Feature Combined Sections Meeting: Better Together and Bigger Than Ever The Combined Sections Meeting brought more than 17,000 people to New Orleans—yet another record-breaking attendance for the annual conference of the association's 18 specialty sections. By APTA Staff | May 2018 Using Causal Models to Develop Knowledge-Based Practice A scientist claiming "Your practice isn’t evidence based" and a clinician countering "Your evidence isn't practical" likely resonates with PTs on both sides of the argument. In his delivery of the Cardiovascular and Pulmonary Section's Linda Crane Lecture, Sean Collins, PT, ScD, asked the audience to consider just how wide the gap is between them: To what extent can practice be evidence based, and to what extent can research be practical? Setting up his discussion for the lecture, titled "Synthesis: Causal Models, Causal Knowledge," Collins contrasted ontology—the ways things are—with epistemology—the way things are known. The concept of critical realism, in which the human mind is part of the process of knowledge, is premised on the claim that ontology determines epistemology. In other words, what is real is still real even if every aspect of the reality hasn't empirically been verified. The challenge to finding evidence for every aspect is that clinicians are faced with all sources of variation at the same time, while dealing constantly with the full burden of the complex system. To illustrate, Collins asked attendees to suppose that a clinician is considering 2 interventions, each with 2 possible states—do or don’t do the intervention. There are 4 possible alternatives. With 4 interventions, there are 16 alternatives, and so on. "But why encode the interventions as only yes or no?" he asked. "Why not high, low, or no," with 2,187 possible alternatives? Or even "high, medium, low, or no" with 16,384 alternatives, and so on? Taking a purely empirical approach to verify all of the alternatives isn’t practical, Collins argued. Instead, causal models (abstract models that attempt to describe the cause-and-effect relationships among a group of variables) provide a bridge for knowledge development in the profession—as opposed to evidence that identifies empirical connections, then is translated to the clinician. "Causal models represent a synthesis of knowledge-based practice," Collins said, in which the models fit with reality "even when we cannot empirically verify each and every component of such models; but where knowledge assumptions that are encoded in the models are clear, combine knowledge with reasoning, and are subject to empirical verification when possible." End the Coddiwompling, Cerasoli Lecturer Urges Physical therapy education must stop "coddiwompling"—slang for traveling in a purposeful manner toward a vague destination—and instead should begin traveling in a purposeful manner toward an intentional destination. That was the message Jodi Frost, PT, DPT, PhD, delivered in her presentation of the Academy of Physical Therapy Education Section’s Pauline Cerasoli Lecture. She asked the audience to reflect on the changes that have occurred in physical therapy during the past 20 years: "What have we learned? With Vision 2020, we understood it was the profession's intention to transition to the DPT degree. Did we imagine that in 20 years the number of high-quality applicants to PT programs would nearly double, or that program development would accelerate? Did we anticipate a decline in PTA enrollment? Did we imagine that the average number of clinical sites affiliated with a PT program would more than double, or that DPT programs would decrease in length? How well did we plan for an aging professoriate and leadership as baby boomers reach retirement age? Did our past 20 years embody coddiwomple?" Frost then suggested factors that can influence the future of physical therapy education. Among those already affecting the profession—and certain to have an even greater impact in the years to come—are disruptive innovation and new technology, big data analytics, and relationship transformation. She described the "flipped classrooms" at the University of Vermont’s College of Medicine, with lectures delivered by videos outside the classroom and small groups of students meeting for active learning during class time. Another example: The HoloLens, a wearable holographic computer that presents 3D images, is the result of a partnership among Case Western University Medical School, Cleveland Clinic, and Microsoft. Frost then asked, "How can we embrace disruptive innovation and contribute to the development of new technologies?" and offered suggestions. One is collaborative and shared leadership: "We must consider models of leadership that enable innovation, flexibility, and bold decision making to navigate a more complex, dynamic, and unpredictable environment," Frost said. She also proposed greater use of design thinking, which begins with empathy and combines creative and analytical approaches. Initiatives for Chronic Pain Management Go Beyond the Opioid Epidemic Speakers for the Orthopaedic Section session "The Chronic Pain Epidemic: National Research, Education, and Practice Initiatives" addressed what they called not just the "opioid epidemic" but also the "chronic pain epidemic"—noting that the issue of pain management is larger than just finding alternatives to opioids, more broadly encompassing the need for better approaches to acute and chronic pain. The presenters were Kathleen Sluka, PT, PhD, FAPTA; Linda Porter, PT, PhD; and Kara Gainer, JD. Sluka said the chronic pain management problem starts in professional education. Most schools—not just for physical therapy but for other health care disciplines as well—do not include curricula for pain management, she said. Research also is lacking: "Funding doesn't match the problem," she said. "The expenditures to address the problem vs the societal cost of the problem is unbalanced." Porter described several federal initiatives to address chronic pain management, including the National Pain Strategy, National Pain Research Strategy, National Institutes of Health Pain Consortium, and Interagency Pain Research Coordinating Committee. One challenge is the need for more data. One hundred million American adults may experience pain, Porter said, "but we don't know if they have access to pain care, or what type of access." She compared PT education on pain management unfavorably with that of veterinary education, saying it is "exponentially less than it is in veterinarian schools—your pets can get better pain care than you can." Gainer described APTA's efforts toward promoting physical therapy as a nonpharmacological option for pain management. At the forefront is the #ChoosePT campaign to increase public awareness of the benefits of physical therapy. But much more is going on behind the scenes as the association advocates for expanded coverage of services, smaller patient copays, and more recognition of the role of physical therapy in prevention strategies. "We talk to the Centers for Medicare and Medicaid Services all the time," Gainer said, in addition to commenting on proposed rules—even those not directly related to physical therapy; for example, Medicare Part D proposals—to bring up physical therapy as an alternative to drugs. Managing Wrist Injuries for Better Function Kristin Valdes, OT, OTD, began the Academy of Hand and Upper Extremity Physical Therapy session "Wrist Injuries: Evaluation and Treatment" by sharing 2 clinical pearls: assess composite motion of the hand and wrist to determine the presence of extrinsic tightness, and assess intrinsic tightness. To assess for extrinsic tightness, Valdes said, have the patient make a fist with the wrist in neutral and then in full flexion. "If the motion is greater with the wrist in neutral, extrinsic extensor tightness is present." To assess for extrinsic flexor tightness, Valdes advised having the patient straighten digits with the wrist in neutral and then with wrist fully extended. "If finger extension is greater with the wrist in neutral, then extrinsic flexor tightness is present." Valdes mentioned many available tests and techniques for assessing various modalities after a distal radial fracture, including the Figure of 8 technique, the Ten Test, and the Patient-Rated Wrist Evaluation (PRWE). She suggested that clinicians, when seeing patients in the first week after fracture, should concentrate on techniques to reduce edema. "Start early edema reduction and passive range of motion to stiff noninvolved joints. Caution patients not to wiggle their fingers, but rather to stretch to full extension." During week 2, concentration should be on scar management and edema reduction, Valdes said. Managing Employer Health Care Costs Requires Managing Employees' Health Two PTs from the Private Practice Section described their experiences in setting up and running health programs designed for employers and their employees. Russell Certo, PT, founded the MOG Group—MOG standing for "medically oriented gym." The MOG Group is a co-op of MOG sites owned by independent PTs and provides a central place for these sites to share policies, procedures, and business practices. The other panelist, Tracy Ervin, PT, is the founder of the Center for Physical Rehabilitation. Certo said, "Companies in the vanguard of containing health costs do it by managing health." He criticized large health care systems and "big insurance," saying "the health of communities continues to deteriorate despite the pseudo-attempts at prevention programs by ‘big insurance’ and health care systems. There is little incentive for change," Certo said. "Less-than-optimum health drives higher premiums and the need for more services." The solution, he suggested, includes employers negotiating health programs by identifying what actually provides value. "True prevention and wellness programs require expenditure initially," he said, "and must have individual incentive-based outcome measures." Ervin described her development of a worker health care model. One critical element was coordinating services with the company's human resources and safety departments, in addition to gaining support at the executive level. Also critical is making a dollars-and-cents case to the company's executives. Ervin cited such figures as the Centers for Disease Control and Prevention's calculation that the medical costs of people who are obese are $1,429 greater—about 42%—than are those of other workers, and that yearly medical costs and lost wages in the United States due to diabetes total $245 billion. Advanced Home Health Competency Program Goes Live at CSM Preparation for assessment, examination, and developing a plan of care in the home health environment can be a daunting task for the PT. A preconference course, "Advanced Competency in Home Health Live Training," was designed to help attendees enhance their skills. As part of the Advanced Competency in Home Health certificate program for PTs, the course fulfilled the face-to-face portion. The program is a partnership between APTA and the Home Health Section. Presenters were Melissa Bednarek, PT, DPT, PhD; Christine Childers, PT, MS; Nick Panaro, PT, DPT; Donald Shaw, PT, PhD, DMin; and William Walsh, PT. Panaro emphasized musculoskeletal assessments. "We need to know what we are assessing, why we are assessing, and how we are assessing," said Panaro, a board-certified clinical specialist in geriatric physical therapy. He stressed strength, range of motion, endurance, and mobility as starting points, suggesting tests and measures for each area. "Ask yourself what the most appropriate screening tool might be. Don't do something just because it is quick and easy," Panaro said. "The reason for using a test is twofold—confirming what we think or fear and planning for short- and long-term goals." Attendees used frequent lab opportunities to practice assessment techniques under the direction of instructors. If the Shoe Fits, Does It Reduce Injury More Than Gait Training Does? The popularity of running has never been greater. Concerns over concussions in high school contact sports, for example, have increased participation in cross country running. The Sports Physical Therapy Section session "Science Meets Practice—Form Before Injury Management" featured a debate on shoe selection versus gait training to manage running injuries. Leading into the debate, Jeff Taylor-Haas, PT, DPT, a board-certified clinical specialist in orthopaedic physical therapy, presented the case study of a teenage female with right anterior knee pain aggravated by running, climbing stairs, prolonged sitting, and squatting. Her running shoe scored a 36% on the minimalist shoe scale, with 100% being a shoe closest to barefoot running. Gait analysis showed that strike factor was the cause of her pain. Blaise Dubois, PT, SPD, opened the debate on "pro-shoe" side explaining that he looked at the science behind the current topic. "Technique is a small part of the puzzle," Dubois said. "We need to do what we can to make sure the body can absorb the shock of running." More technology just increases the bulk of the shoe, he said, and cushioning has no effect. Rich Willy, PT, PhD, argued that gait retraining is more efficient than is shoe type for injury management. "Why the fascination with running shoes?" he asked. "A study showed that shoe type had no bearing on injury rate." Willy, a board-certified clinical specialist in orthopaedic physical therapy, pointed to another study, of 577 runners on the effect of zero heel-to-toe drop ("drop" being the differential in height between the toe and the heel of a shoe), that showed no difference in injury rate over 6 months between a 10-centimeter, 6-centimeter, and zero-drop shoe. He continued, "Certain shoes do reduce knee loads, but this increases Achilles tendinopathy. On the other hand," Willy said, "we know that gait retraining reduces joint loads with lower Achilles tendon force." Spinning Out of Control: Approaching Dizziness in Acute Care As part of the Academy of Acute Care Physical Therapy's preconference course "My Patient’s Dizzy, Now What? An Acute Care Approach to Vestibular Dysfunction," Kerry J. Lammers, PT, DPT, and Gabrielle S. Steinhorn, PT, DPT, led PTs in employing evidence-based practice for patients who present with dizziness to assess, evaluate, and determine the course of treatment or referral in the acute care setting. Vertigo or dizziness may have many causes, but the interplay between the vestibular, oculomotor, and somatosensory systems combines to maintain postural and gaze stability. One cause, benign paroxysmal positional vertigo (BPPV), is triggered by certain changes in head position, such as tipping the head up or down. Steinhorn, a board-certified clinical specialist in neurologic physical therapy, stated that BPPV may account for up to 50% of falls in older adults, but she added that more than 90% of cases can be treated in 1 to 3 sessions. She cautioned that contraindications for treatment may include neck surgery, severe rheumatoid arthritis, and issues with vertebrae C1 or C2. Patients can be screened for balance in the hospital with an oculomotor exam, positional testing, or vestibulo-ocular reflex (VOR) test. "Observe that the patient’s eyes maintain fixation, [and observe] for skew deviation—1 eye higher than the other when performing vision tests," Steinhorn said. She recommended the Vestibular Evidence Database to Guide Effectiveness (V EDGE) as a "great resource from neuropt.org." Video clips and demonstrations by Lammers and Steinhorn, as well as hands-on practice time, gave attendees practical knowledge during the course. CPGs: From Idea to Final Product A team from the Academy of Neurologic Physical Therapy shared the work that went into developing a clinical practice guideline (CPG) on locomotor function that is expected to be published in the near future. The panel for the session "Clinical Practice Guidelines, Strategies That Maximize Locomotor Function" included T. George Hornby, PT, PhD; Darcy Reisman, PT, PhD; Irene Ward, PT, DPT; Allison Miller, PT; and Patty Sheets, PT, DPT. Miller and Sheets are board-certified clinical specialists in neurologic physical therapy. The group conducted a systematic review of the literature from 1995 through 2016 on the use of specific interventions to improve locomotor function—specifically walking—following stroke (cerebrovascular accident, or CVA), traumatic brain injury (TBI), or incomplete spinal cord injury (SCI). "The primary goal most patients had following an acute-onset of neurological injury was to restore walking ability," Hornby noted. "Walking speed predicts survival, and that’s pretty powerful." He said they studied randomized clinical trials and looked at actual interventions in both experimental and control groups. They also examined dosage, frequency, intensity, time, and type of therapy. As a result of the literature review, the CPG's recommendations include these: Clinicians may consider the use of strength-training strategies with multiple sets and repetitions to improve walking. Clinicians should not include sitting or sitting with dynamic standing to improve locomotor function. Clinicians may consider use of balance training with virtual reality. Clinicians may consider circuit training at high intensities with over 70% heart rate reserve to improve locomotion. Clinicians should include moderate- to high-intensity walking interventions for improving locomotor function in patients with chronic central nervous system injury. Clinicians should not perform body weight-supported training in lieu of over-ground walking, but they may use it as an adjunctive intervention for improving locomotor function. Emerging Trends in Telehealth Telehealth and mobile health applications are evolving rapidly, said the presenters of a Section on Research session. While they can’t be a substitute for all aspects of physical therapy, they can be more effective and less costly in the right situations than are traditional face-to-face interventions. Helen Hoenig, MD, MPH, addressed technology barriers to eHealth, as well as work-arounds and longer-term solutions. One challenge is low bandwidth—the inability to transmit enough data to show a patient at a remote location with sufficient detail and movement. "The resolution or the frame rate is reduced," Hoenig said, "resulting in image ‘freezing,’ or the image is blurred." Other challenges include the need for an assistant to hold the recording device, the large amount of storage space required for video, and security concerns. Rana Hinman, PT, PhD, described the Australian experience with telehealth, particularly as it relates to osteoarthritis (OA). There are obviously implications when there is no physical or hands-on contact with patients, she said, suggesting questions to ask when deciding which cases are suitable for telehealth. Regarding assessment, can diagnostic tests be performed remotely? Moving on to treatment, are manual techniques needed? Regarding the safety of patients, are screenings required? Hinman said that setting expectations is relevant for both PTs and patients. For example, a widely held belief among patients is that all physical therapy requires hands-on treatment. Kristin Archer, PT, PhD, cited studies showing that interventions via telehealth can be as effective as, and less costly than, in-person interventions. She conceded, however, that it takes some work to adjust communication styles when working remotely with patients. Is Technology Moving PTs From a Hands-On to Hands-Off Profession? In moderating the 2018 Eugene Michels Forum, James Gordon, PT, EdD, FAPTA, set up a discussion between Fay Horak, PT, PhD, and Dorian Rose, PT, PhD, with a question: Should we embrace the current wave of patient-oriented technologies, or exercise caution and wait for definitive evidence? Such was the topic of debate for the Section on Research session titled "The Current Wave of Technology: Should We Ride It or Should We Start Paddling?" Although neither Horak nor Rose in reality endorsed either position, each had volunteered to take a side for the debate. Horak's arguments for embracing technology now included these: Technologies give PTs more time and data, enabling them to give greater attention to their clinical decision making, as opposed to performing tasks. New equipment and devices "allow measures to be more accurate and sensitive to change than are clinical measures that use a rating scale," she said. Technologies give patients more time and better feedback to practice the quality of the movements their PT has prescribed to them. "In the clinic," Horak explained, "you can ask the patient only a limited number of times to 'turn right,'" and the results may not represent how the patient moves in daily life. Wearing a body-mounted video camera, the patient can record every right turn made in a day for the PT to analyze. Costs for equipment and devices are offset by the time the PT gains—that time being the largest part of a clinic's expenses. Rose said PTs should consider these questions before jumping on the technology bandwagon: Does technology pose a risk to the therapeutic alliance between the PT and patient? Patients want to sense that the PT is listening, engaged, honest, and committed. Is evidence-based practice (EBP) a comfortable fit with technology? One of the 3 pillars of EBP, patient values, shouldn't be discounted. One study Rose cited indicated that patients preferred working with a human to a robot. How will new technologies be taught? There isn’t a standard for teaching across programs, and technologies change so fast that they could be obsolete by the time a student graduates. Does equipment start to drive decisions? PTs might be tempted to think "I just spent thousands of dollars on this equipment, so I'd better use it" even if it isn't best for the patient, Rose said. Treating Patients With HIV Focuses on Independence, Pain Management, Quality of Life Although we may not hear about HIV and AIDS as much as we did 25 years ago, the virus remains prevalent. Sara Pullen, PT, DPT, MPH; Roberto Sandoval, PT, PhD; David Kietrys, PT, PhD; and Mary Lou Galantino, PT, PhD, MS, MSCE, presented the Oncology Section session "HIV in 2018: It's Not Over Yet—What Every Physical Therapist Needs to Know." Pullen said the goals for working with a patient with HIV should be the same as working with any patient—increasing functional independence, decreasing or eliminating pain, independent self-management of impairments, and improving quality of life. "Although there are many potential side effects, you must advise your patients not to stop taking their drugs," said Pullen. "Stopping antiretroviral therapy [ART] allows HIV to multiply and become resistant, and resistant HIV can be passed to others." Kietrys said that 39%-55% of people living with HIV have chronic pain. Among those, 87% are more likely not to adhere to ART. PTs can help manage chronic pain with exercise, transcutaneous electrical nerve stimulation, and manual therapy. As people with HIV are living longer, they are at an increased risk for certain comorbidities, Galantino said, such as cardiovascular disease and stroke, osteoporosis and fracture, metabolic syndromes and diabetes, renal disease, neuropathy, malignancies, and geriatric syndromes. Helping Prevent Toxic Stress in Infants The trauma experienced by neonatal infants—those within 28 days of birth—can have lifelong effects, according to Mary Coughlin, RNC-E, NNP, MS. She presented the Academy of Pediatric Physical Therapy session "Trauma-Informed Care: A New Paradigm for the NICU." Pointing out that "you don't have to be abused to experience trauma," Coughlin said that individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening. Such an event has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. Although she acknowledged that not all stress is bad, Coughlin noted that even toxic stress may result without health care professionals or parents being aware of the situation. For example, an infant's stress may arise from maternal deprivation or separation, unmanaged or undermanaged pain, social isolation, or sleep fragmentation or deprivation. Coughlin cited evidence that 50%-70% of infants born preterm develop behavior problems. Coughlin said, "The secret sauce is maternal care. Parents are integral to the comprehensive care of their hospitalized infants." Another important component, she added, is the knowledge and behavior of PTs who can contribute to the prevention of pain and stress in the hospitalized infant. Medicare A to Z: APMs, CPT, MIPS, PFS, QPP, VBC, SZ, and More Medicare and commercial payers have moved toward value-based care (VBC) models to determine payment—shifting from payment based solely on the volume of care to payment more closely related to outcomes. While changes in some federal approaches have slowed the pace of specific efforts, the overall trajectory still moves toward making providers accountable for the outcomes of patient care. Three Section on Health Policy and Administration sessions ran through the alphabet of Medicare updates. "Emerging Issues in Medicare" (2 sessions) and "Strategies for Implementing Performance Measures in Value-Based Payment Models" featured speakers Stephen Hunter, PT, DPT; Bridget Morehouse, PT, MPT, MBA; Charles Thigpen, PT, PhD, ATC; Alice Bell, PT; Kara Gainer, JD; and Heather Smith, PT, MPH. APTA staffers Bell, Gainer, and Smith offered descriptions, as well as specific instructions and suggestions, for complying with several new Medicare rules. Among the issues covered: 2018 Medicare physician fee schedule (PFS), including changes to CPT code values, and new or revised codes Permanent fix to the therapy cap, and the future differential in payment for PTA services Prospective payment system updates for home health, skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals Postacute care payment reform efforts toward a unified payment system Change from the SZ modifier to 96 and 97 modifiers for habilitation and rehabilitation services Medicare Quality Payment Program (QPP), including the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) Hunter, Morehouse, and Thigpen shared takeaways from their implementation of VBC programs that incorporated performance measurement. Simply knowing a patient’s likelihood of achieving clinical improvement can influence the PT’s clinical decision-making, Thigpen said in opening the presentation. From a private payer perspective, Morehouse said, companies could save "a ton of money if they look beyond number of physical therapy visits" and realize the savings from fewer MRIs, surgeries, and opioid prescriptions (with the potential costs for treating abuse). Hunter noted the challenge of getting accurate data on who's providing the care. "You'll know who signed the note," he said, but any other PT or PTA who provided treatment needs to be identified, too. Getting Around: Skills Training for Wheelchair Use When they are independent in their mobility, people who use wheelchairs report better long-term well-being, health, and participation. Yet many people have trouble negotiating common obstacles. In their presentation of the Federal Physical Therapy Section session "Roll With It! Wheelchair Skills Training From Basics to Extremes," speakers Kendra Betz, PT, MSPT, and Lynn Worobey, PT, DPT, PhD, shared their expertise as PTs and certified assistive technology professionals. Fit is essential to ensuring successful wheelchair skills. "Treat the wheelchair as if it’s an orthosis," Betz suggested. "You want a wheelchair to fit the patient in the same way, with the same precision." Rear-wheel position is particularly important. The wheel should be adjusted as far forward as possible without compromising the user’s stability. Betz cited research that shows this position decreases roll resistance and increases hand-to-push rim contact—allowing users to propel themselves with less muscle effort, smoother joint patterns, and lower stroke frequency. In describing different propulsion patterns, Betz said the most common approach is "single loop," but that a "semicircular" approach provides the best mechanics—with smooth, long strides that limit high impact on the push rim, and that lower the force and frequency of strokes. However, she added, the best approach can depend on the task, and on surface conditions. Despite its benefits, wheelchair training is hampered by barriers such as limited time for individualized training, fatigue and stress, lack of insurance coverage, and clinicians' limited knowledge. Worobey offered that group training can overcome at least some of these obstacles. A group dynamic encourages user collaboration—they can mimic, mentor, cheer each other on, and engage in healthy competition. In addition, users can share their tips, supplier and repair referrals, and frustrations with routine activities such as traveling and parenting. Attendees Urged to Take 'Exquisite Risks' to Enhance Profession's Social Responsibility American Board of Physical Therapy Specialties (ABPTS) keynote speaker Theresa Spitznagle, PT, DPT, MHS, declared, "We should consider a shift in our clinical values. We can do a lot for our patients with very few resources." Spitznagle, immediate past chair of ABPTS, is a board-certified clinical specialist in women's health physical therapy. The theme of her remarks, "Exquisite Risk: Reflections on Professional Values," focused on the dual meaning of the word "exquisite"—suggesting both beauty and intensity. Speaking to physical therapists (PTs) who had earned ABPTS certification, she said, "I wondered: Why did you take this exquisite risk? Was there a benefit for you? For your patients? For our society? For societies beyond our own?" Spitznagle addressed physical therapy's core values of accountability, altruism, compassion, excellence, integrity, professional duty, and social responsibility. She noted that a 2016 study of PTs found that social responsibility was embraced by only 5%. If social engagement were to be better developed as a core value, Spitznagle asserted, more in the profession would engage in pro bono care. "To improve social engagement, we need to move from an individualistic perspective of our profession to a larger lens that includes interdisciplinary activities and strategies for improving society level practice," she said. She asked her audience to consider what their next exquisite risk will be. "Reflecting on our clinical experiences allows us to better serve our patients and, at the same time, put our professional values into action," she said. Adding Women's Health Content To an Already Full Curriculum How can a DPT curriculum add women's health content while retaining other needed and desirable courses? Two PTs described their solution: Make a single course do double duty. Skye Donovan, PT, PhD, and Carrie Pagliano, PT, DPT, explained their strategy in the Academy of Women's Health Physical Therapy session "Women's Health in a DPT Curriculum: Integration Without Adding to Academic Bloat." Professional education programs already are constantly challenged with meeting the demands of advancing evidence, innovative practice, and entry-level practice standards. Curricula may be suffering from "academic bloat," as clinicians and students demand exposure to emerging areas of practice, while emphasis still is needed on an already long list of content areas. Donovan and Pagliano said they realized they could take many modules in the current curriculum and replace them with modules that address those same areas, but from a women's health perspective. For example, CAPTE guidelines include topics—such as genital, reproductive, lymphatic, and systems interactions—that could encompass women’s health. Further, the National Physical Therapy Exam, while containing few questions relating specifically to women’s health, includes questions that potentially could be addressed in women's health courses. Pagliano explained, "In geriatrics, we found a relationship between falls and urinary incontinence, because the patient may get up 5-6 times a night. Rather than focusing on falls, the module can focus on why they’re getting up." Similarly, in acute care, Pagliano described the link between incontinence (and resulting dampness) and pressure ulcers. "If there's moisture, there will be skin breakdown," she noted. "Let's address the underlying cause of the moisture." Stories are abridged from PT in Motion News @ CSM, published by APTA and produced by CustomNews Inc. Contributing editors and writers are Donald E. Tepper, APTA; Lois Douthitt, APTA; Tim Mercer, CustomNews Inc; and Deb Nerud Vernon, BS, MA, EMT-P, CustomNews Inc. Photographer is Jonathan Bachman.