• Feature

    CSM 2020 Coverage

    February seems like a lifetime ago given today's circumstances, but that's when the largest physical therapy conference took over the Colorado Convention Center in Denver.

    Stories are abridged from CSM 2020 News, published by APTA and produced by CustomNews Inc. To read the full articles, visit www.apta.org/CSM/News/. Contributing editors and writers are APTA staff Lois Douthitt and Donald E. Tepper; and Deb Burrows, Tim Mercer, and Jenn Waters from CustomNews. Photography is by Jonathan Bachman unless noted otherwise.

    CSM 2

    Opening Ceremony Attendees Urged to Exercise Curiosity and Practice Observation

    American Board of Physical Therapy Specialties opening ceremony speaker Robert Sellin, PT, DSc, declared, "Rare is the day that goes by that any of us sees something in somebody that we've never seen before or defies our common knowledge. It is only through constant observation and repetition that we can see or sense the outliers that need special attention."

    Sellin is immediate past chair of ABPTS and a board-certified clinical specialist in clinical electrophysiologic physical therapy.

    The theme of his remarks was "The Value of Curiosity, Observation, and Repetition in Developing Clinical Excellence," but he said his original title was, "What Does the Study of the Tongue of a Woodpecker Have To Do With Clinical Specialization?" The latter was drawn from a biography of Leonardo Da Vinci, who made lists of things he wanted to do and learn. One of Da Vinci's goals was to "describe the tongue of the woodpecker."

    It would seem, Sellin said, that knowing about a woodpecker's tongue is unnecessary to draw a picture of the bird or to understand its flight. It turns out, however, that the woodpecker's tongue acts like a shock absorber, protecting the bird's brain while it pecks with exertion 10 times the force that could kill a human. "Da Vinci used his hours and hours of painstaking dissections of woodpecker tongues, other animals, and, especially, human corpses to learn how to produce masterpiece works of art that show amazing, while subtle, aspects of human expression," Sellin said.

    Clinical specialists do something similar, he continued. "We share a passion for clinical excellence, and we use our skills in observation and touch to apply techniques that may look mechanically the same with every application but have subtle differences. We adjust to the contour of the area treated and the response of the client to our body language, our touch, and our words. So, like Da Vinci, we use curiosity, observation, and repetition to create new experiences with every client or patient," Sellin said.

    He also had a suggestion for those receiving their certification, borrowing the idea from his son's graduation from the Navy's diving school. Sellin explained that at the end of the ceremony all of the instructors lined up in front of the military classroom as the graduates were called up one at a time to take a dive pin to proudly wear on their uniforms. Each new Navy diver handed the pin to the instructor who was the most valuable in their training. That instructor pinned the graduate.

    Sellin suggested that the newly certified PTs do something similar: "Approach the person or persons who meant so much to you in your preparation for specialty certification, be it family or a mentor. Thank them, and ask them if they would ‘pin' you. This could be done with your ABPTS pin or symbolically by relating this story."

    Sellin further encouraged the specialists to "play it forward," saying, "Maybe someday a newly minted physical therapist will ask you to pin them. I believe you will find that to be even a better feeling than the terrific feeling you all have earned tonight."

    "We Can Do Better" in Practicing Geriatric Physical Therapy

    "We have an image problem in geriatrics. That image is too often the perspective of decline and decay as aging," said Dale Avers, PT, DPT, PhD, FAPTA, speaking at the Academy of Geriatric Physical Therapy's Carole B. Lewis Distinguished Lecture. "Aging seems to be something folks let happen, without a lot of thought," she continued, adding, "yet most of the health problems of older age are exacerbated by inactivity and deconditioning." In fact, she said, "60%-70% of a person's health is due to factors we can influence, if not control."

    For that reason, Avers said, "We need to adjust expectations to make sure they are reflective of the older person's expectations…We must reset our expectations every time we see a different patient. Low expectations for the aging process and for the capacity-building of older people has no place in communicating the value of what we do and what we have to offer aging adults."

    She proposed five goals for PTs who work with older adults:

    • Possess an expertise about the aging process and geriatric physical therapy that is continually modified, reflected upon, and shared.
    • Practice person-centered care within a capacity-building paradigm.
    • Conduct a comprehensive evaluation that screens for vulnerabilities, informed by meaningful outcome measures.
    • Implement best practice and evidence-based interventions with creativity, appropriate challenge, relevance, and individuality to empower the patient.
    • Actively support and promote intentional aging.

    "Listen to Your Heart, and Let Your Lungs Breathe"

    Attendees of the Linda Crane Lecture, hosted by the Academy of Cardiovascular and Pulmonary Physical Therapy, were promised laughter, tears, dancing, singing, and inspiration. Speaker Anne K. Swisher, PT, PhD, FAPTA, delivered on every one during her talk, "Following Your Heart (and Lungs) as a Professional Development Plan."

    Swisher illustrated her theme by leading the audience through her own professional development. She spoke of her father, describing him as her inspiration to enter the medical sciences.

    After college graduation, she moved to a position in the intensive care unit. "I loved the cutting-edge machines and techniques in the ICU, but I also loved being the advocate for seeing the whole person who was connected to the machines," she said.

    Her career path then led her to pursue a master's degree in exercise physiology. "I learned that exercise is a medicine that must be prescribed, just like pills are," she said.

    Swisher later returned to her home state of West Virginia, where she joined the West Virginia University faculty and earned her PhD while raising a daughter and son with her husband.

    "There were many days when I felt like I wasn't doing anything well," she said. "We all take on more than we can, and we need to be kind to our heart and let our lungs exhale."

    She then spoke about transitioning from being a clinician to academia. "Most of us in academics come from a clinical world," she said. "When your patients went home, or the documentation was completed, your work was done. The biggest surprise to a clinician entering academics is that the work is never done."

    She described academia as a three-legged stool consisting of teaching, research, and service.

    Related to teaching, she said, "What happens in the classroom with our students is magic, but it is also hard work." She added that she makes sure students know they also must work to learn. "Our role is to guide learning," she said, "not to spoon-feed it to passively open mouths."

    Concerning research, she said that those in academia are expected to contribute to the profession. "If you have a question that is exciting you, others will get excited too. Keep pursing it."

    The third leg of the stool — service — is particularly relevant to the physical therapy profession. She encouraged the audience to explore different types of community service activities, including with their professional association.

    Passing around a plush heart, she asked the audience to think about things that make them excited. She then did the same with a set of plush lungs. "The lungs are your chance to take a deep breath and think about diving in."

    Also as promised, she led the room in doing the "ECG dance" — a series of dance moves created to teach electrocardiogram rhythms — as well as in a rousing chorus of "Take Me Home, Country Roads."

    New CPG on Locomotor Training Describes ‘Active Ingredients' in Interventions to Improve Walking

    Walk, walk hard, and walk a lot. Interventions that adopt these main "active ingredients" under the principles of exercise physiology — specificity, intensity, and repetition — can improve walking function in patients with a six-month-or-longer history of acute-onset stroke, motor incomplete spinal cord injury, or traumatic brain injury, based on a new clinical practice guideline published in January in the Journal of Neurologic Physical Therapy.

    "Implementing the Active Ingredients for Locomotor Recovery," a session hosted by the Academy of Neurologic Physical Therapy, explored eight action statements from the CPG.

    Carey Holleran, PT, MPT, DHS, was the main presenter, with fellow speakers Lisa Goodwin, PT, DPT, Allison Miller, PT, DPT, and Meredith Banhos, PT, DPT. In addition, a panel comprising Goodwin, Miller, Maghan Bretz, PT, Thomas Hornby, PT, PhD, and Irene Ward, PT, DPT, answered audience questions at the end of the presentation. Banhos, Holleran, Miller, and Ward are board-certified clinical specialists in neurologic physical therapy.

    The CPG's eight statements are divided into what clinicians should perform, what they may consider, and what they should not perform. In the "should perform" category are walking training at moderate to high aerobic intensities — 70%-80% of heart rate reserve or up to 85% maximum heart rate — and training coupled with virtual reality. Clinicians may consider strength training at 70% or more at one repetition max; circuit training, cycling, or recumbent stepping; and balance training with virtual reality. And what should be avoided? Static or dynamic low-intensity balance activities, body-weight supported treadmill training with emphasis on kinematics (a harness may be used as a safety catch but not for walking support), and robot-assisted gait training. Key to patient safety is continuous heart monitoring during interventions.

    In addition to describing the CPG itself, the presenters discussed the role of CPGs in knowledge translation — applying knowledge, such as a research-based CPG, to practice for improved patient outcomes. A survey of members of the Academy of Neurologic Physical Therapy indicated that respondents agreed or strongly agreed that CPGs are important in effecting change in practice but that barriers exist to their use, such as time to develop a program based on CPG recommendations, time to read, lack of institutional support, lack of access to the CPG, lack of understanding of the recommended practices, and fear of hurting the patient with higher-intensity activity.

    Thumbs Up: A Detailed Look at an Amazing Appendage

    Many misunderstandings and controversies surround the thumb's treatment and anatomy. In the session titled "Thumbs Up!" hosted by the Academy of Hand and Upper Extremity Physical Therapy, presenters Diane Coker, PT, DPT, and Janelle Freshman, PT, DPT, described some of them.

    Both presenters are certified hand therapists; Freshman also is a board-certified clinical specialist in orthopaedic physical therapy.

    Coker said the thumb is unique in that:

    • It has two axes and three planes of motion.
    • It does not lie in the same plane as the hand.
    • Pathways do not intersect.
    • Independent control of pronation would require two additional muscles.

    Discussing the impact of impairments of the thumb, Freshman said that total disability of the thumb equals loss of 22% of bodily function and nearly 40% of hand function. "Proximal phalanx and the base of the metacarpal are frequent places fractures occur. They are most common in children up to 16 years old and in adults over 65." Metacarpal base fractures happen most commonly when the thumb is engaged in grip, she continued, such as when holding onto a steering wheel or motorcycle handle bars. While unstable fractures usually are treated surgically, she added, good outcomes are possible with immobilization.

    In ligament injuries, Freshman explained that the shape of the metacarpal head determines the amount of motion of the metacarpophalangeal joint. "The flatter the head of the joint, the less motion and the more chances of ligament injuries." She added that pain-free stability of the joint is more important in treatment than is range of motion.

    A common condition of the thumb is carpometacarpal osteoarthritis. Freshman said that despite research, the condition's etiology is unknown. She said theories include deterioration of the anterior oblique ligament, or AOL; ligament laxity; hormonal changes with menopause; and genetic disposition.

    When Running Is Part of the Job: Implications of Running Shoe Choice

    Not everyone runs for the love of it. For those in law enforcement, military, and first responder professions, running can be a required component of the job and physical fitness tests. Working with these patient populations presents unique challenges for PTs and PTAs.

    During the Federal Physical Therapy Section's session "What Is All the Hype About Running Shoes? Practical Implications for the Running Tactical Athlete," speakers offered a deep dive into working with this population group. Nancy Henderson, PT, DPT, and Haley Worst, PT, DPT, looked at everything from the type of running they do, to the role of running shoes, to possible rehabilitation and training methods. Both presenters are board-certified clinical specialists in orthopaedic physical therapy.

    "This is a unique population to work with," said Henderson. "It requires specialized physical training strategies to improve physical performance." In particular, understanding the core components of running shoes is critical when it comes to working with runners and tactical athletes.

    As she discussed shoe anatomy, Worst offered tips on modifications that can be made for injuries or running on different surfaces.

    She cautioned that selecting a pair of running shoes can be a daunting process. For tactical athletes, cost may be a factor. Service members, for example, receive a free pair of shoes in basic training, but they pay for subsequent pairs.

    Henderson explained that many running injuries are related to overuse. Reasons for these injuries include running too many miles, lack of ramp-up time, and going "from 0 to 60 miles" too quickly rather than undertaking a 10% weekly mileage increase.

    Treating tactical athletes requires asking a lot of questions, she explained: What do they do each day? How much do they run, and on what types of surfaces? What they are doing during circuit training? What breaks have they taken from physical training?

    It's also important that tactical athletes understand foot strike patterns, Henderson said. She learned from published research that athletes may not know their own pattern: Only 43%-69% of runners accurately describe their foot strike. She recommended using video analysis to improve that accuracy.

    Another consideration when it comes to foot strike is the role of fatigue. "The research has said that the longer runners run, the more likely they are to adopt a rear foot strike pattern," said Henderson. "This shows a potential need to introduce step rate manipulation during a fatigue state." She suggested filming foot strike during a running episode and comparing it before and after pain starts.

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    Linking the Extremities to the Trunk in Acute Care

    Postural control is recognized as critical for functional movement. In the preconference session "Acute, Anticipatory, and Urgent: Reeducating the Foundations of Postural Control in the Acute Care Setting," attendees learned through lecture, lab, and video the importance of the trunk in managing functional tasks.

    Susan Ryerson, PT, DSc, Elise Ruckert, PT, DPT, and Lauren Hurt, PT, DPT, provided current evidence on improving postural treatment of patients with mobility and functional limitations. Ruckert and Hurt are board-certified clinical specialists in neurologic physical therapy, and Ruckert is a board-certified geriatric specialist as well. The session was hosted by the Academy of Acute Care Physical Therapy.

    Hurt began by stating that there is a gap between current acute care practice and the evidence of best practice. Giving examples of many well-known function tests, she noted, for instance, that the grading in the Berg Balance Scale has a vague description of "use of hands." "Patients score better [than what they can really do] because they can do the skill, but we don't really know what's working. The movement-analysis piece is missing."

    Hurt said the focus is on the level of assistance rather than on the cause of the deficit, and scoring is not based on movement analysis. "We focus on function without considering the prerequisites." She believes PTs can be more effective through retraining the foundational components of anticipatory postural control.

    Ruckert noted, "Acute care practice must address the foundations of anticipatory postural control in order to promote recovery." Anticipatory postural responses, or APAs, are the unconscious muscular activities designed to maintain balance prior to perturbation. "Anticipatory postural control helps us to maintain balance before we move. Our muscles start firing 80 to 100 milliseconds before focal limb movement and make functional limb activity possible," said Ruckert. "Reestablishing trunk activation after prolonged immobility or injury requires careful assessment of missing components, using a structured process."

    Ryerson and Ruckert described a motor control framework that puts anticipatory postural control in the center and trunk-limb linkages in close relationship. "Our extremities drive the movement of the trunk," said Ryerson. "Linking the trunk and extremities is necessary to perform functional tasks. Control of trunk movement components is a prerequisite to perform functional tasks."

    "Often as PTs we think of only [treating the] legs, but we need to treat the upper body as a prerequisite to treating the legs, and then link the legs with the trunk. Extremity movements have hierarchical levels of demand on the trunk," said Ryerson.

    She concluded, "Retraining function in the acute care setting requires an understanding of the prerequisites for anticipatory postural control. Trunk movement components form the foundation of trunk-limb linkages."

    Task Force Finds Insufficient Research on PTA Education and Practice

    Although the depth and breadth of entry-level PTA curricular content has increased, as has the role of the PTA, research on PTA education and practice still is lacking. That was one of the conclusions of the PTA Education Trends Task Force of the Academy of Physical Therapy Education, which presented its findings at the session "The Current State of PTA Education: Findings of the PTA Education Trends Task Force."

    Presenters were Michele Marie Avery, PTA, Katherine Griffin, PTA, MSEd, Jennifer Jewell, PT, DPT, Rebecca McKnight, PT, MS, and Krissa Reeves, PTA, MEd.

    The presenters reviewed the history of PTA education, from discussions in the 1940s regarding the possible need for a trained technician to assist PTs with treatment interventions, to the approval in 1967 of the first two PTA education programs at Miami Dade Community College in Florida and St. Mary's Campus of the College of St. Catherine in Minnesota, to expansion to 376 accredited and 32 developing PTA programs as of July 2019.

    The speakers shared some statistics related to PTA education: The average PTA program graduates 18 students annually, the ultimate NPTE pass rate is 92.3%, and the employment rate is 98%.

    Despite this growth and size, the task force found a lack of up-to-date content regarding PTA education. It further found that most APTA documents and work activities are "highly focused" on PT education, with little or no mention of PTA education, and that "there is little documented evidence of work being done on the quality of PTA education or advancement of PTA education."

    The presenters reviewed the findings of a survey to which PTA program directors responded. It found that "the cognitive load within PTA educational programs is inappropriate for an associate degree, which is congruent with higher curriculum expectations placed upon programs by CAPTE and increased outcome expectations regarding the NPTE-PTA." However, there wasn't a clear consensus for a preferred entry-level program length. A slight majority (53%) indicated a preference for either all PTA programs being at the bachelor's degree level or allowing institutions to determine the degree level awarded for PTA entry-level education. The greatest concern in transitioning PTA programs to a bachelor's degree was the impact on student debt.

    The task force also recommended further research into challenges associated with the number and quality of applicants, student retention and graduation rates, graduate employment opportunities, and clinical site availability and variety.

    Elastic Taping Offers New Option for Edema Management

    When you think of elastic taping, you may immediately think of Olympic athletes such as beach volleyball players. But as Nicolle Samuels, PT, MSPT, explained during "Stretch Your Mind and Their Skin: The Role of Elastic Taping in Wound Management," such taping can benefit patient populations with edema, lymphedema, and scarring. Samuels is a certified lymphedema therapist, certified wound specialist, and certified kinesio taping practitioner. The session was hosted by the Academy of Clinical Electrophysiology and Wound Management.

    Samuels pointed out that elastic taping is not a stand-alone replacement for other treatment methods. Rather, it can promote healing or be used when other treatments are not working.

    Among the integumentary applications she discussed were managing edema as an alternative to compression bandaging, reducing mechanical stress, and scar/remodeling techniques. For example, she said that elastic taping can encourage fluid movement around a scar. The goals of taping in wound management include an increased uptake of lymphatic loads; mechanical correction of tissue position; improved mobility, pliability, and coloration; and reduced fibrosis and pain.

    Samuels noted that it's important to be familiar with potential side effects and to avoid using tape with patients who are diabetic; have fragile or irradiated skin, an infection or open wound, or deep vein thrombosis; or are sunburned.

    Physical Activity: The Common Denominator in Treating Delirium, Depression, and Dementia

    Delirium, depression, and dementia are distinct conditions that often affect the older adult population. What they have in common is that physical activity can help patients with those conditions. As movement experts, PTs must possess the ability to promote physical activity in any of the "3Ds," said Christine Childers, PT, MS, PhD. She spoke at the Home Health Section's session "D, DD, DDD: One Size Never Fits All!"

    After explaining the differences between the three conditions, Childers said it's necessary to assess a person's cognitive level with any of the 3Ds to determine how best to manage that individual.

    She provided several tips for working with this population. First: Don't use the term "exercise." "If you ask them if they exercise, they'll say they don't," she said, even though they walk, take stairs, or bend to attend to a garden. And they may shy away from instructions to exercise but willingly will engage in dancing, walking, boxing moves, and other physical activity that's characterized as something other than "exercise."

    Childers also recommended that clinicians "step into their world; don't try to pull them into ours." For example, she uses jitterbug dancing for aerobic activity. Additionally, she said, "everything takes longer because you have to engage them first." It will get easier as they become familiar with the movements, accompanying music or props, and your instructions, "and then you can focus on specific interventions."

    On that last tip, Childers commented that some clinicians may indicate that a patient is unable to cooperate when, in fact, "what they're really saying is that they don't know how to teach them." The profession needs to ensure that clinicians are trained appropriately to engage with these patients, she said.

    She cited several strategies for promoting physical activity in those with dementia. These include goal setting, social support, and a credible source — or combined use of all three, which could be more effective than other behavior change attempts to increase physical activity. Another approach, self-determination theory, incorporates the themes of competence, autonomy, and relatedness or connectedness with others.

    Childers interrupted her presentation often to have the audience engage in cardiovascular physical movements such as boxing moves, tossing and catching a ball, dancing, and stretching — all of which, she said, have a rationale for use with patients in this population.

    How (and Why) to Include Older Adults in Clinical Trials and Research

    Older adults often are excluded from clinical trials. A panel of PTs provided an array of suggestions and techniques to include more of them in that research. The Section on Research session "Including the Often-Excluded Older Adult in Clinical Research: Strategies for Recruitment, Enrollment, Retention, and Engagement" was presented by Margaret Danilovich, PT, DPT, PhD, Jennifer Sokol Brach, PT, PhD, FAPTA, Valerie Lea Shuman, PT, DPT, and Victoria Davila, PT, DPT.

    The presenters acknowledged that designing studies that include older adults can be difficult. They pointed out that research often prioritizes precision, and older adults are scientifically "messy." They pointed out, too, that funding agencies often focus on a specific disease or injury. Older adults often have multiple conditions that can make it difficult to determine how the specific condition being studied is being affected. In addition, older adults can be difficult to recruit and manage.

    The National Institutes of Health's "Inclusion Across the Lifespan Policy" is intended "to ensure that the knowledge gained from NIH-funded research is applicable to all those affected by the conditions under study." In announcing the new policy last year, NIH noted that the population of older adults is "disproportionally absent in clinical research—resulting in insufficient data regarding treatments and interventions for this population."

    The presenters listed traits that make it more challenging to include older adults in research, then provided strategies to address those issues. For example, in dealing with people with sensory deficits — particularly hearing and vision — the panelists suggested using high-contrast and large-print materials, avoiding electronic communication, and minimizing background noise when conducting a study in person. "If you're in a community space where they're calling Bingo in the next room," Brach noted, "you might need to find a quieter space."

    In working with people with mobility limitations, the panelists' strategies included providing transportation or reimbursing travel, minimizing walking during study visits, and accounting for use of assistive devices.

    The presenters had similar tips in addressing health literacy, decisional capacity, and adherence and retention.

    The Future Is Now in Telehealth

    Mark Milligan, PT, DPT, is excited about the possibilities in the telehealth market. A board-certified clinical specialist in orthopaedic physical therapy and a fellow of the American Academy of Manual Physical Therapists, he led the Private Practice Section session "Telehealth: How to Leverage Technology for More than Just Treatment."

    Milligan began with descriptions and definitions. "Telehealth is the application of technologies to help patients manage their own illness through improved self-care and access to education and support systems electronically. Telerehabilitation is the delivery of rehab services over telecommunication networks and the internet," Milligan said.

    He then described different models of telehealth. These include synchronous or live video, and asynchronous modes, which include prerecorded videos, emails, and photos. "Remote patient monitoring, which is reimbursable by Medicare, allows medical data collection from an individual in one location via electronic vehicle to the provider. Mobile health and public health practice education are supported by mobile devices such as cell phone or tablet and involve using an app."

    "Virtual reality in telerehabilitation is one of the newest tools available," said Milligan. "Computer technology allows the development of three-dimensional virtual environments that make it fun and engaging for the patient."

    "Many companies provide telehealth physical therapy platforms that you can use to provide care, but whatever platform you use, make sure that it is HIPAA-compliant," cautioned Milligan. "Know the rules," he said. "They must sign the same papers as if you were treating them in the clinic, and a digital policy as well. It is your due diligence to maintain your patient's privacy." He said that HIPAA violation fines range from $100 to $4 million. "There were over 800 million attempts to break into health records in 2018. Every record is worth over $400 on the black market."

    Noting limitations in Medicare policy related to PTs' use of telehealth, he said, "Medicare does not consider physical therapists as one of their approved telehealth providers, and many states adopt Medicare language. Legislatively we need to change this."

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    How to Help Your Patients Sleep Better

    For patients with pelvic pain, sleep might not be the first connection you think of, but during the Academy of Pelvic Health Physical Therapy session "Sleep Management and Persistent Pelvic Pain — Could This Be Your Missing Link?" speakers looked at the importance of sleep and provided practical suggestions for attendees to take to their patients. Presenters were Mark Shepherd, PT, DPT, Katie Siengsukon, PT, PhD, and Jennifer Stone, PT, DPT.

    Stone spoke about the roles of the parasympathetic system, bowel and bladder functions, and sphincter control in working with patients who experience pelvic pain. "All of the other things we do are important, such as talking about pain management," said Stone. "But if we don't address sleep, we may not be giving patients all the tools they need."

    Shepherd picked up on the importance of sleep as "one of the cornerstones to a healthy well-being." He discussed how many different body systems are related to sleep and the relationship between sleep and pain.

    Siengsukon discussed social determinants of health and their impacts on sleep. These factors include race and ethnicity, social support, job opportunities, and the affordable, healthy foods. "If a patient does not have enough food to eat or can't pay their rent, sleep may not be their priority," she said. "Sleep can be seen as a luxury."

    She shared some ways to screen patients, stressing that there is a need to screen all patients for sleep challenges. Screening a patient includes asking questions about sleep disruption, sleep quality, and perceived sleep issues. It also may include conducting a further assessment using a questionnaire, and possibly referring a patient to a sleep specialist.

    She cautioned that talking about sleep can be very personal for a patient. "They are inviting you into their bedroom, into their relationship with their partner."

    Movement Evidence in Sports

    Movement analysis, assessment of key impairments, addressing errors, and clinical treatment were among the topics discussed during "Sports Medicine Secrets: Evidence-Based Lower Extremity Sports Movement Analysis: Sprinting, Cutting, and Jumping," a session hosted by the Academy of Orthopaedic Physical Therapy. Marshall LeMoine, PT, DPT, Michael Wong, PT, DPT, Andrew Morcos, PT, DPT, ATC, Stephania Bell, PT, and Leigh Weiss, PT, DPT, ATC, MS, presented.

    LeMoine, Wong, Bell, and Weiss are board-certified orthopaedic clinical specialists. LeMoine, Marcos, and Weiss are board-certified sports clinical specialists. Morcos is also a board-certified pediatric clinical specialist. LeMoine, Wong, and Morcos are fellows of the American Academy of Orthopaedic Manual Physical Therapists, and Morcos and Bell are certified strengthening and conditioning specialists.

    "When athletes are performing cutting maneuvers, I want them to have good lower limb control," said Wong. He said that common movement errors with cutting include high center of mass, excessive knee valgus, and poor hip and core stability.

    LeMoine said the top three faults associated with injury are decreased dorsal flexion, quadriceps weakness, and fatigue. He suggested giving movement corrections with both external and internal cues. "External cues might be ‘land with your knees over your toes,' ‘land like an egg,' ‘land quieter,' or ‘spread the floor away with your feet from the direction you are going.' We want a low center of mass for optimal deceleration. For optimal cutting we want good knee alignment in the frontal plane, with a lower center of mass."

    Marcos suggested filming the athlete's movements and then reviewing them in slow motion and at multiple angles to see how each area is flexed at landing. "Some joints are meant to move and some are meant to be stable," he said. The mobile joints are the ankle, hip, and thoracic area, and the stable joints are the knee, lumbar area, and neck. "If it's a knee problem, the ankle or hip may not be moving enough. You must look at the whole body to find the problem," he said.

    Engaging All Cultures in Cancer Rehabilitation

    We all try to be equitable in supporting patient populations, but is equity all that's needed? "Equity is giving patient populations what they need, but justice looks at what is causing inequality and removes it," said Ann Marie Flores, PT, MSPT, PhD. Flores joined Kristin Campbell, PT, PhD, BSc, and April Gamble, PT, DPT, in addressing vulnerable populations in oncology rehabilitation during the Academy of Oncologic Physical Therapy's session "If You Build It Will They Come?"

    Flores has conducted numerous studies involving minority populations and cancer rehabilitation. She presented one that looked at cancer survivors of Puerto Rican descent. Most participants had household incomes of less than $20,000 a year, had lower than a ninth-grade education, and lived in the Boston area. "Cancer types included breast, prostate, and colorectal, and many had surgery," she said.

    Of those in the study with one or more impairments, only around 18% actually received physical therapy. Flores said that barriers to receiving physical therapy included lack of a recommendation by their physician (28.6%) and cost (12.9%).

    Gamble lives and works in the Kurdistan region of Iraq, which she described as "a very diverse region." She told the audience that it is the therapist's job to provide culturally responsive care. "If we don't," she said, "there are lower health outcomes. To make treatment plans more responsive we need to consider every level of the health care system." She suggested examining the therapeutic relationship with the patient, using appropriate written materials, and individualizing assessment, education, and treatment. Outreach barriers must also be addressed: "Do your public awareness campaigns only feature attractive white people?" she asked.

    The community being served should be involved, she said. "You need to be purposeful in giving them a voice," said Gamble. "If you are addressing a population, they should be at the planning table with you."

    The Role of Aquatic Therapy in Spinal Cord Injury Rehabilitation

    Incorporating aquatic therapy into the recovery of a patient with a spinal cord injury offers physical and mental benefits. During "Getting Back in the Pool: An Interdisciplinary Approach to Aquatic Therapy Post Spinal Cord Injury," hosted by the Academy of Aquatic Physical Therapy, presenters Brian Maloney, PT, DPT, and Gabriel Shivers, MS, discussed the role aquatic therapy has played in patient care at the Shepherd Center in Atlanta, Georgia.

    Maloney reported that even though patients with a spinal cord injury are living longer, less than 50% of them return to any form of recreation and are dying from secondary complications that are cardiovascular- or pulmonary-related.

    Because patients with a spinal cord injury from a diving accident had enjoyed being around the water prior to their injury, they should be encouraged to return to it, Maloney said. "They may have some issues early on," he added, "but it is something they can enjoy. It can promote lifelong fitness." He stressed that the earlier a patient can start aquatic therapy, the better.

    Incorporating aquatic therapy requires many different types of practitioners coming together with the patient to work for one goal. Maloney said each team should include a PT, occupational therapist, physician, psychologist, speech-language pathologist, and dietitian.

    Throughout the session, Maloney and Shivers narrated videos depicting patient experiences, best practices for helping patients into and out of the pool, and patients performing various exercises.

    One area of the body that can particularly benefit from aquatic therapy is the shoulder, Maloney said, noting that up to 90% of patients experience pain there. He explained that overloading the humerus can lead to downward rotation and winging of the scapula. Therapies in the pool can offload the humerus and help the patient improve range of motion.

    Shivers discussed ways to integrate physical therapy and occupational therapy goals into aquatic sessions. Occupational therapy goals can include, for example, getting in the shower, getting dressed, and practicing transfers.

    Children With Autism Can Benefit From Movement Interventions

    Audience members packed a room and two overflow areas for "Creative Movement and Play Interventions for Children With Autism Spectrum Disorder," a session hosted by the Academy of Pediatric Physical Therapy. Speakers Anjana Bhat, PT, and Sudha Srinivasan, PhD, discussed the benefits of movement interventions to children with autism spectrum disorder, and explained why it is necessary to evaluate patients for movement impairments even though such impairments are not considered part of the diagnostic criteria of autism.

    "Studies show that 87% of autistic children aged 5 to 15 years are at risk for motor impairment," Bhat said.

    Given the increased prevalence of ASD, it is important, Srinivasan said, to develop interventions that can be used throughout the lifespan. She noted that dysfunction in several areas of movement may be observed in children with ASD, including gross, fine, and oral motor skills; balance and posture control; gait; multi-limb coordination; motor timing, imitation, and praxis skills; and physical fitness, including BMI, muscular strength, and cardiovascular endurance.

    "Autistic children tend to prefer sedentary activities because movement difficulties affect their ability to participate in activities," Srinivasan said. "We have the opportunity to impact this population by developing movement-based interventions for them." She warned, though, that parents sometimes are less concerned about their child's physical fitness and more about their social interaction. Working with this patient population requires knowing their interests and goals, she said, and what methods will be most successful in reaching them.

    Bhat concurred, saying that when conducting patient assessments, it's important to engage with children so that they'll more likely adhere to the plan of care. It's also important to know what has and has not worked, and to observe children in multiple settings: at school, on the playground, at home, and in a one-on-one setting. Bhat suggested, as well, asking the child's teachers which communication methods work best with that individual.

    Tips to incorporate into treatment strategies, Bhat and Srinivasan said, include:

    • Using small spaces.
    • Understanding that children want predictability and structure.
    • Using picture schedules to help children understand what's going to happen, which reduces their stress.
    • Being less verbal and more visual.
    • Incorporating singing, dance, and musical instruments.

    Attendees Get Hands-on Learning at Technopalooza

    At Technopalooza, CSM attendees were invited to step outside the classroom setting and take advantage of hands-on experiences with new technologies. The annual event, hosted by the Health Policy and Administration Section, focused on telerehabilitation and remote patient monitoring, and featured product demos and information about such areas as AI advancements at 20 different stations.

    Robert Latz, PT, DPT, is a member of the Technopalooza organizing team. Now in its ninth year, the event continues to grow, he said, noting that music with a DJ was added for CSM 2020.

    "Everything is hands-on," Latz said. "It helps attendees get comfortable with technology and see what's currently being used in practice. We look for what's brand-new and cutting-edge, and also at how old technology is being used in new ways."

    Attendee Misti Thompson, PT, DPT, took the opportunity to wear an exoskeleton device designed to help patients with spinal cord injuries walk with robotic assistance. "Technopalooza is a nice way to stay up to date on everything," she said, "and to get a glimpse of things I can incorporate into my practice and share with my students."

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