged the audience to stop assuming that first and ultimate pass rates distinguish one program from another. Instead, Cook said they should identify legacy measures of success within a specific program. Combat Stress With Resilience, Linda Crane Lecturer Advises "It's not stress that kills us. It is our reaction to it," said Anne Mejia-Downs, PT, PhD, MPH, quoting Hans Selye, MD, PhD, considered to be the "father of stress research." Mejia-Downs delivered the Cardiovascular and Pulmonary Section's Linda Crane Memorial Lecture "Resilience: Everyone Has It—What Will You Do With Yours?" on February 16. Meija-Downs explained that acute stress has myriad physical effects, including increases in cortisol levels, heart rate, respiratory rate, blood pressure, and blood glucose. As a result, stress can damage arteries, increase cholesterol, increase blood clotting, decrease blood flow to the heart and brain, and damage cells. She noted that people's immediate reaction to stress varies from throwing something across the room to eating an entire carton of ice cream. (The latter prompted enthusiastic applause from the audience.) But, she continued, the best long-term response is to strengthen one's resilience, which she defined as "the ability to bounce back to baseline when confronted with a difficult situation" or "successful adaptation to chronic adversity." Among the components of resilience identified by Mejia-Downs are thinking positively, maintaining optimism, and humor. Physical activity is another element of resilience, Mejia-Downs said, adding that vigorous physical activity is related to lower stress levels. Further, physical activity releases brain-derived neurotrophic factor (BDNF), a substance that improves brain health. Social support is another contributor to resilience. "Social support, both perceived and actual, has been shown to be protective against stress," Mejia-Downs said. "Social support decreases the chance of developing depression. It helps to recover from emotional trauma. Studies have shown higher rates of heart disease among the socially isolated." Steps to strengthen social support include thinking about people who make you feel good, and building and caring for those relationships. Finally, she addressed the results of her study of resilience in physical therapist students. DPT students randomly were assigned to a 4-week curriculum or waitlist control group. Measures were assessed at baseline and postintervention: stress, resilience, optimism, coping flexibility, positive/negative emotions, social support, and illness symptoms. The study found "significant increases" in both resilience and positive affect in the group assigned to the curriculum. Clinical Specialists Must Be Leaders, ABPTS Keynoter Says "As clinical specialists, you have the distinct clinical viewpoint to not only become sought-after master clinicians by continuously perfecting your clinical content expertise through maintenance of certification," Jean M. Irion, PT, EdD, ATC, said the evening of February 15, "but also to foster not only your own leadership development but that of the clinicians around you." Irion addressed the American Board of Physical Therapy Specialties (ABPTS) Ceremony, which recognized PTs who had become board-certified specialists or were recertified in 2016. Irion cited remarks recently made by Emma Stokes, current president of the World Confederation for Physical Therapy, who "challenged us to consider whether transition to the DPT as the entry level degree and the content of our curriculum facilitates leadership skills needed by our clinicians to serve the current and changing health care needs of society." In considering whether her own institution's newly developed DPT curriculum incorporated leadership development, Irion said she was prompted to recall John Quincy Adams' definition of a leader: "If your actions inspire others to dream more, learn more, do more and become more, you are a leader." Building on that, she called on all the newly certified clinical specialists to "go back to to become a leader to your fellow physical therapists, to your physical therapist assistants seeking advanced proficiency knowledge and skills through the Advanced Proficiency Pathways program, and to your colleagues in other practice areas with whom you engage in collaborative practice." Irion had begun her address by noting that 2 topics have touched her professional and personal life—the need for leadership development in physical therapy education and practice, and the importance of country music. Throughout her remarks, she touched on country music titles and lyrics that she related to the theme of certification and professionalism. To conclude her remarks, Irion chose what she described as "my favorite country song that most definitely exemplifies your new role as clinical specialists and evolving leaders"—"Humble and Kind" by Tim McGraw. She asked those in attendance to remember the lyrics: "When the dreams you're dreamin' come to you / When the work you put in is realized / Let yourself feel the pride / But always stay humble and kind." Health Literacy ABCs Health literacy (HL) is multifactorial and often more limited than is general literacy. "The context is often more challenging than general literacy," said Renee Cordrey, PT, MSPT, MPH, at the February 17 Health Policy and Administration Section (HPA The Catalyst) session "I Don't Understand What You Told Me: Working With Low Health Literacy." Factors that influence HL include communication skills, culture, beliefs, math skills, and even comfort level with technology. "We need to be aware of where patients are [on the literacy spectrum]," Cordrey said. "I can't just tell them 'we are going to make your cells more active,' when the patient didn't have biology or science classes in high school." Patients with good HL can make good decisions. For instance, in people with cancer, higher HL is associated with higher quality of life in all domains. "It is challenging for those with low HL to fill out forms and know how to answer health history questions," Cordrey noted, "let alone follow instructions for self-care or understand lab values. Even giving consent for care can be problematic." She stated that more than half of all US adults have limited general literacy. Only 12% of English-speaking adults have proficient HL skills, and this includes health professionals. Risk factors for HL include being male, nonwhite or non-Asian/Pacific islander, speaking a language other than English at home before entering school, and living in a rural area. Many tools are available for health literacy screening. Cordrey mentioned the Short Assessment of Health Literacy—Spanish and English versions—and the Rapid Estimate of Adult Literacy in Medicine–Short Form (REALM). Several others are available from the Agency for Healthcare Research and Quality. Cordrey suggested using analogies that relate to everyday things to help improve patient education. She also advised using examples that are concrete and personal, not abstract and general. Using lay terms for medical terms also will improve understanding. For example: Instead of saying "positioning"—say "how you lie in bed" Instead of "non-weight-bearing"—say "keep your weight off of your foot" Don't use the term "anterior"—say "the front" Describe "3 sets of 10"—say "do it 10 times, then 10 more, then 10 more" Targeted Training Useful for Postural Head Control in Children With Developmental Neurological Conditions Head control requires the integration of visual, vestibular, and proprioceptive input. "Posture control through the whole trunk and head requires neutral vertical alignment," said Danielle Bellows, PT, MHS. Bellows, along with Sarah Bew, MCSP, and Sandra Saavedra, PT, PhD, MS, were the speakers for the Academy of Pediatric Physical Therapy session "Targeted Training for Head Control" on February 17. "Children learn head control in vertical position from birth," said Bellows. "Parents naturally support the head, and as children grow, parents support down the trunk, so upright posture is the best position for the physical therapist to work on targeted head control." She added that this position is more energy-efficient, simplifies task complexity, and allows the child to learn to switch muscles so that muscles on both sides of the spine are used. Bew described the concept of a controlled kinetic chain. "A chain is a collection of rigid segments [bones] that are connected by joints, where control is essential at all joints." She added that chains can be open or closed and can consist of different numbers of segments. "In a controlled open kinetic chain, the end segment is free of support, such as standing on a single leg. Free movement is possible, and neuromuscular control demands are maximal at all joints, if the position is to be held." "A 3-segment controlled closed kinetic chain is a rigid structure," stated Bew, and no control is required. You might liken this to holding your chin on your hands while leaning on a table. In this case movement is possible and predictable. "The therapist can progress to controlled open kinetic chains after he or she assesses where the child is using controlled closed kinetic chains and where the child is compensating." "If the patient is using closed chains, you as a therapist don't know if that individual actually has head control," said Saavedra. "It gives you a different perspective as a PT if you can isolate the segments." Effective Sleep Is Critical to Health and Wellness The one-third of our lives we spend sleeping plays a vital role in the wakeful other two-thirds. While the wakeful time is where more attention typically is paid in promoting healthful habits, presenters of the February 17 Academy of Neurologic Physical Therapy session "Sleepless in San Antonio: Guiding Patients to Better Sleep and Wellbeing" emphasized how important it is to give a good night's sleep its due. Session presenters were Katie Siengsukon, PT, PhD, and Janet Bezner, PT, DPT, PhD. Sleep is a critical period of recovery that supports cardiovascular, neurologic, immune function, tissue repair, pain modulation, and other life functions. The Centers for Disease Control and Prevention (CDC) has stated that sufficient sleep "should be thought of as a 'vital sign' of good health." But the CDC also has called insufficient sleep a public health problem. According to various reports, some 50 million to 70 million US adults experience chronic sleep disturbances, and costs associated with insomnia are more than $100 billion annually from health care costs, accidents, and decreased work, the presenters said. Not only do sleep disturbances occur in individuals with conditions that PTs typically manage, but they also can impede progress in a physical therapist's (PT's) plan of care. This means the opportunity is there for PTs to ask questions about sleep quality, sleep disruption, and perceived sleep issues. Little is known, Siengsukon said, about using exercise to improve sleep quality in individuals with neurologic conditions, but a small randomized trial she conducted indicated that sleep quality in individuals with multiple sclerosis improved for those who participated in an exercise program of aerobics, walking, and stretching. The best activities for sleep health won't work if the patient doesn't do them, so Bezner discussed approaches to behavioral change that included how best to engage patients in a conversation, how to promote good, sustainable sleep habits, how to assess patients' readiness to change, and how to build self-efficacy so patients feel accomplished and empowered to continue on their own. Getting the Jump on Ankle Instability Ankle sprains account for 40% of sports injuries in the United States, with approximately 30,000 cases each day. The Orthopaedic Section highlighted this condition during "A New Etiological Factor in Ankle Instability: Understanding Balance Training" on February 16. "Eighty-five percent of ankle sprains are lateral ligamentous injuries," said W. Liu, PhD, adding that 15%-60% of patients develop chronic ankle instability. "There are 2 types of ankle instability—functional (FAI) and mechanical—with very little overlap. FAI impairs balance control and presents with difficulty doing sport-specific skills." Previous testing on healthy ankles showed that painful stimulation and supinated ankle position increased response. "This research left us with unanswered questions," said Liu, who was an author of the study and now is involved in a new one. "The 2 objectives of our current study are to examine unloading reaction under dynamic ankle stretching and nociceptive stimulation and to see if there are correlations with other measured variables." A platform with a trap door to test unloading reaction was used along with the Cumberland Ankle Instability Tool questionnaire (CAIT). "Our results show that the mean VFV—vertical force variation measured by subtracting downward peak value of vertical forces after the stimulation from the mean of vertical forces before electrical stimuli—in the injured ankles with painful stimulation was significantly greater than that in the injured ankles without painful stimulation, or in the uninjured ankles with or without painful stimulation," said Liu. Tarang Jain, PT, PhD, discussed balance exercise treatment in subjects with FAI. To determine the effect of balance training intervention in patients with unilateral FAI, a research study was conducted. Some results of the study showed that "hyper-reactivity to unloading reaction decreased following balance training, and subjects reported significant improvement in self-assessed function following balance training. No difference was found in the ankle joint laxity and peroneal muscle strength between and within groups following balance training," Jain said. He conceded limitations in the study, including the limited number of subjects, the accuracy of the test in simulating a real ankle giving way, and the fact that measurements of FAI factors, rather than unloading reaction, were done in a non-weight-bearing seated position. "With continued research in this area, PTs will be able to design better rehabilitation programs for patients with FAI," said Liu. Making the Shift From Volume to Value: Partnerships Can Fill the Gap The benefits of collaborative business models and how they can bridge academic-to-practice gaps were discussed February 16 in the Academy for Acute Care Physical Therapy panel presentation "The Value Proposition: Developing Academic-Clinical Partnerships." Sharon Kurfuerst, OTR/L, EdD, led off with the reasoning behind partnership building: improved patient care experience, improved health of populations, and reduced per capita costs. "We want to make the shift from volume to value," she said. "We want to deliver the right care to the right patient at the right time." Kurfuerst touted investing in partnerships within and across health systems, as well as with academic institutions. In her position as senior vice president for the Christiana Care Health System, she found gaps in what their physical therapists (PTs) were able to do and talked to the University of Delaware to find a remedy. Ellen Wruble Hakim, PT, DScPT, MS, said the current academic climate is that of threatened fiscal health of universities, departments, and/or programs, along with increased cost of education and rising student debt. "There is a national faculty shortage, and there are expanding numbers of PT programs and cohort sizes," she said. "We need to reframe competition into collaboration." Academic institutions need to align content to reflect emerging evidence and practice expectations, Wruble Hakim continued. "To secure educators with contemporary expertise in areas of instruction, we can seek partnerships with clinical facilities to capitalize on shared resources." Molly Hickey, PT, DPT, said there are sometimes challenges to building partnerships. She mentioned differences in mission and vision, organizational structure, systems of accountability, and metrics by which success is measured. "When you don't think like partners, things fall apart." "Failure to anticipate a natural process of team development can cause partnerships to stall at a variety of points," said Hickey. "It's important to recognize that there will be struggles along the way." Common pitfalls include scheduling difficulties, unrealistic expectations, and a culture lacking absolute trust. Patient-Centered Care: Motivational Interviewing and Health Coaching The transition away from "productivity-driven care" to a collaborative patient-clinician relationship means that PTs must be "mindful, informative, and empathic," said Tracy L. Collins, PT, PhD, MBA, Paige Fleagle, PT, DPT, ATC, and Nicole Reale, PT, DPT, during a February 16 Home Health Section session. In "Patient-Centered Care: Motivational Interviewing and Health Coaching," the presenters explained how to use the title techniques to actively engage home health patients in their recovery. According to research, motivational interviewing (MI) can increase participation, adherence to treatment, and exercise, while health coaching can improve a patient's health through better self-management and self-care. MI involves using conversation to increase a patient's motivation and commitment to change. For it to be successful, there must be patient-provider collaboration, patient motivation, and patient autonomy—and a lot of listening. Attendees heard about different communication styles in health care—following, directing, and guiding—and when each is appropriate to use. Following relies heavily on listening, and early in an evaluation can help the PT understand the patient's signs and symptoms and how they fit into his or her overall health. Directing implies an uneven relationship, weighted toward 1 person's knowledge, expertise, authority, or power. Patients often appear to expect this communication style from a PT and want a "take-charge" approach. A guiding style can help patients in more self-directed learning, communicating that the PT can help them solve issues for themselves. While all 3 styles are suited for different circumstances, a mismatch can cause problems. In particular, directing can be overused when clinicians are under time and cost pressures to "check off boxes" and render patients passive recipients of care. MI is a refined form of the guiding style that can help patients make their own decisions about behavior change. PTs Should Reach Out to MMA Fighters, CSM Attendees Told Mixed martial arts (MMA) is the fastest growing sport in the United States. Due to the high injury rate—25%-35%—a growing number of PTs will see MMA fighters, so PTs must be prepared for this influx and know how to treat these athletes. That was the take-home message at the February 19 session "Kicking and Punching: PTs Working With Combat Athletes," presented by the Tactical Athlete Special Interest Group of the Sports Physical Therapy Section. George Davies, PT, DPT, MEd—a black belt in karate, karate instructor, and competitor in point-awarded fighting tournaments—placed MMA in perspective. It recently surpassed boxing as the most popular full-contact sport in the United States. One of its promotions—the Ultimate Fighting Championship—recently sold for $4 billion, making it worth more than the Dallas Cowboys or New York Yankees. MMA fighters use a variety of martial arts—often including wrestling, kickboxing, Brazilian jiu jitsu, and others. Davies conceded, "Despite the proliferation of general information on MMA, there is limited high-quality evidence available to inform clinicians and strength and conditioning specialists about the sport." LCDR Charles Rainey, PT, DPT, DSc—a former professional MMA fighter—reviewed studies that analyzed the various forms of injuries experienced by MMA competitors. The most common injuries were abrasions and lacerations, concussion, and orthopedic injuries. Injured body areas included face, hand, nose, eye, shoulder/arm/elbow, and knee/ankle/foot. Rainey noted that while MMA fighters have access to protective equipment, limited use of it during training may lead to increased injuries during training and competition. "PTs can get involved here," he said, in encouraging the proper use of protective equipment. According to Matt Hixon, PT, "Until recently, MMA has been ignored by the health care community, so the fighters have sought help from whoever they can get it from—chiropractors, athletic trainers, or by searching Google." On the other hand, Hixon acknowledged that some MMA fighters are skeptical of the health care establishment. "They don't trust us. How often have they heard from their physicians, 'You probably should stop doing that.'?" Hixon recommended that PTs look at a fighter's kinetic chain: "Look at linkages and connections, not just specific body parts." He also discussed specific exercises and drills to strengthen a fighter's abilities. "Most MMA athletes make little or no money at the sport. The least we can do as PTs is a better job at putting them back together," he concluded. Turn Everyday Teaching Into Scholarship of Teaching and Learning Excellence in teaching is expected of every faculty member, but finding time to undertake scholarly projects in pursuit of excellence, as well as conducting research, can be challenging. Presenters of the February 16 Education Section session "Working Smarter, Not Harder: Crafting Scholarly Projects That Count!" offered a solution—make your work count twice by turning everyday teaching into the scholarship of teaching and learning (SOTL). The practical session enabled participants to identify SOTL projects in their own practice and leave with an action plan for low-cost SOTL solutions to implement back at their home institutions. Session presenters were Kimberly Acquaviva, PhD, Margaret Plack, PT, DPT, EdD, Maryanne Driscoll, PhD, and Jennifer Halvaksz, PT, DPT. They began by explaining what SOTL involves, including clear goals and a purpose, adequate preparation with relevant literature, systematic collection and analysis of data, significant results, dissemination for replication, and reflective critique. Turning to development of an action plan, the presenters walked participants through a series of facilitated exercises, rapid-cycle brainstorming, and peer-feedback sessions. These included various sets of questions and statements to be completed. First was "What do you do well?" in terms of an aspect of teaching, such as a particular concept, theory, approach, or style. Following up, participants were invited to explain how they know they do it well—how do they know that a teaching strategy worked, or that the strategy be successfully duplicated by others? Reminding attendees that being rigorous and systematic in data collection is key to SOTL, the presenters asked additional questions to that end, such as: "What data will you need to answer your question?" "From whom (and when and how) will you collect your data?" "How will you ensure the rigor of your data collection?" "How will you minimize bias?" And, "What will you do with the data once you collect it?" Details about identifying possible collaborators and allocating specific time slots for research and writing filled out the discussion. Panel Addresses Multiple Aspects of Pain "Fixing 1, 2, or even 3 tires on a car with 4 flat tires won't get you very far," said Kristin Archer, PT, DPT, PhD, summarizing the February 16 Section on Research session "Bringing Pain and Psychosocial Factors to the Forefront of Sports Rehabilitation." Archer was 1 of 3 panelists who discussed the various components of pain, especially in the sports context. Scott Stackhouse, PT, PhD, gave an introduction to pain science. He said, "We know most of what's going on in the segmented model [brain, midbrain, and spinal cord]. You have something that steps on the gas and something that steps on the brakes." However, he said, much more is involved in pain sensation, particularly chronic pain. Specifically, tendon changes, motor changes, and pain sensitivity all appear to contribute to chronic tendon pain. Calling pain sensitivity the factor that most requires further examination, he said, "Pain reduction has been observed before morphological changes in the tendon. And bilateral symptoms have been resolved with unilateral treatment," suggesting the involvement of the central nervous system in even what appears to be localized pain. Brian Noehren, PT, PhD, spoke on the application of measures of pain sensitivity and behavioral alterations to sports-related conditions. He addressed quantitative sensory testing—techniques to measure alterations in somatosensation following injury. Like Stackhouse, he described the relationship between pain at a specific body location and the central nervous system. Noehren also addressed psychosocial functions as they relate to sports physical therapy and interventions for patients after a restructured anterior cruciate ligament (ACL). "It is increasingly recognized that psychosocial factors can have a major impact in physical therapist care and movement mechanics." He cited a survey of athletes after an ACL injury that found higher test scores for self-efficacy among patients with higher rates of satisfaction. Archer addressed psychosocial risk factors and patient outcomes, as well as strategies for addressing psychosocial risk factors. She described how to integrate psychologically informed physical therapy (PIPT) into practice, explaining that PIPT is based on cognitive behavioral therapy, elements of which have been adapted from psychologist practice for use by PTs. These elements include deep breathing, grounding and centering, guided imagery, and mindfulness. Quality Cancer Care Includes The Physical Therapist Throughout the Patient's Journey Oncology rehabilitation programs have many components in which the PT should play an integral part, including physical therapy and/or occupational therapy consultation screening, pediatric rehabilitation, prevention, survivorship exercise and wellness, and acute care therapy services. "The NIH [National Institutes of Health] recommends elevating awareness and education among health care providers, patients, and payers regarding rehabilitation as an integral part of quality cancer care," said Reyna Colombo, PT, MA, during the Oncology Section's February 16 session "Growing and Sustaining a Cancer Rehab Program: Building a Foundation for Success." Every member of the health care team has responsibility that is measured by tracking the patient's outcomes longitudinally, Colombo added. "The philosophy for sustainability and growth revolves around administrative structure, education, and communication. This model, developed by the World Health Organization, has been adopted by most national physical therapy associations worldwide," said Colombo. She said that her facility uses a method composed of prevention, intervention, and a sustained wellness model. PTs fit in all areas, she stated—stressing that "oncology rehab is more than lymphedema management." Chris Wilson PT, DPT, DScPT, said there are many participatory points for a PT to be integrated along a survivor's cancer journey. "Be part of oncology management early in the survivors' trajectory," Wilson advised. "Participate in multidisciplinary clinics and tumor board meetings, know and support the physicians and their patients throughout the treatment and posttreatment, and create a proactive, patient-centered process." "We need to change the mindset that, if you treat patients correctly, you will never need to see them again, when patients really need to have a relationship with the PT through all stages of their care," Wilson said. PTs Must Understand Sexuality in Marginalized Populations Understanding sexuality is a complicated yet necessary goal for physical therapists, according to Uchenna Ossai, PT, DPT, and Rena McDaniel, LCPC, MEd. The 2 spoke on "Sexuality, Race, and Transgender Health: Sexuality in Marginalized Populations," a February 19 session hosted by the Section on Women's Health. McDaniel cited the World Health Organization (WHO) definition of sexual health: "A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction, or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be protected and fulfilled." Ossai said, "We must recognize the impact of our clients' marginalized identities on their physical bodies, including their sexual health, and provide spaces of affirmation, empathy, and healing. Otherwise, we are failing as holistic practitioners." McDaniel described the concept of "intersectionality," which she defined as multiple aspects of social identity having a negative impact on overall health and outcomes. Intersecting factors influencing health include sexuality, race, the justice system, transgender identity, and political, health, and institutional policy. For example, African American mothers with a college degree have worse birth outcomes than do white mothers without a high school education. "We haven't done a good job with marginalized populations," she said. McDaniel insisted that society cannot ignore transgender issues. She said, "There are roughly the same percentage of people who are transgender as there are redheads or twins. [If we ignored this population] it would be as if society said there are no such things as redheads." As Hackers Evolve, Protection From Them Must Evolve, Too Physical therapy practices—as well as businesses of all sizes and types—are at risk from an evolving breed of hackers, warned 2 speakers from the VGM Group on February 16. "Your options," said VGM Advantage Vice President Warren Freeman, "are to pull the plug [on use of computers], or learn how to combat them." They presented the Private Practice Section's session "Navigating the Highway of Cyber Crime and Web Marketing." Bill Wilson, vice president of VGM Insurance Services, elaborated on the types of threats faced by businesses. "The number-one concern of chief executive officers is a data breach." He gave as an example "ransomware," in which hackers freeze or encrypt a company's data and then charge a ransom for its release. When hackers seek information today, he said, they're less likely to go after credit card data. Instead, the new target is personal health information. Meanwhile, the cost and risk to smaller companies and clinics lies in the cost of notifying people whose information has been breached. "Sixty percent of small businesses hit by cybersecurity attacks will close within 6 months. They just don't have the resources [to cover the expenses and remain in business]," Wilson said. Even if a company has an information technology department, Wilson advised that those firms bring in outside professionals and review the procedures that are in place. Breaches can occur intentionally, either by outside hackers or employees. Often, though, the breach is unintentional—a laptop computer with patient records is stolen from a car or a breach in a supplier's system is linked to another company's system. Also, an employee may click on an innocent-appearing email, only to infect his or her own computer and computers linked to it. Wilson and Freeman offered tips on a range of issues, from buying cybersecurity attack insurance, to avoiding open-source code for websites, to strengthening a company's protection via firewalls, anti-virus systems, and strong employee passwords. Make Your Life Larger So Pain Feels Smaller in Comparison Pain is among the most frequently reported conditions of veterans receiving care under the US Department of Veterans Affairs (VA). Treating veterans for pain, though, usually is more complex than straightforward pain management because 90% of those who report pain also report posttraumatic stress disorder (PTSD), traumatic brain injury, or both. Nearly 42% of vets with pain report all 3 conditions. Helping these patients was the focus of the Federal Physical Therapy Section session "The PT's Role in Chronic Pain Management for Military Service Members and Veterans" on February 18. Presenter LTC Robyn Bolgla, PT, DPT, MSPT, of the US Army Reserve, was clear in her commitment to providing the best possible care: "Being a military physical therapist [PT] is more than treating conditions. We have a duty to honor our veterans. It's part of our mission." To that end, Bolgla discussed issues around pain management for active military and veterans, and shared her thoughts on best treatment. Of late, she said, increased attention to the opioid abuse epidemic has brought recognition of the disproportionate number of vets who are at risk of overdose compared with the general population. This largely is because of high instances of PTSD, depression, alcohol use, and suicide attempts, Bolgla said. Shifting practice away from prescribing pain medications is good news, she continued, but "Then what do you do? If we take them off pain medication we need to replace it with something." One obvious answer is treatment by a PT. The benefits of exercise (in general and in rehabilitation), and the PT's role in developing a plan of care that includes it, are shown to be a safe and effective way to manage pain. However, shifting behavior away from pharmacological management can be a challenge. For 1 thing, the brain may perceive that exercise is pain, Bolgla noted: Endorphins are the body's "natural pain medication" and are released not only in response to stress and pain, but also in response to exercise. Bolgla described a process of "back pain boot camp" in which PTs gradually increase the intensity of exercises to increase back strength and flexibility, and teach patients it's okay to move normally again. "The last thing we want," she said, "is for people to not move." Stress is another common condition for active and retired military. Bolgla described how the hormone oxytocin negates the effects of the stress hormone cortisol. One way to release oxytocin is though touch, but military personnel (unlike PTs and physical therapist assistants) aren't necessarily comfortable with hugging and the like. So, Bolgla, said, "We 'trick' people into touching each other with group exercise" such as partner sit-ups, and by encouraging fist-bumping and high-fives. Bolgla described a Veterans Health Administration protocol using cognitive behavioral therapy to foster behavior changes in veterans with chronic pain. It includes techniques to help them cope with catastrophizing—negative thoughts that contribute to pain and functional decline. "We do resilience training," she explained. "Instead of focusing on the pain, focus on what's good in your life—spouse, pet, anything to look forward to—and put it in perspective." With practice, she continued, the brain can "expand" the positive aspects of life, making the pain feel smaller by comparison and less overwhelming. Aquatic Activity Can Increase Circulatory Efficiency, Reduce Blood Pressure Aquatic therapy offers many benefits to patients that land-based therapy doesn't, said Bruce Becker, MD, clinical professor at the University of Washington. Becker presented the Aquatic Section session "Aquatic Activity and the Brain" on February 17. Becker explained that aging produces a reduction in arterial vessel elasticity and responsiveness to neural control. "This is a harmful effect, raising blood pressure and reducing circulatory efficiency throughout the body," he said. "Aquatic activity has been shown to increase blood vessel elasticity, increasing circulatory efficiency in both large and small arteries. Endothelial nitric oxide synthase increases during aquatic exercise, permitting a vasodilatory response from vascular smooth muscle, further reducing blood pressure." Becker cited several studies in which both aquatic and land-based exercises produced benefits. He highlighted other studies as well, such as one that addresses endothelial function, showing a benefit to aquatic treadmill exercise but no change following use of land-based treadmills. Addressing the effect of aquatic exercise on blood pressure, Becker said, "Because the peripheral blood vessels relax during immersion, blood pressure drops. Repeated exposure to immersion and exercise has shown a positive effect upon blood pressure in hypertensive individuals. This effect has been seen with both swimming exercise and aquatic treadmill exercise. The elevation in blood pressure during exercise is also lower with aquatic activities." Describing the effect of aquatic exercise on blood flow to the brain, Becker said, "Aquatic immersion has been shown to positively impact brain blood flow. Both carotid arterial diameter and blood flow velocity increase during immersion. Simultaneously, blood flow through both the anterior and posterior cerebral arteries increases significantly, providing a substantially greater blood flow to the brain. This increase in brain arterial flow velocity, averaging greater than 7%, persists during aquatic exercise." Changes in Medicare Payment for 2017 Summarized in Hand Therapy and HPA Session The Academy of Hand and Upper Extremity Physical Therapy and the Health Policy and Administration Section sponsored "2017 Medicare Update for Hand Therapists" on February 17. Speaker Marsha Lawrence, PT, told the audience, "It's going to be an interesting year with all the changes coming in Medicare." Lawrence explained that Medicare funding comes from the Hospital Insurance Trust Fund [HI] and the Supplementary Medical Insurance Trust Fund. "Based on 2015 data expenditures, Medicare Part A [HI] exceeded income by $4 billion." (The source of the information, a 2016 report from the Trustees of the Medicare program, also estimates that the trust fund will be depleted in 2028.) The Centers for Medicare and Medicaid Services (CSM), which administers the Medicare program, continues to seek ways to reduce or eliminate long-term financial shortfalls. Lawrence described Medicare's initiative to review potentially misvalued codes under the CPT coding system, an ongoing program that determines if code values match current practice. In 2015, CMS identified several CPT codes within physical medicine and rehabilitation (PM&R)—including codes that physical therapists (PTs) commonly use—for review. Many of these targeted codes, Lawrence said, have not been revalued since the 1990s. Any new values for codes under review are expected to be announced in the 2018 Medicare physician fee schedule rule. Probably the biggest news in PM&R coding is the move from the single evaluation code, 97001 for physical therapy, to 3 tiered codes that reflect the complexity of the evaluation. (Occupational therapy and athletic training evaluation codes also moved from a single evaluation code to 3 tiered codes.) As of January 1, 2017, PTs must determine whether an evaluation is low, moderate, or high complexity, based on 4 components of the evaluation process: history, examination, clinical presentation, and clinical decision making. Lawrence reminded attendees: "You are ranking how difficult it is for you to evaluate the patient and come up with a treatment plan, not how difficult it is to treat the patient." Under history, PTs must state if and how any personal factors and comorbidities impact the plan of care. "It's not good enough to say the range of motion is 45 degrees," said Lawrence. "You must document that that you did tests and measures and what standardized tool was used." The PT, and not the biller or coder, is responsible for determining the code level, she cautioned, adding that even though the codes are untimed, the time spent on an activity should be included in documentation.