Feature Highlights From NEXT Conference and Exposition 2019 From an inspiring account of one person's rise from opioid addiction to a discussion of implementing direct-access physical therapist services in a hospital, APTA's NEXT conference offered sessions, presentations, and networking events for PTs, PTAs, and students. Here are some highlights from the June meeting in Chicago. By APTA Staff | September 2019 Opening Event: A Moving Account of A Journey out of Pain and Addiction "I failed my marriage. I failed as a father. I failed my career. And I didn't even know it was happening." That's how Justin Minyard describes the lowest point in his life: After 2 spine fractures and multiple surgeries, he became addicted to the opioids prescribed to him. He found himself consumed by his pain and his meds—how many he had on hand, when he could take the next one, where to get refills. His addiction led to a suicide attempt and 2 accidental overdoses. But most devastating for Minyard was that his addiction hurt the people he loved the most. "I let them down," Minyard said. "You didn't want to be around me." Now things are different. With the help of an interdisciplinary care team that included a physical therapist (PT), Minyard said he learned how to "make pain a footnote, not the header" of his life and defeat his addiction. He became 8 years clean in July. Minyard's moving story was delivered as the keynote address at the NEXT opening event on June 12. The retired Army Master Sergeant recounted the injuries he received—first during a rescue attempt at the Pentagon during the 9-11 attacks and then while on a mission in Afghanistan—but focused more on what happened afterward: the multiple fusion and other surgeries, the intense pain, and his eventual slide into addiction. "I didn't wake up one day and say, ‘This sounds great,'" Minyard said of his use of opioids, He believes, however, that his passive approach to exploring treatment options played a role in his use of drugs. "I was not an educated patient; I didn't ask questions," he told the audience. After more than 2 years of attempting to manage his pain through opioids and other medications—and becoming addicted along the way—Minyard began to see options for change. His last fusion surgery kept him in the hospital for 3 months. Then a physician who called Minyard a "hot mess" offered him another avenue: a pain-management program that involved 9 different professionals, including a psychologist, psychiatrist, a pharmacologist—and a PT. Minyard took him up on the offer, and moved from what he describes as a "pain-centric to a patient-centric model of care." Minyard credits his PT with helping him accept the idea that, yes, he might be in pain for the rest of his life, but he could find ways to manage the pain and make it "more of a footnote, less of a header." Now, Minyard says, on most days his pain level is moderate but manageable—around a 3 on a pain scale of 10. Minyard also feels that it wasn't just about the physical therapy itself. He thinks his relationship with his PT was a major factor in his recovery. "She wasn't just my PT, but my psychologist, my sounding board, my marriage counselor, educator of my options, and my kick in the ass," Minyard said. "She was all of those things." His recovery included taking his PT up on a suggestion that he try handcycling. He liked it—so much so that he wound up medaling in traditional upright cycling at the Invictus Games for armed services personnel and veterans. Even more important for Minyard is how the changed approach to pain management gave him back his life with his family. "I am my 11-year-old daughter's soccer coach," he said. "I get to be her coach. I don't know a damn thing about soccer, but I get to be her coach. I almost lost that. I was this close, multiple times." While Minyard credits a single PT with a major role in his own recovery, he told the NEXT audience that the entire profession of PTs and physical therapist assistants (PTAs) should be proud of the life-changing work they do. "You're going to continue to make such a tremendous impact on countless other patients," Minyard said. "Choose PT." McMillan Lecturer Outlines Keys to Excellence in the Physical Therapy Profession Tom McPoil, PT, PhD, FAPTA, said he intentionally wrote the title of the 50th McMillan Lecture—"Is Excellence in the Cards?" as a question to "raise an element of doubt or uncertainty in our quest to achieve excellence." That's because, he said in delivering the address on June 13, he has several concerns. Before listing them, however, McPoil recognized some of the profession's significant accomplishments since he began his career in 1973. "We no longer serve as a subservient technician in the health care system, our students now obtain an exceptional education and are granted a doctoral degree, we can practice in a variety of specialty areas in multiple practice environments, and we have achieved the ability to practice autonomously with patients having direct access to our services," he noted. But, he said, there still is room for improvement from both clinical and academic perspectives. From the clinical standpoint, he described 3 areas. First, McPoil questioned continued acceptance of examination and management methods that may have been proven to have no evidence to support their use. As an example, he identified what is known as the podiatric model, which classifies foot types based on the concept of subtalar joint neutral position. McPoil said that subsequent studies—including those he and colleagues conducted—showed that "subtalar joint neutral position had no relevance to the typical pattern of rearfoot motion. In short, our results challenged the validity of the podiatric model." Yet, he continued, many physical therapist education programs and postprofessional continuing education courses still teach the model. McPoil expressed hope that the profession will continue to stress the importance of using methods that have been validated with basic science and clinical evidence, especially at entry level and in education programs, "as it is our new doctor of physical therapy graduates who must serve as our profession's change agents." Second, McPoil expressed concern over a lack of acknowledgment of historical research studies that provide evidence for a practice's continue use. He quoted a 2009 article by Mary Halefi ("Forget This Article: On Scholarly Oblivion, Institutional Amnesia, and Erasure of Research History," Studies in Art Education) noting that "recurring themes, issues, and concerns are part of any field" and that failing to cite them along with more contemporary studies risks the loss of past scholarly endeavors upon which current research may be based. "Hopefully," McPoil said, "our professional journals will always perform their due diligence" to retain the contributions of past scholars and researchers. Inconsistence in the level of care was McPoil's third area of needed improvement. He noted some probable causes of inadequate care, such as limited patient time resulting from low payment rates, some highly specialized areas of practice that not all PTs are familiar with, and lack of clinical practice guidelines (CPGs) that address needed services. As for specialized areas of practice, he said that physical therapist-to-physical therapist referral is "rare" and that the value of intraprofessional referral needs greater emphasis during entry-level education. Concerning CPGs, McPoil argued that while they are important, they cannot always guide the clinician to an appropriate decision and "cannot replace the need for clinical reasoning and practice knowledge." Such knowledge, he said, "can be achieved only through residency or fellowship training." To that end, McPoil said it may no longer be feasible to train a generalist at entry level. The profession must consider allowing specialization to begin before graduation. He identified challenges to developing residency and fellowship programs, such as student loan debt, salaries that aren't commensurate with advanced clinical specialization, and lack of federally funded support. He expressed hope that the profession will prioritize development of these programs, as needed funding for them won't occur until they are the expected route after professional graduation. "Our pathway to excellence demands no less," he said. McPoil followed up with his thoughts on achieving academic excellence, specifically the need for every faculty member to have "a personal agenda for scholarship that includes publication." For Optimal Outcomes, Look Beyond Compensation Patterns, Maley Lecturer Says "Any movement-related profession—personal trainers, athletic trainers, dance therapists, yoga instructors—who can observe impairments such as a weak muscle can try to fix it," said Beth Fisher, PT, PhD, FAPTA, in delivering the 24th John H. P. Maley Lecture on June 14. However, too often the "fix" involves the patient compensating with movement patterns that interfere with the ability of an affected limb to improve to its true potential. Fisher argued that with their level of education and skill, PTs can and should identify and help the patient recover that capability. During her presentation "Beyond Limits: Unmasking Potential Through Movement Discovery," Fisher said that in earlier clinician practice with patients with stroke and brain injury she continually hit ends points with her patients, but then she realized "these were my endpoints and not the patient's, [because] at least 1 aspect of the movement abnormalities…were the results of compensation." Given the brain's ability to continuously alter its structure and function, and the body's ability to achieve movement goals in more than 1 way, people with an impairment tend to progress toward the movement pattern that is most efficient—that achieves a goal using the least amount of energy and the fewest body parts. But while a compensatory solution may get the job done, this easy route that comes naturally may not lead to optimal improvement—thus denying the patient the best possible outcome. In fact, "the compensations [patients] choose may be the source of the problem—may actually predispose the problem to occur," Fisher said, by keeping the patient from exploring better ways to achieve movement goals. She asked: Is this really the best PTs can do? "If we want to reach someone's full capacity, then we need to go beyond this limited choice that patients come up with on their own without a physical therapist," Fisher said. However, she argued, PTs have been academically trained to view movement from an impairment-driven perspective—assuming that a patient's compensatory movement pattern results from an impairment that is masking his or her capability. So, both PT and patient expect that compensation will provide the best—or only—results. "If I have minimal expectations," Fisher asked, "how is that going to impact my patient's expectations? What is that going to do for recovery potential?" Instead, as professionals with the expertise to look beyond compensation approaches, PTs must encourage potentially riskier, more-difficult solutions. "With what we know about brain plasticity, it is our job to help patients realize that they have more options," she said. By modifying that implicit choice, the PT can help patients discover a capability they may not have even realized they have. "The most rewarding moments I have had in my career have come when I hear ‘I didn't know my leg (or arm) could do that,'" Fisher said. She noted that PTs can't ignore impairment, "but if we are only viewing the problem from that perspective, we and our patients will reach a plateau-minimizing capacity." Instead, every student and therapist should consider how a movement choice can mask capacity. "We need to start from the bottom up," Fisher said, "and teach students to observe movement and hypothesize how implicit choices—not just impairments—may be driving movement faults." Otherwise, "We have limited patients and their potential to discover other options for movement by a perspective that does not consider the choices they make." How One Hospital Implemented Direct Access During a June 13 session, a panel of PTs from the Hospital for Special Surgery (HSS) in New York explained how that institution implemented direct access (DA) to physical therapist services. They then advised attendees how to operationalize DA at their own institutions. Presenters from HSS were Carol Page, PT, DPT; Mary Murray-Weir, PT, MBA; Robert Turner, PT, DPT; and Jaime Edelstein, PT, DScPT. Also presenting was Aaron Keil, PT, DPT, from the University of Illinois at Chicago. Keil noted that while DA was achieved in all 50 states and the District of Columbia in 2015, only 18 states have unrestricted access. The other states include limits or restrictions, meaning there still are barriers to DA. Keil cited a 2015 APTA survey in which nearly 65% of respondents said the major administrative barrier to DA implementation was "My supervisor/facility requires all patients to have a referral." Keil noted that this is especially true in hospital-based inpatient and outpatient facilities, as hospitals tend to be more risk-averse and "may be more restrictive than state law." Page said that an essential first step to achieving DA was getting buy-in. One key group was physicians—particularly surgeons—who were concerned that their patient levels would drop. Page explained, "We showed that direct access would ‘widen the funnel' and actually provide them with more patients," while at the same time screening to send only appropriate patients to the surgeons. Administrative staff were taught how to screen patients and schedule them with appropriate PTs. They also were made responsible for tracking the timing and number of permissible visits for adherence to state provisions, building on an HSS foundation of training and competency programs it conducts for all staff. The hospital established criteria for DA PTs that were more stringent than those required by the state. For example, while New York requires 3 years of clinical experience, HSS further required that experience to be at outpatient facilities. It also required continuing education in certain areas, such as spine, manual therapy, and differential diagnosis. Turner described the development of a written exam for aspiring DA PTs. Questions were developed following the same item-writing guidelines used by the American Board of Physical Therapy Specialties. A score of 80% is required to pass the test. HSS also developed a practical examination involving an actual patient. The primary question to be answered is: "Can you take this patient and treat him or her? Or do you refer to a physician?" The program was made voluntary for PTs since some didn't initially feel comfortable with it. "Not everyone fits the mold," Turner said. Page addressed operationalizing DA, which she divided into 4 categories. The first was resources. She advised those in the audience to search APTA's website for "direct access" and browse the resources. The second category was billing, which she made clear "is different in a hospital setting" from a private practice and requires a hospital-wide effort. The team leading the DA program at HSS made a conscious decision not to contact insurance companies in advance and announce their intentions. "We did a soft launch with a small number of patients. We let them know that their interventions might or might not be covered," Page said, but he found that most insurers did cover the services, and HSS now contacts insurers in advance. The other elements of operationalizing DA were documentation and marketing. These included developing specific policies and procedures, providing notice of advice for patients, identifying common ICD-10 codes, and developing tip sheets for patients and physicians. Building Wellness Programs in The Least Likely Places Sometimes, basic assumptions beg to be questioned. Just ask PTs in the oncology rehabilitation department of Froedtert Hospital and Medical College of Wisconsin, who wondered why prevention and wellness couldn't be a part of the patient experience from the moment they enter the facility's doors. That questioning led to development of an innovative group exercise program for patients in the hospital for chemotherapy and other treatments primarily related to blood cancers. So far, the program seems to be allowing many patients to leave as mobile as, if not more so than, when they arrived. On June 13, the PTs shared their story of how they established and expanded the program, known as the Strength in Numbers exercise class. The idea behind the program was based on a reality check of the typical path of an oncology patient visiting the hospital for treatment, explained Kelly Colgrove, PT. Unlike patients who arrive with other conditions such as congestive heart failure, "our patients walk in strong and independently." During the course of treatment, however, they often experience decreased muscle strength, challenging PTs to play catch-up before the patient is discharged. The Froedtert PTs wanted Strength in Numbers to change that. As it now operates, the program—known as "SIN" to the amusement of patients—offers a 1-hour group circuit training class 2 times a week. Colgrove describes SIN as "a fun environment based on camaraderie and music, but all within the acute care setting." Patients are selected for the voluntary program based on their health at the time of check-in, Colgrove explained. Those whose condition is more fragile receive more typical 1-on-1 physical therapy. Patients who qualify for SIN are assessed, given goals, and scheduled to participate in the group. Once in SIN, patients still can choose to return to the more traditional therapy program. Besides the direct physical benefits to patients, SIN has helped reinforce what the presenters called a "culture of mobility" at the hospital. The presenters led attendees through their process of developing and maintaining the program, encouraging audience members to envision similar possibilities in their own practice settings. They explained the importance of a solid basis in research, careful consideration of stakeholder concerns, evaluation of current and needed resources, and program metrics to evaluate outcomes, among other areas. Through their recaps, the presenters demonstrated how flexibility and creativity are key elements in all areas of development, implementation, and evaluation. "Being able to adapt and evolve is going to be key," explained Alyssa Kelsey, PT, DPT. For SIN, that means seeking ongoing input from patients and staff, as well as conducting monthly check-in meetings to monitor operations and identify future goals. That flexibility also should include the capacity to question your own assumptions and evaluative measures, explained Colgrove. "Sometimes, the questions you think you want to answer at the beginning of the program may not be the questions you want to answer after a year." One question has been consistent throughout SIN: Does it work? So far, the answer seems to be yes. Outcome measures for patients with a length of stay longer than 20 days and more than 50% participation in SIN found that 72% maintained or improved their 5-time sit-to-stand scores, 64% maintained or improved on functional gait assessment, and 53% maintained or bettered their scores related to self-perceived deficits at discharge. If patient enthusiasm for the program is any measure, SIN also is doing well. According to the presenters, the lone criticism expressed by many patients is that classes are held only 2 days a week. Rural Health Care Has Plenty of Challenges but Promising Opportunities When it comes to rural health, there's no denying that demographic and financial challenges can affect care. But there also are opportunities for improvement, and PTs and PTAs need to be ready to advocate for them and, when necessary, create them. That was the message of a session on rural health care delivered on June 14. The session explored the factors that make rural health care different from health care in more urban areas—differences that in some instances point to the need to rethink how funding is allocated. Presenters pointed to the possibility that the US Centers for Medicare and Medicaid Services (CMS) might be in the early stages of doing just that. Meanwhile, they said, the potential for better patient access through telehealth needs to be seized. Presenter Jeremy Foster, PTA, boiled down the status of rural health care to a single sentence: "We have all these conditions that are worse in rural settings, but the money's not there." Foster led attendees through a tour of the demographic elements that create challenges, including a higher percentage of people in rural areas who describe themselves as having "fair or poor" health compared with those in urban settings, and a generally older population. Other disparities include higher rates of tobacco use in rural areas, an average annual income gap of $9,242, and life expectancy that averages 2 years shorter than that of the urban-dwelling population. Access to care is, of course, a significant problem in rural areas, Foster explained, and although critical access hospitals (CAHs) often provide high-quality, patient-centered care, current funding systems tend to be based on population more than on need. Gaps can arise, therefore, when a smaller population begins to experience conditions that lead to worse health conditions. This must change, Foster said, because CAHs are providing much-needed care and economic benefits that are worth supporting, including contributing more than $7.1 million to local communities annually through wages and benefits, and providing needed care—an average of 39 million outpatient visits, 809,000 adult hospital admissions, and 82,000 infant deliveries per year. "There needs to be a lot more research around rural health care," Foster said, but he added that providers in the rural setting have a responsibility to be "trustees of the money we receive." Brendon Larsen, PTA, BS, took a deeper dive into the current state of CAHs and rural health care in general, saying that rural health providers are challenged to care for a population that is considered "older, sicker, and poorer" than its urban counterpart. CAHs' challenges include an aging infrastructure and a workforce shortage that isn't limited to clinicians, Larsen said, with CAH leaders reporting a 61% shortage in applicants for nonclinical and administrative support positions. At the same time, the type of services provided by CAHs is evolving, with outpatient treatment now making up 60% of CAH gross revenue. The problem, he explained, is that many funding assumptions regarding rural health care are rooted in inpatient care. When those factors are added to ever- increasing regulatory burdens, CAHs and other rural health providers find themselves struggling to stay afloat when the need for better patient access is increasing—including the need to respond to the nation's opioid crisis. But could some relief be on the way? Maybe, said Larsen: CMS has formed a Council for Rural Health that is looking at developing a rural health policy initiative. The idea, Larsen explained, is to apply a "rural lens" to CMS programs, to maximize providers' scopes of practice, empowering patient decision-making in rural areas, supporting new partnerships, and further expanding telehealth opportunities in rural areas. Of those potential improvements, telehealth could be of the most immediate benefit, said Carmen Cooper-Orguz, PT, DPT, MBA, who rounded out the program by describing the promise of telehealth, and specifically telerehab, for improving patient access to care. "There are more ‘cans' than ‘cannots' when it comes to telerehab," Cooper-Orguz told the audience while running through a list of assessments and treatments that could be accomplished remotely. The problem, she explained, is that while most providers understand the potential for telerehab, the on-the-ground conditions for providing it need to improve. That will take action from the physical therapy community to advocate for changes to payment policies, state licensing laws and regulations, and provision of rural broadband. Cooper-Orguz said one of the most important ways for PTs and PTAs to pave the way for better policy around telerehab is to press for adoption of the Physical Therapy Licensure Compact in all states. By dismantling geographic boundaries to practice, the compact opens up the possibility for increased use of telerehab—but only if compact adoption is accompanied by licensing laws and regulations that permit remote practice, she added. Oxford Debaters Argue: Is Social Media Hazardous? The verdict is in. The results of the 12th annual Oxford Debate found that social media is hazardous to the profession. That was the ruling of the debate's moderator, Charles Ciccone, PT, PhD, FAPTA, who presided over the event on June 14. Debating the pro position—arguing that social media is hazardous to the profession—were Jimmy McKay, PT, DPT (team captain); Jarod Hall, PT, DPT; and Karen Litzy, PT, DPT. Taking the opposing position were Ben Fung, PT, DPT, MBA (team captain); Jodi Pfeiffer, PTA; and Rich Severin, PT, DPT. Leading off for the pro team—all of whom were dressed in bright yellow hazmat suits—was Litzy. She explained, "Our job isn't to say that social media is good or evil, but that it's hazardous. People there bitch and moan, sell pseudoscience, and attack others. This is where social media becomes hazardous. There's misinformation and disinformation. Misinformation is false, whether or not the intent is to mislead. Disinformation is deliberately false. CAPTE [the Commission on Accreditation in Physical Therapy Education] acknowledges that the use of social media should be included in the curriculum. As a profession, we have to work for the good. We should improve our media literacy and fact-check so that we don't spread misinformation. " The con team—in a tip of the hat to NEXT 2019's Chicago locale and the movie "The Blues Brothers"—consisted of Fung and Severin dressed as the Jake and Elwood Blues, and Pfeiffer as the nun Sister Mary Stigmata. Pfeiffer led off, arguing, "Social media is vital. It's how we communicate with each other. Some people disseminate misinformation on social media. How do we correct it? On social media. We will use it to get rid of the misinformation. Social media is addressed in APTA's Code of Ethics because we need it. We need to reach the Millennials. It's what they read. We use social media to tell everyone what great work we are doing and to promote the profession." Hall responded, "One study said that, across social media, young professionals spend 116 minutes a day." Borrowing the concept of schadenfreude—defined as pleasures derived from the misfortunes of others—Hall referred to "schadenFacebook." "It's where you relate the great things you said to Mrs Jones and ignore the stupid things you said to 50 others. Sometimes the grass looks greener because it's fake." Fung, however, insisted that social media does more good than harm, asking, "Which is more hazardous to our profession—that questions are being asked or that we're not part of the conversations? One study found that only 1 in 10 people who need physical therapy will receive physical therapy. If you want to get the average person away from the screen, you have to be part of the conversation. The greater issue is that when people ask questions, we're not there [on social media] in their time of need." Audience participation followed, with a near-even split of 7 for the pro position and 6 for the con. Among the comments: Anything can be hazardous. If we're not using social media, we're missing an opportunity. How many people have met people on social media? How many of you have met people at NEXT and other APTA events? For me, it's about the human connection. Attendees also made their views known by using clappers, running from one side of the room to the other as a debater made a persuasive point, and enthusiastically cheering. Severin summarized for the con team: "PTs are the movement experts. But people have an outdated image of physical therapy. #ChoosePT changed many views about physical therapy. The Day of Service, under the brand of physical therapy, has helped. Social media is key to that movement. Illinois and Texas recently adopted direct access legislation, and social media was vital in that effort. Social media has removed hazards to the profession. It's where we create communities. In addition, it's where patients and the next generation of PTs are going. We need to engage with our communities on social media." McKay summarized for the pro team: "My job isn't to show that social media is good or bad, just that it's hazardous. Social media leads you to do things you'd never do in person. APTA has policies regarding the dangers of social media. Social media is how the anti-vax science goes viral. This is how Flat Earth Society thought goes around the world. Social media filters and distorts information. That's hazardous. But social media is not going away. So we must be safe when using it." After weighing the arguments and presentations, Ciccone found in favor of the pro team by a score of 29-23. NEXT Attendees Rebuild Toy Cars to Aid Children's Mobility PVC ratchet cutters, screwdrivers, and wire strippers may not be among the tools usually used by PTs and PTAs. But at the NEXT 2019 session "Go Baby Go: Mobility Research, Design, and Technology," those and other devices—such as electrical tape, collections of screws, a power drill, and myriad other items—were part of a clinician's toolbox. Jason Craig, PT, DPhil, and Skye Donovan, PT, PhD, led the session, which addressed the importance of mobility for young children. The program—conducted on June 13 and 14—primarily focused on converting 9 battery-powered children's ride-on cars into effective, affordable mobility devices. Go Baby Go is a national program developed by Cole Galloway, PT, PhD. The cars that arrive from the toy manufacturer are designed to be operated with a foot pedal. But, Craig explained, "Most kids can't operate a pedal, so we have a large button that can be positioned anywhere on the car." Usually the button is on the steering wheel—which was where conference participants placed them in the 9 onsite cars—but the location can change based on the child's need. "We've placed it behind the head when the goal is to improve a child's posture," Craig said. "We placed one on the seat so the car would move only when the child stood up; it stopped as soon as he sat down." In addition to enhancing interventions, the modified toys serve another purpose. "This is about providing the children an experience they haven't had. By providing these cars, the children can explore the world," he said. It's also affordable. The cars as modified cost approximately $150, "versus thousands for a motorized wheelchair." Pointing to an array of unmodified, rideable cars on tables in the room, Craig then told the session attendees: "We need you to build these, because the kids are coming in later today for their cars." Each car was accompanied by an information sheet on the child—including his or her name, age, diagnosis, and interests. Session attendees worked in teams of 4 to 6 to modify the cars—disconnecting the pedal power control and connecting the large red plastic button the size of a small plate to the center of the steering wheel. The task was challenging not only because many PTs weren't familiar with the hardware tools and wiring schematics but also because of variations in both the cars and the needs of the children. About an hour into the session, the children and their parents began arriving, with the children telling the PT team working on "their" car what customizations and decals they wanted. Most of the cars were finished that day—a few needed additional work—and the session ended with the children test-driving their cars around the room and down the hotel's halls. Understanding Personality Types Can Enhance The PT-Patient Relationship Understanding one's own personality, as well as the personalities of coworkers and patients, can make PTs and PTAs more successful in both their workplace and home life, according to Jacky Arrow, PT, DPT. Arrow presented "He Said, She Said: How Personality and Communication Can Improve Patient Education" on June 14. She pointed out that in communication between the PT and the patient, "It's not their responsibility to come to us or to meet us halfway. It's our responsibility to meet them." Arrow first recommended that attendees determine their own personality types. She mentioned several tests but focused on the Myers-Briggs Type Indicator, which places a person on 4 scales: extraversion vs introversion, sensing vs intuitive, thinking vs feeling, and judging vs perceiving. For example, Arrow explained, an introvert typically waits to be asked a question and then needs time to construct an answer. Extraverts, on the other hand, tend to be talkative and fast-paced. Regarding body language, extraverts tend to lean forward and talk with their hands, while introverts pause before answering and often sit back, sometimes with arms crossed. When treating patients who are introverts, she suggested, provide information in advance or tell them you plan on asking specific questions. Be prepared for follow-up questions either later in a session or at the next session. A strategy to working with extraverts includes active listening, thinking out loud, and planning talking points. Another example Arrow provided related to judgers vs perceivers. Judgers respect rules and deadlines such as structured activity, she said, and they prefer a specific plan of care, with milestones. Perceivers tend to be flexible with rules and deadlines and are open to adjustments in a plan of care. For those reasons, judgers do better with a written program calendar, while perceivers like to link progress to big-picture goals. To illustrate, she suggested that if the goal is to have a patient do an exercise for 30 seconds, tell a judger to exercise for 30 seconds. Tell a perceiver to sing the song "Twinkle Twinkle Little Star" to gauge the elapsed time. Understanding the personality types of colleagues also can be beneficial. "Knowing the other personality types fosters better working relationships. And it allows PTs and PTAs to practice their skills with those of other personality types," Arrow said.2019 House of Delegates Sees Important Role for APTA in Professional and Societal IssuesAPTA's outward-facing, forward- leaning vision continues to guide APTA's House of Delegates. The policy-making body considered 70 motions during the 75th House session addressing a wide range of issues, but 1 overarching theme was clear: The House believes APTA has the potential to be a change agent for the profession and for society at large.APTA as AdvocateDelegates approved multiple motions aimed at positioning the association as an advocate for a more diverse, equitable, and inclusive profession, beginning with a general statement that APTA "supports efforts to increase diversity, equity, and inclusion to better serve the association, profession, and society." The House also unanimously adopted stronger language around the association's commitment to nondiscrimination on the basis of race, creed, color, sex, gender, gender identity, gender expression, age, national or ethnic origin, sexual orientation, disability, or health status; as well as a charge directing APTA to work with stakeholders to advance diversity, equity, and inclusion in all areas of physical therapy, including clinical, educational, and research settings.The House also voted to add language to the Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant that more clearly describes the duty of PTs and PTAs to report verbal, physical, emotional, or sexual harassment. In addition, delegates approved revisions to the Standards of Practice for Physical Therapy that better align the document with the APTA vision statement and more explicitly reflect the role of PTs in population health and community engagement. In addition, the House created a single set of core values for PTs and PTAs to replace separate versions, noting in discussion that core values are common to PTs and PTAs but discrete from behaviors, which continue to be appropriately described in the separate ethics documents.Other profession-focused House actions included unanimous approval of the definition of the movement system as "the integration of body systems that generate and maintain movement at all levels of bodily function," further describing human movement as "a complex behavior within a specific context…influenced by social, environmental, and personal factors." The definition will further strengthen APTA's efforts to promote the movement system as a critical component of the physical therapy profession's identity.Societal Issues and Population HealthThe House passed multiple motions related to the ways both the association and individual PTs and PTAs are connected to larger societal issues. In addition to updating positions on the association's role in advocacy for prevention, fitness, wellness, health promotion, and population health, delegates voted to broaden APTA's ability to respond to health and social issues. The House provided examples of what those broader efforts will entail, approving motions that support taking a public health approach to gun violence, promoting public participation in vaccination schedules, improving health literacy, and supporting the availability in physical therapy settings of the drug naloxone to reverse the effects of opiate overdose.New Area of Specialization: Wound Management Physical TherapyMaking it the 10th area of physical therapist clinical specialization, delegates approved the creation of a wound management specialty area for certification by the American Board of Physical Therapy Specialties, a proposal developed by the APTA Academy of Clinical Electrophysiology and Wound Management.Document Review Finally, in keeping with APTA's ongoing efforts to follow best practices in governance, the motions deliberated at the House included the second phase of a complete review of all House-generated documents. The review, conducted by a special committee of the House over the course of 2 years, focused on updating, consolidating, and sometimes rescinding documents—resulting in recommendations for changes to more than 100 House policies, positions, directives, and other guidance.