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  • JAMA: Better Health Care Workplace Violence Prevention Plans Needed

    With half of all workplace assaults involving health care workers already, and the number of violent crime episodes in hospitals on the rise, it's time for health care facilities to address workplace violence "aggressively and comprehensively," say authors of an editorial recently published in JAMA.

    The "Viewpoint," (first-page sample only available for free) written by 2 employees of the Joint Commission and a representative from a Veterans Health Administration workplace violence prevention program, cites data from the Joint Commission, Occupational Safety and Health Administration (OSHA), and Bureau of Labor Statistics (BLS) to outline what they assert is a growing problem. Among the data:

    • Within health care settings, approximately 24,000 workplace assaults occurred between 2010 and 2013, with most threats and assaults occurring between noon and midnight.
    • Between 2012 and 2015, the incidence of violent crime events in hospitals rose from 2.0 to 2.8 per 100 beds.
    • According to BLS, 50% of all workplace assaults involve health care workers, while workers in this labor segment only account for 20% of all workplace injuries.
    • An OSHA study of 100 health care worker or patient fatalities in health care settings found that nearly a third (27%) were attributable to assaults and violence.
    • A Joint Commission study of 33 homicides, 38 assaults, and 74 rapes in health care workplaces between 2013 and 2015 concluded that "root causes of these events were failures in communication, inadequate patient observation, lack of or noncompliance with policies addressing workplace violence prevention, and lack of or inadequate behavioral health assessment to identify aggressive tendencies in patients," authors write.

    Authors of the JAMA article assert that increasing workplace safety will require health care employers to step up the creation of violence prevention programs. These programs, they write, must be rooted in a recognition that "personnel underreport violent events because they believe these experiences are part of the job, reporting is either cumbersome or unlikely to result in action from leadership, or they fear retaliation for reporting." To counter that tendency authors urge the development of reporting systems that are "simple, trusted, secure, and with optional anonymity," result in "transparent outcomes and delivery of a report confirmation," and are "fully supported by leadership, labor unions, and management."

    "Safety in health care workplaces relies on leadership enacting appropriate polices; trained employees intervening and reporting; multidisciplinary teams using evidence-based threat assessments and management practices, communicating safety plans, and analyzing environmental context; and ongoing evaluation of program effectiveness," authors write. "A workplace violence prevention program should be a required component of the patient safety system of all health care organizations."

    Landmark NIH Plan Delivers 5-Year Roadmap for Rehabilitation Research

    Rehabilitation research, one of APTA's longstanding areas of advocacy, has just received a major boost with the publication of a revised National Institutes of Health (NIH) Rehabilitation Research Plan, a 5-year roadmap intended to address a broad swath of research science. Nearly 2 years in development, the revision is the first change to the plan made in over 2 decades, and was guided by a blue ribbon panel that included prominent APTA members and physical therapy researchers.

    The plan, which will guide NIH support for rehabilitation medicine, addresses 6 priority areas: the need for rehabilitation research, NIH's investment in rehabilitation research, current rehab research activities at NIH, coordination with other federal agencies, and opportunities, needs, and priorities. According to NIH, each area has witnessed significant change since the 1993 edition of the plan, attributable to everything from an increase in rehabilitation researchers and growth in evidence to advances in brain-computer interfaces and other technologies that have altered the rehabilitation landscape.

    Among the topics covered within the priority areas: investigation of new approaches to assistive technology in the home; increasing resources to recruit more researchers; ramped-up efforts to analyze biological, chemical, and genetic components of recovery; and intensified research on rehabilitation and disability across the lifespan.

    A call for a revision to the plan, and the establishment of a 5-year update cycle, were among the recommendations from an NIH blue ribbon panel that was co-chaired by former Physical Therapy (PTJ) Editor-in-Chief Rebecca Craik, PT, PhD, with members that included Anthony Delitto, PT, PhD, and current PTJ Editor-in-Chief Alan M. Jette, PT, PhD.

    Improvements to rehabilitation research and support of NIH work in this area are among APTA's public policy priorities. In addition to its individual advocacy efforts, the association is a member of the Disability and Rehabilitation Research Coalition, a group of more than 40 organizations working together to promote this type of research.

    "The rehabilitation research plan now published will be a major resource, both for researchers and the agencies that provide funding," said Justin Moore, PT, DPT, chief executive officer of APTA. "Rehabilitation science can help providers truly transform lives, and this new plan marks a long-awaited and significant step forward."

    Development of the plan was led by the National Center for Medical Rehabilitation Research (NCMRR), under the leadership of Director Alison Cernich, PhD. NCMRR is part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

    FDA Clears First Device Specifically Designed to Assess Function After Concussion

    The US Food and Drug Administration (FDA) has given its first-ever clearance for marketing of devices designed to help clinicians assess cognitive function immediately after a suspected brain injury or concussion.

    Called Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and ImPACT Pediatric, the tool was approved under a new FDA category titled "Computerized Cognitive Assessment Aid for Concussion." The test battery is already used by more than 7,400 high schools, 1,000 colleges and universities, and 900 clinical centers as a way to test cognitive skills such as word memory, reaction time, and word recognition. ImPACT is designed for use on individuals aged 12 to 59, and operates on a desktop or laptop computer; ImPACT Pediatric is intended for children aged 5 to 11, and is run on an iPad.

    While not intended as the sole tool for making a diagnosis or return-to-play decision, the ImPACT device can provide additional evaluative information though comparisons with age-matched databases or patient baseline scores, according to an FDA news release. Pittsburgh, Pennsylvania-based ImPACT Applications submitted more than 250 peer-reviewed articles—half of which were independent clinical research studies—supporting the safety and reliability of the devices.

    Prior to the ImPACT approval, the FDA had cleared only devices that help determine the need for imaging after a head injury.

    $20 Million NIH Health Disparities Program Includes Project Focused on Increasing Physical Activity in Communities

    The National Institutes of Health (NIH) is starting a new community-based research program to address health disparities related to chronic disease. One the program's first targets: a project that will focus on improving physical activity and healthy eating for a community in Flint, Michigan.

    The program, operating under NIH's National Institute on Minority Health Disparities (NIMHD), will establish so-called "transdisciplinary collaborate centers" (TCCs) to address "the need for more robust, ecological approaches to address chronic diseases among racial and ethnic minority groups, underserved rural populations, people of less privileged socioeconomic status," and other groups subject to discrimination, according to an NIH news release. The TCCs will involve coalitions of research institutions, community organizations, providers, health care systems, and state and local public health agencies to develop interventions "that can be implemented in real-world settings."

    NIMHD plans to spend about $20 million over 5 years to support 2 projects—one will apply "community-engaged health disparities research" around interventions aimed at increasing physical activity and healthy diet; the other aims to control hypertension among American Indians, Alaskan natives, native Hawaiians, and other Pacific islanders.

    The first program, known as the Flint Center for Health Equity Solutions, will evaluate the effectiveness of interventions that approach physical activity and diet issues from multiple levels, including programs that involve local churches, peer coaching, family reunification, and support for individuals in recovery from substance abuse.

    "Multilevel interventions that take into account complex interactions between individuals and their environments can better address the determinants of health and enhance chronic disease prevention and health promotion for local communities," said NIMHD Director Eliseo Perez-Stable in the news release. "Studies in these centers will add to our knowledge of what works in health disparities populations, thus advancing knowledge towards our nation's health."

    How do health disparities affect physical therapist practice, and what are some of the driving forces behind them? Check out APTA's health disparities webpage for more insight.

    Emphasizing Mobility in Elderly Hospital Patients: One Facility's Journey

    A hospital in Alabama had what seemed to be a fairly straightforward idea: it wanted to get its elderly patients up and moving as soon and as often as possible. Accomplishing that goal, however, has required the restructuring of an entire unit, and a "culture change" in how staff prioritize mobility in patients.

    A recent article in Kaiser Health News (KHN) recounts the efforts of the University of Alabama-Birmingham (UAB) Hospital Highlands to rethink care of the elderly through the creation of a special unit, called Acute Care for Elders (ACE). The focus of the 26-bed unit's efforts: to do everything possible to promote mobility. According to KHN, the ACE unit is among only "a few hundred" facilities in the US attempting to provide "better and more tailored care to geriatric patients."

    The unit, which opened in 2008, employs a multidisciplinary team approach, with every team member receiving training on the importance of movement while a patient is in the hospital. The ACE rooms are also designed to facilitate mobility, with plenty of space to move, handrails on the walls, low-glare lighting, and floors that aren't slick. In addition, the program includes "geriatric scholars" who advocate for the cognitive and physical needs of geriatric patients, as well as volunteers who regularly walk with patients.

    Adres Viles, a nurse coordinator at the hospital, told KHN that the new approach requires a "culture change" for staff. In the KHN story, he describes a typical hospital staff so busy "administering medications and tending to wounds" that they don't have the time to walk with patients.

    In addition to time constraints, the KHN article also points out another possible reason mobility isn't emphasized: fear of patient falls.

    "We are doing an awful lot to prevent falls, but there is a cost," Heidi Walk, associate professor at the University of Colorado School of Medicine, told KHN. "The cost is decreased mobility."

    KHN asserts that part of the reason for hospitals' reluctance to emphasize movement may have to do with reporting requirements mandated in the Affordable Care Act (ACA). Hospitals must monitor injury from falls—regarded as a preventable adverse event—and face penalties if those rates are too high.

    Those fears are not stopping the UAB program from emphasizing movement. According to KHN, it's because the hospital understands that "making sure hospitalized patients spend sufficient time out of their beds can save money, keep them mobile after they return home, and improve overall health."

    ACE Program Coordinator Terri Middlebrooks frames the issue more succinctly when she speaks with her patients, KHN reports. "Don't quit walking," Middlebrooks tells a patient. "It's the most important thing you can do … This bed is not your friend."

    Advance your knowledge and skills related to mobility and falls in older adults through APTA Learning Center courses, including: Create a Culture of Mobility in Acute Care, Musculoskeletal Changes With Aging, and Geriatrics Focus for the Physical Therapist – 2016. Also, check out the association's Balance and Falls webpage for resources, and find a clinical practice guideline on falls and fall injuries in the older adult and a clinical summary on falls risk in community-dwelling elderly people in PTNow.

    Zika Virus Effects Go Beyond Microcephaly, Guillain-Barré, Say Researchers

    Medical experts have long known of the link between microcephaly and Zika virus infections in expectant mothers. But new research is shedding light on the extent of virus' effects—both on fetal and adult brains.

    A cranial imaging study in the journal Radiologyhas found other severe brain abnormalities in Brazilian babies with congenital Zika virus infection, even in those with typical head circumference at birth.

    Radiologists identified ventriculomegaly in 43 out of 45 infants with confirmed or presumed Zika infections. Authors hypothesize that these larger-than-normal fluid-filled structures in the brain, as well as cerebral atrophy, are responsible for the often unusual skull shape in these infants; essentially, the baby’s soft skull collapses as the brain shrinks.

    Researchers also observed calcium deposits in most cases. In 38 of the infants, the corpus callosum, which connects the 2 sides of the brain, was thin, malformed, underdeveloped, or completely absent. Several of the infants had incomplete or atrophied brainstems, and in all but 1 case had abnormal migration of neurons in the cerebral cortex.

    Co-author Deborah Levine, MD, told the Washington Post, “The likelihood the babies in our series are going to have normal development because of so many abnormalities — the prognosis is not good.”

    Public health officials continue to focus on warning pregnant women to avoid exposure to the virus. However, a new study in Cell Stem Cell indicates the potential for the virus to affect adult brain cells as well. Study authors examined the 2 areas of the adult brain that still contain neural stem cells. Adult mice injected with Zika virus experienced nerve cell death and generated fewer new nerve cells compared with the control group.

    While researchers don’t know the exact ramifications yet, it's already understood that cognitive decline, Alzheimer’s disease, and other neurological conditions are associated with deficits in new nerve cells. Co-author Sujan Shresta also suggests that “infection of adult neural progenitor cells could be the mechanism behind” the development of Guillain-Barré syndrome in adults who have previously been infected with Zika virus.

    The Centers for Disease Control and Prevention (CDC) have issued an advisory for people living in or traveling to South Florida, as Miami-Dade County has experienced 29 locally acquired cases. Officials worry that Zika will spread to Texas and Louisiana, due to the standing water from massive storms and flooding. The CDC awarded $6.8 million to a number of national public health organizations to help with mosquito surveillance and public awareness efforts.

    For the most up-to-date Zika research, see the World Health Organization open access studies, and the Pan American Health Organization list of published research, and the BMJ free access content.

    Surgeon General Letter Urges Action on Opioids, Recommends CDC Treatment Guideline That Includes Physical Therapy

    Physicians across the United States can expect something in their mailboxes soon—a letter from the Office of the US Surgeon General urging them to take part in the battle against the opioid epidemic, accompanied by a card that specifically mentions physical therapy as one of the preferred first-line approaches for treatment of chronic pain.

    "Everywhere I travel, I see communities devastated by opioid overdoses," writes Surgeon General Vivek Murthy, MD. "I meet families too ashamed to seek treatment for addiction. And I will never forget my own patient whose opioid use disorder began with a course of morphine after a routine procedure."

    In the letter, Murthy asks physicians to sign a pledge at www.TurnTheTideRx.org, the surgeon general's initiative to stem the opioid abuse epidemic.

    Murthy also asks doctors to review an enclosed pocket card that contains the basics of the US Centers for Disease Control and Prevention (CDC) opioid prescription guideline. That guideline lists physical therapy as among the preferred options for the treatment of chronic pain without the use of opioids. Murthy calls the CDC guideline a "good place to start" toward better physician education on how to treat pain "safely and effectively."

    A CNN report on the letter includes Murthy's remarks during a speaking engagement, in which he described how many physicians were taught that opioids are not addictive. Some continue to believe that false information, Murthy told the audience, including 1 of his own physician friends—until Murthy informed him otherwise. He was taught that opioids aren't addictive so long as a patient is "truly in pain," Murthy said.

    "Years from now, I want us to look back and know that, in the face of a crises that threatened our nation, it was our profession that stepped up and led the way," Murthy writes in the letter.

    APTA has added its voice to the effort to curb opioid abuse through its national #ChoosePT campaign, an initiative to promote physical therapy as a safe and effective alternative to the use of opioids in the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, the #ChoosePT campaign will unfold throughout 2016 and include national online advertising, TV and radio public service announcements, and other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.

    Stem Cell-Protein Combination Reverses Poststroke Brain Damage in Mice

    Could brain damage poststroke be reversed? Researchers in a National Institutes of Health (NIH)-funded study say they have found a combination of human stem cells and a protein that created new, functional neurons in the brains of stroke-induced mice.

    In the August 22 edition of Nature Medicine (abstract only available for free), researchers from the University of Southern California outline how they combined 2 methods that individually have demonstrated limited success as treatments for neurologic injury poststroke: surgical grafting of human neural stem cells in the damaged area and administration of the 3KL3A-APC protein, which is derived from the human-activated protein-C.

    When the researchers combined these approaches in stroke-induced mice, they found that the grafted stem cells developed into neurons that made "functional and structural connections with the host's nervous system," explained lead researcher Berislav Zlokovic in an interview with Science Daily. Use of the protein compound resulted in mice with 16 times more human stem cell-derived neurons than mice that received the stem cells and a placebo, Science Daily reports.

    When the mice were tested a month after their stroke, researchers found significant improvement in motor and sensory function compared with that of mice administered neither or only 1 of the 2 components.

    "Functional deficit after 5 weeks of stroke were minimized, and the mice were almost back to normal in terms of motor and sensorimotor functions," Zlokovic told Science Daily. "Synapses formed between transplanted cells and host cells, so there is functional activation and cooperation of transplanted cells in the host circuitry."

    Researchers plan to begin testing whether the improvements can be replicated in human patients. If so, Zlokovic and his team will test the treatment on other neurological conditions, such as spinal cord injuries.

    TIME Article: US Must Rethink Pain Treatment, Become 'Insistent' on Physical Therapy

    A recent opinion piece in TIME magazine says that when it comes to pain treatment, unless a "fundamental mindset" is changed—a change that includes being "insistent" on the use of physical therapy in pain management—no real progress will be made in the fight to end the opioid abuse epidemic in the United States.

    In "We're All Responsible For Our Opioid Reliance—Even Patients," Andre Machado, chairman of the Neurological Institute at the Cleveland Clinic, describes how opioids are little more than a "quick fix" for pain that miss what should be the true goal of pain treatment, which he describes as "recovery of function, not complete resolution of pain."

    "This crisis is a failure of our health care ecosystem and our quick-fix culture," Machado writes. "We can all share the blame: physicians who feel anxious to meet patients’ expectations, pharma companies that oversell opioid benefits (and downplay the risks), insurers that fail to flag patients receiving high volumes of opioid prescriptions (and not properly reimbursing therapy) and patients who demand passive treatment."

    Machado argues that to truly change outcomes, "we all need to first change the metric of success" from focusing solely on the elimination of pain to helping patients better understand and manage their pain. Part of that shift, he writes, must include becoming "insistent on the use of physical therapy as an integral treatment component."

    As part of his own efforts to make that shift, Machado describes his participation in a Cleveland Clinic pilot program to treat more than 1,000 patients with chronic leg and back pain with physical therapy and counseling as a first-line response. The key metric of success, he writes, will be "restoration of function."

    "Ultimately, this methodology should serve to lessen the community's reliance on opioids and improve the utilization—and timing—of invasive procedures," Machado writes.

    APTA has added its voice to the effort to curb opioid abuse through its national #ChoosePT campaign, an initiative to promote physical therapy as a safe and effective alternative to the use of opioids in the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, the #ChoosePT campaign will unfold throughout 2016 and include national online advertising, TV and radio public service announcements, and other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.

    NYT: Racial Disparities in Pain Treatment

    As if the national conversation over how pain is treated isn't already complex enough, The New York Times (NYT) points out another important facet of the problem: regardless of where approaches may be heading in the future, pain treatment as it stands now is far from equal among racial minorities and whites.

    "Finding Good Pain Treatment Is Hard. If You're Not White, It's Even Harder" combines interviews with research findings to highlight what NYT describes as a "persistent" problem: "Minorities tend to receive less treatment for pain than whites, and suffer more disability as well." Among the findings reported in the story:

    • Blacks have been affected by the prescription opioid epidemic at "much lower rates" than whites.
    • Blacks are 34% less likely than whites to be prescribed opioids for back pain, abdominal pain, and migraines, and 14% less likely to be prescribed opioids for pain from traumatic injuries or surgery.
    • Pharmacies in poor but majority-white neighborhoods are 54 times as likely as pharmacies in poor minority neighborhoods to have "adequate supplies" of opioids.
    • In Alabama (the state used as an example in the NYT report because of its high opioid prescription rate), Medicare data show that "in all but 1 of Alabama's majority-black counties, the rate of opioid prescribing is below the state average," with 4 of the 5 counties at the low end of prescription rates being majority-black.
    • Workers' compensation programs in 2004 spent less to treat blacks with low back injuries, with shorter treatments, regardless of income level.
    • In 2014, 71 out of every 1 million white Americans died of prescription opioid overdose, compared with 33 out of every 1 million black Americans.

    NYT reporter Abby Goodnough interviewed several physicians and pain researchers on possible causes for the disparities, including some who believe the differences are at least partially rooted in false stereotypes and "a tendency for doctors to empathize less with patients whose race is different than their own—perhaps subconsciously—and to underestimate the severity of their pain."

    As for what the NYT describes as the "silver lining" argument—that the disparities have spared blacks from being as severely affected by the opioid abuse epidemic as whites—1 pain researcher discounted the sentiment.

    "We may agree that opioids can be harmful and that fewer of them may be a good thing," pain researcher Adam Hirsh told NYT, "But we should not ignore that black and white patients are getting treated differently."

    The article also mentions nondrug approaches to pain treatment, tracking the progress of Roslyn Lewis, who suffered a back injury for which she was able to receive little treatment. Eventually, she was enrolled in a study that used cognitive behavioral therapy to address pain—an approach she found helpful. Not long after that study ended, she was able to qualify for Medicaid, which allowed her to begin physical therapy.

    "I feel proud of myself that I finally got something to go for," Lewis told NYT.

    How do health disparities affect physical therapist practice, and what are some of the driving forces behind them? Check out APTA's health disparities webpage for more insight.

    APTA has added its voice to the effort to curb opioid abuse through its national #ChoosePT campaign, an initiative to promote physical therapy as a safe and effective alternative to the use of opioids in the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, the #ChoosePT campaign will unfold throughout 2016 and include national online advertising, TV and radio public service announcements, and other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.