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  • Humana Adopts PTA Coding System, Anticipates Payment Differential Beginning in 2022

    Commercial health insurance giant Humana has announced that it's falling in line with rules from the Centers for Medicare and Medicaid Services designed to establish an 85% payment differential for therapy services delivered "in whole or in part" by a PTA or occupational therapy assistant. Consistent with CMS, Humana is requiring use of code modifiers in 2020, with no changes to payment until 2022.

    The new system, which establishes a code modifier ("CQ" for PTAs and "CO" for OTAs) began on January 1 for Medicare Part B payments. The new approach was triggered by federal law that mandated the creation of a way to denote the volume of physical therapy and occupational therapy services delivered by PTAs or OTAs, and then create a payment differential for those services. In its announcement, Humana states that its policy will mirror the CMS rule, "as applicable in the Federal Register and relevant CMS guidance." Like CMS, Humana also is requiring the modifier on all applicable claims submitted for services delivered beginning January 1, 2020.

    While the modifier system won't affect payment immediately, both CMS and Humana have stated that they intend to reimburse at 85% of the physician fee schedule for services delivered "in whole or part" by a PTA or OTA beginning in 2022.

    Recognizing that CMS was legally bound to establish a differential system, APTA fought initial drafts of the rule that were needlessly burdensome and seemed to ignore the realities of PT and PTA practice. The final rule included several modifications either suggested or supported by APTA, and the association continues to advocate for changes to the system.

    APTA will meet with Humana representatives to address the adoption of the modifiers and the payment differential and will work to limit the adoption of this policy by other payers.

    APTA offers a quick guide to using the PTA modifier and provides more resources on the differential at the APTA fee schedule webpage.

    APTA's Physical Therapy Outcomes Registry Again Receives QCDR Designation for MIPS Reporting, Adds New Measures

    APTA's Physical Therapy Outcomes Registry has been approved for the fourth year in a row by the U.S. Centers for Medicare and Medicaid Services as a qualified clinical data registry, or QCDR. This designation means that participating physical therapists can submit Merit-based Incentive Payment System — MIPS — reporting data to CMS directly from the registry. QCDR approval recognizes APTA's demonstrated expertise in quality measure development.

    The Physical Therapy Outcomes Registry supports 19 Quality Payment Program measures, 11 QCDR measures, and two electronic clinical quality measures. CMS requires that the electronic clinical quality measures must be reported using certified electronic health record technology, also known as CEHRT.

    As of January 2019, PTs who provide services under Medicare Part B who meet qualifying criteria must participate in either MIPS or an Advanced Alternative Payment Model (Advanced APM). PTs who participate in the Registry can meet MIPS requirements in both the Quality and Improvement Activities categories. Submitting data via a QCDR also earns "bonus" points in the Promoting Interoperability category, which is not yet required for PTs.

    Whether or not PTs participate in MIPS, according to Heather Smith, PT, MPH, APTA's director of quality, APTA’s registry is a valuable tool for optimizing patient outcomes.

    "Participants have found that registry data has opened their eyes to areas for improvement, and even informed changes to the way they deliver care," Smith said. "Registry analytics allow therapists to objectively understand how their practice patterns and interventions are impacting patient outcomes."

    Registry users can access nonproprietary outcomes measures supported by CMS, as well as specific measures shared from other QCDRs.

    By directly integrating with EHRs, the registry enables PTs — whether or not they participate in MIPS — to leverage their existing EHR data to track and benchmark outcomes, apply dashboard insights to improve quality of care, and demonstrate the value of physical therapist services to payers and providers. For more information about the Physical Therapy Outcomes Registry, visit www.ptoutcomes.com.

    Headed to the APTA Combined Sections Meeting in February? Visit the APTA Pavilion in the Exhibit Hall to learn more about how the registry can benefit your practice. Related education sessions include "Demonstrating Value: Using Clinical Data and Databases to Improve Outcomes for Patients and the Population" and "Through the Looking Glass: What Are the Emerging Payment and Quality Issues?"

    2020 Federal Advocacy Forum Coming March 29; Registration Open Through March 16

    While 2019 saw some real advocacy achievements for the physical therapy profession, the year also brought challenges to tackle in 2020 — not the least of which is the proposal by Medicare to cut reimbursement to physical therapy in 2021. And with APTA's fight against the cut already in motion, the 2020 Federal Advocacy Forum, set for March 29-31, couldn't come at a better time.

    Registration is now open for the annual event, which brings PTs, PTAs, and students together in Washington, DC, for a three-day conference that provides the latest on regulatory and legislative issues affecting the profession, and ends with an opportunity for attendees to apply what they've learned by making in-person visits to Senate and House offices. Registration deadline is March 16.

    The forum's keynote speaker will be Paul Begala, political analyst and commentator at CNN. An affiliated professor of public policy at Georgetown University, Begala served as counselor to President Bill Clinton.

    Begala's participation is in keeping with the forum's tradition of offering a variety of speakers with diverse perspectives. Past keynote speakers include political commentator Fred Barnes, FOX News host Tucker Carlson, and political strategist Donna Brazile.

    Other forum activities will include an evening reception and breakout sessions on advocacy-related topics.

    "The proposed 8% cut will be one of the issues the profession will share with their elected officials, and APTA will continue to educate Congress about the essential role that physical therapists play in the delivery of quality health care for patients of all ages across the country," said Michael Matlack, APTA's director of congressional affairs. "Now, more than ever, the voice of the physical therapy profession is critical to the health and well-being of our patients and our industry. "

    Want to get a feel for what the Federal Advocacy Forum is all about? Check out the video recap of the 2019 forum on the Federal Advocacy Forum webpage.

    NCCI Code Edits: Your Questions Answered

    Background: A surprise coding change issued by the Centers for Medicare and Medicaid Services (CMS) caused an uproar in the physical therapy community earlier in January, and for good reason: The new requirements state that CMS won't reimburse for certain activity and evaluation codes if they're used in the same day. APTA argues that accepted physical therapist practice often includes the startup of care on the same day as evaluation (and continued care on the same day as reevaluation), and that the prohibition runs counter to CMS' own aims for care.

    Reaction: Since the announcement, Capitol Bridge, LLC, CMS' National Correct Coding Initiative (NCCI) contractor, has been inundated with comments from PTs, PTAs, and other stakeholders slamming the decision and requesting that the change be reversed. And it's not too late to add your voice to the effort. APTA is communicating with representatives from Capitol Bridge, CMS, and the American Medical Association, which plays a significant role in coding development.

    Where things stand: As of the date of this report, no changes have been made. That leaves PTs and PTAs to deal with the current prohibition, as problematic as it may be.

    To help you navigate the system as it is, here are answers to some of the most common questions we've been receiving on the NCCI coding change.

    1. What are NCCI Procedure-to-Procedure (PTP) code pair edits?
    NCCI PTP edits are intended to prevent payment of services that should not be reported together. Each edit has a Column One and Column Two Health Care Common Procedure/Current Procedural Terminology (HCPCS/CPT) code, called a “pair.” If a provider reports the two codes of a pair for the same beneficiary on the same date of service, only the Column One code is eligible for payment; the Column Two code is denied unless a clinically appropriate NCCI-associated modifier is also reported.

    As for modifiers, each PTP edit has a modifier indicator, represented by (0), (1), and (9), that appears after the code number. Here's what those numbers mean:

    • 0 - There are no circumstances in which a modifier would be appropriate. The services represented by the code combination will not be paid separately.
    • 1 - A modifier is allowed in order to differentiate between the services provided. Assuming the modifier is used correctly and appropriately, this distinction provides the basis upon which separate payment for the services billed may be considered justifiable.
    • 9 – The deletion date of the code pair is the same as the effective date. In other words, these edits are no longer active, so the code combinations are billable, and no other modifier is needed.

    2. What happens if I bill 97530 (therapeutic activities) and 97161, 97162, or 97163 (physical therapy evaluations) together on same day for same patient?
    This is at the heart of the recent edit. Under the new rules, the use of both codes is prohibited, and there's no modifier that you can use to bypass the denial. That includes the 59 modifier/X modifier: You can't use the 59 modifier/X modifier when billing 97530 with 97161, 97162, or 97163 to bypass the edit.

    Bottom line: when 97530 and one of the physical therapy evaluation codes are billed together on the same day for the same patient, the evaluation code will be denied. This is because in the PTP edits list, 97530 is the Column One code and 97161, 97162, and 97163 are Column Two codes (see the answer to question 1 for more background on Column One and Column Two codes).

    3. Why is 97530 (therapeutic activities) in Column One and 97161-97163 (physical therapy evaluations) in Column 2?
    Good question. We believe this PTP edit is inconsistent with the general guidelines for PTP edits, and it's one of the reasons APTA and other stakeholders are working with CMS to have this edit removed as soon as possible.

    4. What happens if I bill 97150 (group therapy) and 97161, 97162, or 97163 (physical therapy evaluations) together on the same day for same patient?
    As with the therapeutic activities code covered in question 2, the answer is, you won't get reimbursed for the evaluation — and there is no modifier you can use to bypass the edit, including the 59 modifier/X modifier. This is because in the PTP edits list, 97150 is the Column One code and 97161, 97162, and 97163 are Column Two codes. Under the policy, when Column One and Column Two codes are billed, the Column One code is eligible for payment and the Column Two code is denied.

    5. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97140 (manual therapy) and 97161-97163 (physical therapy evaluation codes)?
    Yes. It's possible to bypass the edit by using the 59 modifier/X modifier when billing 97140 with the physical therapy evaluation codes (97161, 97162, or 97163). If you don't use the modifier for this combination of codes, CMS will deny the manual therapy code. This is because in the PTP edits list, 97161-97163 is the Column One code and 97140 is the Column Two code. Under the policy, when Column One and Column Two codes are billed, the Column One code is eligible for payment and the Column Two code is denied — unless an appropriate modifier is used.

    6. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97530 (therapeutic activities) and 97164 (physical therapy re-evaluation)?
    Yes, you are permitted to bill 97530 with 97164 if you use the 59 modifier/X modifier. If you do not bill with the appropriate modifier, then 97164 (Column Two code) will be denied. (See question 5).

    7. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97150 (group therapy) and 97164 (physical therapy re-evaluation)?
    Yes, for the same reason explained in questions 5 and 6.

    8. Do PTP edits apply across disciplines?
    Unfortunately yes, when services are billed under the same provider number. For example, if the occupational therapist performs 97530 on the same day as the PT who bills an evaluation code, the evaluation code will be denied if the services of both providers are billed under the same provider number (as in institutional billing).

    9. What settings do PTP code pair edits apply to?
    The NCCI edits consist of two provider-type choices of PTP code pair edits: practitioners and hospitals.

    By "practitioners," CMS means that the NCCI edits apply to claims submitted by physicians, nonphysician practitioners, and ambulatory surgical centers. This includes PT private practitioners.

    The definition of "hospital," for purposes of this edit, extends to outpatient hospital services and other facility services including, but not limited to, therapy providers in Part B skilled nursing facilities, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers, and home health agencies for certain claims billed under Type of Bill (TOB) 22X, 23X, 75X, 74X, 34X.

    10. Do NCCI edits apply to all third-party payers?
    Yes and no. Technically, the NCCI edits only apply to Medicare fee-for-service, but the majority of commercial payers do use the NCCI edits in their systems, so there's a good chance you'll need to comply with the edits even if you aren't working with Medicare. Some workers compensation programs and self-insured plans may create their own edits.

    11. Are there other edits I should be aware of?
    Yes, there are many PTP edits for hospital and practitioner settings. The PTP edits are updated on a quarterly basis. To stay up to date, visit the CMS PTP Coding Edits page, scroll down to related links, and click on the appropriate setting link (Hospital PTP edit or Practitioner PTP edit) for the relevant time period.

    12. What happens next?
    APTA continues to pressure CMS to remove these edits. CMS has met with the NCCI contractor to discuss the edits and is working on a resolution. We hope to have additional information to share in the near future.

    Looking for additional information about NCCI edits? Visit the National Correct Coding Initiative Edits webpage or contact APTA at advocacy@apta.org.

    The Good Stuff: Members and the Profession in the Media, January 2020

    "The Good Stuff" is an occasional series that highlights recent media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs, PTAs, and students are transforming health care and society every day. Enjoy!

    PT leadership for USA Gymnastics: Kim Kranz, PT, DscPT, has been named USA Gymnastics' first vice president of Athlete Health and Wellness. (Around the Rings)

    When resolutions become a pain: Ryan Balmes, PT, DPT, and Jessica Douglas, PT, MSPT, offer advice on how to take on that New Year's fitness resolution without getting hurt. (Boston Globe)

    Redskins score a key PT: Kevin Wilk, PT, DPT, FAPTA, is now the Washington Redskins' medical trainer. (Redskins Wire)

    The importance of the pelvic floor: Riana Taktikos, PT, DPT, explains the ways pelvic floor physical therapy can help conditions that many people think they just have to live with. (Warren, Ohio, Tribune-Chronicle)

    Home is where the gym is: David Reavy, PT, MBA, shares his favorite piece of home gym equipment. (Gear Patrol)

    Solving middle back pain: Tony D'Angelo, PT, outlines what's different about middle back pain, and provides tips on addressing it. (Shape)

    Balance in all things: Ben Fung, PT, DPT, MBA; and Kathleen Walworth, PT, DPT, stress the importance of good balance, and suggest ways to improve. (Vitacost.com)

    Flying with the Eagles: St. Francis University (Pennsylvania) physical therapy students helped members of the Philadelphia Eagles create adaptive ride-ons for kids with disabilities at a recent GoBabyGo event. (Altoona, Pennsylvania Mirror)

    The power of neurologic physical therapy: Ian Lonich, PT, DPT, is making a difference for patients in southwest Pennsylvania. (Uniontown, Pennsylvania Herald-Standard)

    Pillow talk: Karena Wu, PT, DPT, MS, discusses the advantages of body pillows. (Bustle)

    Goodbye, crunches: Bethanie Bayha, PT, DPT, provides insight on better core-strengthening exercises. (Self)

    Go ask pectoralis: Danielle Weis, PT, DPT, discusses ways to counter pectoralis muscle imbalances that cause neck pain. (Well and Good)

    The PT's role in responding to autism spectrum disorder: Anjana Bhat, PT, is leading the way helping children with ASD improve social skills and communication through physical therapy. (University of Delaware News)

    Speedbumps on the road to fitness: Todd Kruse, PT, MPT, shares insights on preventing injury while pursuing fitness resolutions. (KEYC12 News, Mankato, Minnesota)

    I'll be sore for Christmas: Anna Friedman, PT, says yes, Virginia, there is a "Santa strain." (KOMO News, Seattle)

    Delivering postpartum fitness: Carrie Pagliano, PT, DPT, unpacks the trend toward exercise programs for new mothers. (Wall Street Journal)

    GoBabyGo, Colorado style: Jessica Albers, PT; and Kristen Holman, PT, DPT, spearheaded a recent effort to retrofit children's vehicles to provide independence — and a lot of fun — for children with disabilities. (Coloradoan)

    There's no place like foam: Theresa Marko, PT, DPT, MS, discusses the advantages and uses of foam rollers. (Insider)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    We Have a Winner: ONE by ONE Member Recruitment Effort's Prizewinner List Continues to Grow

    Heather Prather, PT, DPT, says APTA membership gives her the information and peer connections she needs to thrive in her profession. And she must make a pretty compelling case, at least as far as new APTA member Erin Brannan, PTA, is concerned.

    Prather is the latest prize-drawing winner in APTA's ONE by ONE membership campaign, a project that encourages members to recruit their fellow PTs, PTAs, and physical therapy students — in Prather's case, it was Erin Bannan — to join APTA. Every member who refers a new or returning member is entered into a monthly drawing for a free year of APTA membership. In December, Prather's name was drawn. Both Prather and Brannon are from New Mexico.

    "I renewed my APTA membership, as I enjoy having access to the clinical tool box for quick access to different outcome measures and appropriate exercises and protocols to utilize based on diagnosis," Prather said. “I enjoy receiving the PT in Motion magazine and reading about up-to-date topics and what’s happening in the physical therapy world. The community boards are helpful to see what is being discussed, or as a lifeline to ask fellow members their advice or suggestions from their experiences on certain topics. It is great to be a member of APTA, to show support and that we are proud of our profession."

    The ONE by ONE campaign also holds a monthly prize drawing for new or renewing members referred through the campaign, awarding winners a subscription to APTA's Passport to Learning continuing education access system. The most recent winner was Steve Baron, PT, DPT, a new member from Pennsylvania. Baron was recruited by Matthew Will, PT, DPT, also from Pennsylvania.

    ONE by ONE offers additional opportunities to win, including a prize for the participating section that experiences the largest year-over-year growth rate during the campaign, and the chance to win one of five iPads that will be given away in a drawing of members who recruit five or more new members by the end of the campaign.

    Details on the recruitment effort — and a list of past prize winners — can be found on the ONE by ONE webpage, including a toolkit that gives you everything you need to join the campaign. ONE by ONE runs through September 30, 2020.

    APTA CEO Moore Joins Amputee Coalition Board

    APTA Chief Executive Officer Justin Moore, PT, DPT, has been unanimously elected to serve a four-year term on the Board of the Amputee Coalition, a leading national advocacy organization.

    The Amputee Coalition serves the more than two million Americans with limb loss and limb difference and more than 28 million at risk for amputation. Its mission is to raise awareness for and advocate on behalf of that population on Capitol Hill, and ensure that legislators and policymakers are educated about the unique needs of this community. The coalition’s work helps to secure the services, supports, and resources for individuals to live the lives they want to live.

    Moore will join 11 other board members who advise the organization on initiatives including federal policy outreach, insurance protections for patients, the organization’s National Limb Loss Resource Center, summer youth camp, and hospital partnerships.

    “Having Justin join our esteemed board of directors strengthens our ability to make progress toward our strategic goals and grow the coalition,” said Coalition CEO Mary Richards. “We all look forward to his vision, leadership, and insights about the federal policy landscape and how we can best serve our community.”

    “I am honored to have been elected to the Board of Directors of the Amputee Coalition," Moore said. “Clearly the coalition’s mission closely reflects APTA’s own vision — transforming society by optimizing movement to improve the human experience — which makes this position all the more significant to us. I look forward to working with the coalition to advocate for those they serve.”

    Paul Rockar Named Foundation President

    The Foundation for Physical Therapy Research (FPTR) has named former APTA President Paul Rockar Jr., PT, DPT, MS, as its president. Rockar, who served as a foundation trustee for three years prior, assumed his new role on January 1, 2020.

    Rockar is a well-known figure in the physical therapy profession, having served as a member of the APTA Board of Directors, as its vice president, and finally, as president of the organization from 2012 to 2015. Rockar is the former CEO of the Centers for Rehab Services.

    APTA and the foundation have a more than 40-year relationship focused on promoting physical therapy research. As a designated Pinnacle Partner of the foundation, APTA invested over $500,000 to support foundation initiatives including scholarships and fellowships in 2019.

    In his role as president, Rockar will work alongside his fellow Board of Trustees members to continue the foundation’s 2019-2022 strategic plan.

    “I am honored to have been chosen by my fellow trustees to lead FPTR at a time when research is so important to the profession,” said Rockar. “I look forward to collaborating with our partners and like-minded supporters — including APTA — to support research that leads to the best clinical guidelines and excellent patient care.”

    Rockar succeeds Edelle Field-Fote, PT, PhD, FAPTA, who concluded her term at the end of 2019.

    Separate Studies, Similar Conclusions: Bundling for Knee, Hip Replacement Seems to be Working

    Has all the bundling been worth it? Two new studies of bundled care models used by the Centers for Medicare and Medicaid Services (CMS) conclude that, at least for lower extremity joint replacement (LEJR), the answer is yes. Taken as a whole, the studies make the case that while the savings achieved through some bundled care models may not be dramatic, they do exist — and aren't associated with a drop in quality.

    The studies, published in Health Affairs, take different approaches to answering questions about the effectiveness of bundling programs mostly associated with CMS' voluntary Bundled Payments for Care Improvement (BPCI) initiative: one was a systematic review that analyzed existing research (abstract only available for free) on the programs, while the other focused on data from hospitals that did and did not participate in BCPI (abstract only available for free) over a three-year period. Their conclusions, however, had much in common.

    The bottom line, according to both studies, is that bundled care models for LEJR seem to be lowering overall costs without sacrificing quality.

    The systematic review revealed that most studies that evaluated spending recorded decreases in overall postacute care spending of between $591 and $1,960, while the hospital data researchers identified an average 1.6% decrease in episode spending for LEJR — about $377 per patient. At the same time, neither study uncovered evidence of reduced quality outcomes, with the hospital study finding variances between BPCI and non-BPCI care for LEJR of less than 2%. The systematic review found that, if anything, research indicates that bundled care tends to lead to lower rates of hospital readmission, a datapoint strongly associated with quality.

    The studies did have some differences. The hospital data researchers focused solely on LEJR data, which they describe as the most common procedure associated with BPCI, while the systematic review included a bundled care model for a range of procedures. In the end, authors of the systematic review found that bundled payment "has yet to demonstrate [benefits similar to those associated with LEJR bundling] for other clinical episodes," including spinal fusion, shoulder arthroplasty, and cardiac surgery. Another difference between the studies: The systematic review included data from CMS' Comprehensive Care Joint Replacement (CJR) model mandated for use in some 450 facilities across the country; the hospital data review excluded CJR facilities.

    [Editor's note: APTA offers multiple resources on bundling, including separate webpages devoted to BPCI Advanced participation and the CJR.]

    Each study offered its own takeaways. The systematic review emphasized the effectiveness of bundling for LEJR and suggested that CMS "scale up” its bundling programs in those areas, while cautioning that more work needs to be done on bundling programs for other procedures, especially those that tend to be associated with higher baseline patient complexity. The hospital data study, focused on LEJR only, found that most of the savings associated with bundling came from early adopters (which maintained their savings over time), and less so from facilities that joined later, which "may have been less able to influence episode spending." That study also acknowledged that while voluntary bundling models may be subject to cherry-picking of less complex patients, data revealed that "it does not fully account for associated savings."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    New APTA-Supported CPG Looks at Best Ways to Improve Walking Speed, Distance for Individuals After Stroke, Brain Injury, and Incomplete SCI

    In this review: Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury
    (Journal of Neurologic Physical Therapy, January, 2020)

    The message
    A new clinical practice guideline (CPG) supported by APTA and developed by the APTA Academy of Neurologic Physical Therapy concludes that when it comes to working with individuals who experienced an acute-onset central nervous system (CNS) injury 6 months ago or more, aerobic walking training and virtual reality (VR) treadmill training are the interventions most strongly tied to improvements in walking distance and speed. Other interventions such as strength training, circuit training, and cycling training also may be considered, authors write, but providers should avoid robotic-assisted walking training, body-weight supported treadmill training, and sitting/standing balance that doesn't employ augmented visual inputs.

    The study
    The final recommendations in the CPG are the result of an extensive process that began with a scan of nearly 4,000 research abstracts and subsequent full-text review of 234 articles, further narrowed to 111 randomized controlled trials (RCTs), all focused on interventions related to CNS injuries, with outcome data that included measures of walking distance and speed. CPG panelists evaluated the data and developed recommendations, which were informed by data on patient preferences and submitted for expert and stakeholder review.

    Development of the CPG was supported through an APTA-sponsored program that assists APTA sections — in the case, the Academy of Neurologic Physical Therapy — in the development stages such as drafting, appraisal, planning, and external review (for more detail on the program, visit APTA's CPG Development webpage).

    Findings

    • Moderate- to high-intensity (60%-80% of heart rate reserve or up to 85% of heart rate maximum) walking training was associated with the strongest evidence for improvements in walking speed and distance.
    • Walking training using VR also fared well, due in part to the ability of a VR treadmill system to allow "safe practice of challenging walking activities," something that's hard to do in a more traditional hospital or clinic setting.
    • Strength training, while not included among the interventions that should be performed, was designated as an intervention that may be considered. Authors cite inconsistent evidence on the connection between strength training and improved walking speed and distance, but they acknowledge potential benefits.
    • Also among the list of interventions that "may be considered": circuit training, as well as cycling training. In both cases, authors cite a paucity of evidence related to how the interventions affect walking speed and distance. They note that these interventions may be revisited during a future reevaluation of the CPG.
    • Body-weight supported treadmill training was labeled as an intervention that should not be performed in order to increase walking speed and distance, with authors finding little evidence supporting the approach, which is often associated with a greater cost. However, they write, the individuals included in the studies reviewed for the CPT were able to ambulate over ground without the use of a body-weight support device, and "different results may occur in those who are nonambulatory or unable to ambulate without the use of [body-weight support]."
    • Both static and dynamic (nonwalking) balance training and robotic-assisted walking training were also characterized as interventions that should not be performed. Authors acknowledge the ways that postural stability and balance are associated with fall risk and reduced participation, but they were unable to find sufficient evidence to support these particular interventions as effective in increasing walking speed and distance (although static and dynamic balance training with VR fared a bit better). As for robotic-assisted walking training, CPG authors note that while ineffective for individuals with CNS who were already ambulatory, "this recommendation … may not apply to nonambulatory individuals or those who require robotic assistance to ambulate."

    Why it matters
    Authors note that "the implementation of evidence-based interventions in the field of rehabilitation has been a challenge," and they believe that the new CPG offers a real opportunity for clinicians to "integrate available research into their practice patterns." Further, they believe that the CPG has arrived at an important moment in the evolution of health care, with its greater emphasis on evidence for the cost-effectiveness and outcomes of various interventions.

    More from the study
    The CPG also offers tips for clinicians to implement its recommendations, including acquiring equipment to help providers monitor vital signs, implementing "automatic prompts in electronic medical records that will facilitate obtaining orders to attempt higher-intensity training strategies," providing training sessions for clinicians, establishing organizational policies to promote use and documentation of the recommended interventions, and simply keeping a few copies of the study on hand for easy reference.

    Keep in mind …
    Authors acknowledged that the CPG has a few limitations. While the review of RCTs only is a strength, they write, some of those studies involved small sample sizes, and many lacked details on intervention dosage. Additionally, the CPG does not fully address the potential costs associated with its recommendations — specifically VR — which could impact a clinic's ability to implement a particular intervention. Authors also acknowledge that walking speed and distance are not the only important outcomes related to mobility among individuals with CNS injury, and that other factors such as dynamic stability while walking, peak walking capacity, and community mobility may be incorporated in an assessment of walking function.