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  • JAMA: Easing Administrative Complexity, Eliminating Low-Value Care Among Ways to Reduce Health Care Waste and Lower Expenditures

    In this review: Waste in the US Health Care System: Estimated Costs and Potential for Savings
    (JAMA, October 7, 2019)

    The message
    A review of published research and government reports found that the estimated annual cost of health care waste ranged from a total of $760 billion to $935 billion in the areas of failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. Interventions that reduce waste could significantly "reduce the continued increases in US health care expenditures," authors write.

    The study
    Researchers analyzed data from peer-reviewed articles and government reports published between 2012 and 2019 that focused on US cost of health care waste or savings from interventions to address waste. The study categorized waste by the following domains identified by the Institute of Medicine: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity.

    Authors were interested in a number of causes of waste, including clinician-related inefficiencies, lack of adoption of preventive care practices, unnecessary admissions or avoidable complications and readmissions, low-value interventions and tests, payer-based health services pricing, and administrative burden.

    Studies of savings from interventions addressing waste included initiatives targeting the reduction of adverse hospital events and hospital-acquired infections, bundled payment models to reduce unnecessary variability in care, care coordination within accountable care organizations (ACOs), prior authorization, payer-focused interventions, and strategies to reduce fraud and abuse.

    Findings

    • The cost of waste from failure of care delivery ranged from $102.4 billion to $165.7 billion. Authors estimate that interventions to address this category could save from $44.4 billion to $93.3 billion annually.
    • Waste from failure of care coordination costs from $27.2 billion to $78.2 billion each year. Implementing initiatives in this area could save anywhere from $29.6 billion to $38.2 billion.
    • Overtreatment or low-value care costs between $75.7 billion and $101.2 billion annually. Researchers project that successful initiatives to minimize such care could result in savings ranging from $12.8 billion to $28.6 billion.
    • Overpriced medication and other health services cost an estimated $230.7 billion to $240.5 billion each year. Interventions such as pricing transparency initiatives could save between $81.4 billion and $91.2 billion.
    • Medicare fraud and abuse cost from $58.5 billion to $83.9 billion. Legislative, administrative, and integrity strategies could result in annual saving of $22.8 billion to $30.8 billion.
    • Annual cost of waste due to administrative complexity was $265.6 billion—the largest contributor of all 6 categories. However, no studies addressed savings from interventions in this area.

    Why it matters
    The United States spends more money each year than any other country on health care costs—projected to be more than $3.8 trillion for 2019, approximately 18% of the nation’s gross domestic product. According to authors, addressing unnecessary waste could reduce total health care expenditures by 25%.

    Value-based arrangements, "payer-health system collaboration to improve care coordination and transitions in care," and "greater alignment between payers and clinicians" could greatly reduce waste, as well as low-value care, authors write.

    More from the study
    "Fragmentation in the health care system is one of the causes of costs from administrative complexity, the largest contributor to waste," authors write. They believe that as value-based care models continue to be more widely adopted, there will be "increasing interdependency" among all 6 categories of waste. They estimate that interventions to address waste in care delivery, failure of care coordination, and overtreatment or low-value care categories alone could reduce cost of waste by as much as half.

    Related APTA resources
    APTA's Integrity in Practice website offers resources and information on reducing fraud, waste, and abuse. The association continues to advocate for reducing administrative burden, and members can encourage their House representatives to address the burden of prior approval by supporting H.R. 3107, the "Improving Seniors' Access to Care Act," through the Legislative Action Center or the APTA Action app.

    Keep in mind…
    Authors note several limitations in the existing studies reviewed for this study. Much of the research comes from data on Medicare enrollees, which may not be generalizable to the entire Medicare population or private insurance. Thus, the resulting costs estimated are conservative. Similarly, some studies included multiple sites, rather than nationwide data, limiting the generalizability of the results. In addition, more realistic estimates of cost savings from interventions to address waste would be possible if studies included data on costs of implementing the interventions. Estimates do not include pediatric health care spending, because research in this area is limited.

    APTA Co-Sponsored Study: Seeing a PT First for LBP Lowers Odds of Early and Long-Term Opioid Use

    In this review: Observational retrospective study of the association of initial health care provider for new-onset low back pain with early and long-term opioid use
    (BMJ Open, September, 2019)

    The message
    An analysis of more than 200,000 commercial and Medicare Advantage insurance beneficiaries has revealed what researchers describe as a "significant" pattern: among patients seeking treatment for low back pain (LBP), those whose initial visit was with a physical therapist (PT), chiropractor, or acupuncturist decreased their odds of early opioid use by between 85% and 91%, and lowered their odds of long-term opioid use by 73% to 78% compared with those whose index visit was with a primary care physician (PCP).

    The study
    Researchers reviewed insurance claims from 216,504 adults with new-onset LBP between 2008 and 2013 to explore the relationship between the type of provider seen at the initial (index) visit and subsequent opioid use. The study looked at opioid use in terms of both "early" use, defined as a filled opioid prescription within 30 days of the index visit, and "long-term" use—a filled opioid prescription within 60 days of the index visit and either an opioid supply of 120 days or more over 12 months or a supply of 90 days and 10 or more opioid prescriptions over 12 months. The analysis included claims for patient visits, inpatient and outpatient treatment with initial providers, and pharmacy services.

    Authors of the study were also interested in gauging the impact of varying levels of direct access to PT visits as allowed in state laws, and evaluated rates of initial physical therapy use in states with access laws they defined as "limited," "provisional," and "unrestricted."

    The de-identified data, provided by OptumLabs®, included both commercial insurance and Medicare Advantage claims, and are described by authors as "representing a diverse mix of ages, ethnicities, and geographical regions across the USA." The study itself was sponsored by the American Physical Therapy Association (APTA) and UnitedHealthcare®, and included APTA members Christine McDonough, PT, PhD, and Julie Fritz, PT, PhD, FAPTA, among the authors.

    Findings

    • Of the patients who met inclusion criteria for new-onset LBP (no previous LBP diagnosis, no previous back procedures for at least 12 months before the index event, and insurance enrollment for at least 12 months before and after the index date), 53% initially met with a PCP. Among what authors call "conservative providers"—PTs, chiropractors, and acupuncturists—chiropractors were the most frequently seen, drawing 23.1% of patients, followed by PTs (1.6%), and acupuncturists (0.8%).
    • About 18% of patients filled an opioid prescription within 3 days of the index visit, and 22% received a fill within the first 30 days. Only 1.2% of patients met the researchers' criteria for long-term use.
    • In terms of early opioid use, patients who saw a PT first had 85% decreased odds of receiving an opioid fill within the first 30 days after the index visit compared with patients who saw a PCP first. Patients whose index visit was with an acupuncturist were associated with 91% decreased odds compared with PCPs, and those who saw a chiropractor first were correlated with 90% decreased odds.
    • The decreased odds of opioid use with conservative treatment also carried over to long-term use, with 73% decreased odds associated with a PT index visit, 74% decreased odds for acupuncturists, and 78% decreased odds for chiropractors compared with patients whose index visit was with a PCP.
    • Compared with states in which direct access to PTs is limited, patients in states with provisional access to PTs—for example, states that impose time or visit limits—had 21% increased odds of seeing a PT at index. Those odds increased to 67% in states with unrestricted direct access.
    • Compared with patients whose index visit was with a PCP, patients who saw other types of physicians, such as orthopedic surgeons and neurosurgeons, tended to have lower odds of early opioid use—but those lower odds disappeared when it came to long-term use.

    Why it matters
    This large-scale retrospective study—authors believe it's one of a very few to look at opioid use patterns across multiple providers—adds to the evidence that conservative approaches to LBP can significantly lower the odds of opioid use, an important consideration as the country continues to struggle with its opioid crisis.

    The bottom line, according to authors is that "early engagement of conservative therapists may decrease initial opioid prescriptions in association with MD visits by providing the opportunity to incorporate evidence-based nonpharmacological approaches."

    More from the study
    Authors believe several factors might be at work when it comes to lower opioid use among patients whose index visit was with a conservative care provider:

    • These providers can't prescribe opioids, which may lower short-term use rates.
    • Patients who seek out conservative care providers may be doing so because they don't want to take opioids.
    • Conservative therapies tend to decrease LBP, lowering the need to seek other treatment.

    Related APTA resources
    The study's results are consistent with the policy recommendations in a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches. In addition, APTA offers a wide range of consumer-focused resources on pain and pain management at its ChoosePT.com website.

    Keep in mind…
    Because the study was based on claims data only, researchers couldn't account for the severity of the LBP being experienced by patients, a factor that could influence the decision about which type of provider to see first. Researchers were also unable to dive more deeply into patient preferences and behavioral factors that might influence index visits and opioid use.

    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.

    [Editor's note: McDonough and Fritz are also the recipients of grants from the Foundation for Physical Therapy Research: McDonough received a Magistro Family Foundation Research Grant in 2015 as well as a New Investigator Fellowship Training Initiative in Health Services Research grant in 2009; Fritz was awarded an Orthopaedic Research Grant in 2002.]

    PTs in Pain: Study Finds Relationships Between PTs Who Experience MSK Pain and Hours Worked, Patient Volume, and Years of Experience

    In this review: Professional experience, work setting, work posture, and workload influence the risk for musculoskeletal pain among physical therapists: a cross-sectional study
    (International Archives of Occupational and Environmental Health, August, 2019)
    Abstract

    The message
    A survey of physical therapists (PTs) in Spain revealed that about half of all respondents had experienced moderate-to-high levels of low back pain in the last 30 days, and nearly 3 in 5 had experienced neck pain in the same time frame. Researchers analyzed those and other areas of pain in relation to work conditions and demographic variables, and found several elements that they believe increase—and sometimes decrease—the odds of experiencing musculoskeletal pain (MP). Among the connections: larger patient loads, more hours worked per week, and more frequent use of machines and manual therapy raised the odds of some types of MSK pain, while more years of experience in the field tended to have the opposite effect.

    The study
    Members of Spain's physical therapy professional association were invited to participate in an online survey that asked them about any MP they may have experienced in the past 30 days, including the pain site as well as the severity of the pain on a 0-10 scale. For purposes of the study, researchers focused on pain episodes with ratings of 3 and above, and limited pain sites to neck, shoulders, upper back, low back, elbow/forearm, and hand/wrist.

    The pain episodes were then compared with self-reported work-related factors including years of experience, work in the public vs private sector, hours worked per week, number of patients per week, prevalence of treating multiple patients at a time, primary patient type, and primary type of treatment used. A total of 981 questionnaires were analyzed. The study population had an average age of 34.3 years, with females making up 70.6% of respondents.

    Findings

    • Overall, 57% of respondents reported experiencing moderate-to-significant neck pain within the past 30 days, and 49.4% reported low back pain (LBP). Upper back pain was the third most reported site at 36.1%, followed by shoulders (33.8%), hand/wrist (32.7%), and elbow/forearm (16.7%)
    • Higher odds of experiencing LBP were associated with treating more than 1 patient at the same time (2.14 times as likely than treating individual patients), working more than 45 hours per week (1.73 times as likely compared with working fewer than 35 hours per week), and working in a seated position (2.04 times as likely compared with standing work).
    • PTs who reported using exercise interventions as their primary type of treatment tended to have lower rates of neck pain compared with PTs whose primary approach was manual therapy. PTs who primarily used machines "consistently reported higher rates of upper back pain," compared with the use of manual or exercise therapy, according to the study's authors.
    • In addition to its correlation to LBP, working more than 45 hours per week was also associated with higher prevalence of upper back pain compared with PTs who worked fewer than 35 hours per week.
    • Patient load was found to have a weak-to-moderate effect on increased rates of shoulder pain, with PTs who treated 30 or more patients per week reporting a higher prevalence than those who treated fewer than 30 patients per week.
    • PTs with 6 to 15 years of experience were found to have lower odds of experiencing shoulder, low back, and elbow/forearm pain compared with PTs reporting 5 or fewer years of experience. PTs with more than 15 years' experience were found to have lower odds of experiencing pain in those same areas, as well as lower odds of neck pain, compared with the 0-5 year group.

    Why it matters
    While MP is common among health care providers, PTs tend to be at higher risk, with a recent systematic review predicting that as many as 91% of PTs will experience MP in their lifetimes. Authors of this study hope that their findings could help in the development of clinical guidelines and interventions "to prevent work-related MP and better working conditions among PTs."

    More from the study
    Authors were particularly interested in the reasons why more experienced PTs reported a lower prevalence of MP. They suggested 4 possible explanations:

    • Better patient management skills and "the dearth of practice about how to reduce the risk of MP"
    • Better injury prevention strategies among more experienced PTs such as "modification of treatment techniques or increasing the use of support staff"
    • Attrition as PTs who experience MP early in their careers leave those careers sooner (the "healthy workforce effect")
    • The possibility that "more experienced PTs developed a higher pain threshold due to higher work volume"

    Related APTA resources
    APTA's Safe Patient Handling webpage offers resources for avoiding injury, including links to online courses, US Food and Drug Administration guidelines on proper use of patient lifts, and a bibliography of journal articles from multiple disciplines.

    Keep in mind...
    The study, based on survey results, looked at exposure and outcomes simultaneously, which can influence the ways associations are established. Additionally, researchers didn't know how many PTs received the initial survey, so they couldn't determine a response rate—data that could also color the findings.

    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.

    Posture and Movement Coordination, Sensorimotor Integration May Affect Motor Skills in Children With Autism

    In this review: Postural Control and Interceptive Skills in Children With Autism Spectrum Disorder
    (PTJ, August 2019)

    The message

    In children with autism spectrum disorder (ASD), problems with sensorimotor integration and difficulty in coordinating posture and arm motions may result in impaired motor planning and control. These children also exhibited fewer anticipatory postural adjustments and demonstrated more corrective control during arm movements. Compared with typically developing peers, children with ASD were less likely to use visual cues to plan for motions required to catch an item, such as a ball.

    The study

    To examine the interplay of sensory cues, postural demands, and arm movement during ball-catching, researchers in Taiwan asked children with and without ASD to catch a ball rolling down a ramp toward them. Of the children, 15 had ASD and 15 were typically developing age- and sex-matched peers.

    During the task, each child was asked to catch a foam ball rolling down 3 stationary tubular ramps inclined at 4 degrees. The first ramp was placed directly in front of the child, while 2 others each were placed 35 degrees to the left and right. The first 59-centimeter section of each ramp was enclosed so that the child could not see the ball. A sensor within the tube activated a beep as the ball passed through, and, to test catching with and without visual cues, a second sensor lit up an arrow sign during half of the catching attempts.

    A real-time motion-capture system measured the children's arm movements while catching the ball. The authors measured center of pressure (COP) displacements using a computerized pressure plate and recorded ball-catching on video, both synchronized with the motion capture system.

    Findings

    • Children who were typically developing had a significantly higher success rate for all 3 ramps than did their peers with ASD.
    • Children with ASD were more successful in catching on the left side and right side ramps than they were in catching on the center ramp.
    • Visual pre-cues had no effect on rates of ball catching. However, children with ASD used visual information to plan their arm movements significantly less often than did their typically developing peers.
    • Overall, children adjusted their posture before moving their arms in nearly half of catching attempts. While children with ASD had a lower rate of postural adjustment for lateral ramps compared with their peers, all of the children were more likely to adjust their posture for lateral directions than they were for the middle ramp. Children with ASD made anticipatory postural adjustments later than did children who were typically developing, and all children adjusted their posture earlier when presented with visual pre-cues.
    • Amplitude of shoulder excursion was greater in children with ASD, and was higher overall when visual pre-cues occurred. In contrast, elbow displacements were larger when no visual pre-cues were present. Visual pre-cues were associated with slower arm movements for lateral catches. In general, children with ASD moved their arms faster than did their peers.
    • During lateral catches, both groups demonstrated larger COP displacements and greater COP velocity, but visual pre-cues resulted in slower COP velocity.
    • Children with ASD demonstrated more corrective control during arm movements than did their typically developing peers.

    Why it matters

    Physical therapist interventions for children with ASD, the researchers write, "could focus on the integration between perception and motor components as well as motor adaptability of the motor skills."

    Related APTA resources

    The association offers a Cochrane systematic review and several clinical practice guidelines through the PTNow resource area. Individuals who want to learn more about physical therapist treatment for autism spectrum disorder can visit APTA's consumer-friendly guide at MoveForwardPT.com, the American Physical Therapy Association's consumer website.

    Keep in mind…

    The study excluded children with intellectual disability and attention deficit and hyperactivity disorders, which might reduce generalizability to the entire ASD population. Also, the small sample size limited the authors' ability to analyze the effect of any comorbidities.

    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, where's you'll also find a clinical summary on Autism Spectrum Disorder in Children.

    New Clinical Guidelines Find Strong Evidence Supporting Exercise Therapy for Knee Pain

    In this review: Patellofemoral Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association
    (The Journal of Orthopaedic and Sports Physical Therapy, September 2019)

    The message    
    It's all about movement: In its first-ever comprehensive clinical practice guideline (CPG) on patellofemoral pain (PFP), APTA's Academy of Orthopaedic Physical Therapy (Academy) lays out a set of recommendations that stress exercise therapy as the best approach to improve functional performance in the short, medium, and long term. But that's just 1 facet of the guidelines, which also include recommendations on diagnosis, classification, and examination.

    The study
    A panel of content experts from the Academy conducted an extensive review of scientific articles associated with PFP from 1960 to 2018, evaluating each for its evidence related to physical therapist (PT) clinical decision-making around the condition. From an initial field of 4,691 articles, reviewers winnowed the studies down to 271 that addressed diagnosis and classification (120), examination (56), and interventions (95). The panel then analyzed the overall strength of evidence, and shared a draft of its recommendations with members of the Academy and, later, with a panel of consumer representatives and other stakeholders that included claims reviewers, coding experts, researchers, and academic and clinical educators.

    Recommendations were assigned letters according to the strength of the evidence evaluated: A-"strong," B-"moderate," C-"weak," D-"conflicting," E-"theroretical/foundational," and F-"expert opinion."  

    Among the Recommendations
    Recommendations within the following CPG categories include:

    • Interventions. CPG authors found strong evidence supporting exercise therapy with combined hip- and knee-targeted exercises to reduce pain and improve outcomes, stressing that a combination of hip and knee exercises is better than a focus on knee exercises alone.
      The guidelines also find strong evidence that dry needling shouldn't be used for PFP, and moderate evidence that clinicians should stay away from the use of "biophysical agents" including ultrasound, cryotherapy, electrical stimulation, and laser treatments.
      Taping was supported by moderate-level evidence. The guidelines state that clinicians should combine physical therapist interventions such as foot orthoses, taping, mobilizations, and stretching when appropriate, but that "exercise therapy is the critical component and should be the focus in any combined intervention approach."
    • Diagnosis. Use of diagnostic tests that reproduce retropatellar or peripatellar pain during squatting received an A-level recommendation as a diagnostic tool, as did "performance or other function activities that load the patellofemoral joint in a flexed position, such as stair climbing or descent."
    • Examination. Strong evidence supports the Anterior Knee Pain Scale, the patellofemoral pain and osteoarthritis sub¬scale of the Knee Injury and Osteoarthritis Outcome Score (KOOS-PF), and the visual analog scale (VAS) for activity or the Eng and Pierrynowski Questionnaire (EPQ) as ways to measure pain and function. Moderate-level evidence supports the use of "clinical or field tests" that reproduce pain and allow for assessment of movement. Authors write that "these tests can assess a patient's baseline status relative to pain, function, and disability; global knee function; and changes in status throughout the course of treatment."
    • Classification. The guideline panel found no "previously established valid classification system" for PFP, so it developed one. The system is based on impairment and function-based categories that include overuse/overload, muscle performance deficits, movement coordination deficits, and mobility impairments.


    Why the CPG Matters
    PFP is estimated to affect 1 in 4 adults every year, with women reporting knee pain twice as often as men do. Authors of the CPG write that while the recommendations shouldn't be considered a standard of care that guarantees a successful outcome for every patient, they are a reflection of the best-available evidence around the condition. They add that "significant departures" from the CPG "should be documented in the patient's medical records."

    APTA's Role
    The association provided funding and technical support during development of the CPG. This support is part of an ongoing APTA initiative to work with its sections and academies to produce a range of guidelines that highlight the evidence base for physical therapy in treatment of a variety of conditions. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    What a Difference a Day Makes: Researchers Say That for TKA, Post-Op Same-Day Physical Therapy Reduces Opioid Use and Shortens Length of Stay

    In this review: Same-Day Physical Therapy Following Total Knee Arthroplasty Leads to Improved Inpatient Physical Therapy Performance and Decreased Inpatient Opioid Consumption
    (The Journal of Arthroplasty, August 2019)

    The message
    Total knee arthroplasty (TKA) patients who received physical therapy on the same day as their surgeries were able to walk more while in the hospital and had lower rates of opioid consumption during their stay compared with patients who didn't receive physical therapy until the day after their surgeries. The same-day patients also tended to have shorter lengths of stay and higher rates of discharge to home.

    The study
    Researchers at the New York-based Columbia University Medical Center tracked 687 patients with knee osteoarthritis (OA) who received TKA at the facility between July 2016 and December 2017. A total of 295 "PT0" patients received postoperative physical therapy on the same day as their surgeries (POD0), consisting of a 30-minute session that included information, education, knee exercises, and activities-of-daily-life training. The remaining 392 "PT1" patients received the same session, but not until the day after surgery (POD1). Patients weren't randomized into the groups; instead the "PT0" and "PT1" groups fell into place, depending on whether factors such as patient motivation, fatigue, or pain during physical therapy prevented same-day physical therapy.

    All patients were asked to participate in 2 physical therapy sessions on postoperative day 1 if willing and able. Researchers evaluated ambulation distance, morphine equivalents consumed, pain levels, length of stay, and discharge disposition among the PT0 and PT1 groups. They also analyzed demographics, treatment details such as length of surgery, and preoperative function and outcome measures using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Knee Society Score (KSS).

    Findings

    • The PT0 group experienced an average 76% increase in "physical therapy performance" (number of steps taken) compared with the PT1 group. Authors of the study think the difference may be attributable to the idea that "early interaction with the physical therapist (PT) motivates and affirms patients that they can ambulate with full weight-bearing immediately postoperatively." That confidence-building, they write, paves the way for better progress in subsequent sessions.
    • While self-reported pain levels between the groups were similar, the PT0 group consumed about 25% less opioids than the PT1 group while in the hospital.
    • Average length of stay for the PT0 group was less than for the PT1 group—2.7 days compared with 3.2 days for the PT1 patients. The PT0 patients also tended to be discharged to home at a greater rate than the PT1 group, with 81.7% of the PT0 cohort sent home, compared with 54.8% of the PT1 patients.
    • Factors including gender, pain scores, preoperative KSS and KOOS, and age-influenced results, but did so similarly between the 2 groups. The groups showed no major differences in baseline characteristics.

    Why it matters
    TKA is an ever-increasing procedure predicted to rise to a rate of 1.3 million surgeries a year by 2030. Expenditures are high, with hospital length of stay and postacute care figuring heavily into costs—2 factors that seem to be positively affected by starting physical therapy the same day as surgery. Additionally, as authors point out, "any intervention that can demonstrate decreased opioid consumption is beneficial."

    Related APTA resources
    The association offers a TKA clinical summary, the Knee Outcome Survey-Activities of Daily Living test, and the Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement through the PTNow resource area, and individuals considering TKA can find a consumer-friendly guide at MoveForwardPT.com, the American Physical Therapy Association’s official consumer website. APTA's highly successful #ChoosePT campaign is helping to spread the word about effective nonopioid approaches to pain management, while the association continues to work for increased patient access to physical therapy for pain through direct advocacy and publications, such as its white paper on physical therapy's role in pain management. And be on the lookout: APTA's own clinical practice guideline on TKA is coming soon.

    Keep in mind…
    The research didn't employ a formal randomization process.

    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.

    Study: Mothers Who Exercise During Pregnancy Give Their Infants a Motor Skills Boost

    In this review: Effects of Aerobic Exercise During Pregnancy on 1-Month Infant Neuromotor Skills
    (Medicine and Science in Sports and Exercise, August 2019)

    The message
    Infants of mothers who engaged in aerobic exercise during pregnancy tend to show better motor development at 1 month compared with infants of nonexercising mothers, according to authors of a new study. The researchers believe that aerobic exercise during pregnancy could be a hedge against childhood overweight and obesity.

    The study
    Researchers analyzed data from 60 healthy mothers (ages 18 to 35, with an average age of 30) and their infants. During their pregnancies, 33 women participated in 45-50 minutes of supervised aerobic exercise, 3 days a week. The remaining 27 women in the control group were asked to engage in a 50-minute supervised stretching and breathing program 3 days a week, but were otherwise advised to continue with "normal" activities. The infants of both groups were then evaluated for motor skills development at 1 month using the Peabody Developmental Motor Scales, second edition (PDMS-2), a tool that tests reflexes, locomotion, and a child's ability to remain stationary. The measure also provides a composite score, known as the Gross Motor Quotient (GMQ).

    APTA member Amy Gross McMillan, PT, PhD, was lead author of the study.

    Findings

    • The PDMS-2 scores, expressed as percentiles, were higher for the exercise group in the areas of stationary (45.5 compared with 39.5 for the control group), locomotion (55.7 compared with 50), and overall GMQ (56.3 compared with 52.5). They were lower in the reflex category (63.1 for the exercise group, compared with 66.2 for the control).
    • In the control group, male infants performed better than female infants in most tests—a finding that researchers expected given what's known about the role of testosterone in male infant development. However, in what authors describe as an "intriguing" finding, female infants in the exercise group tended to close that gap and even outperformed males, albeit slightly, in reflex, stationary, and GMQ scores.
    • There were no significant between-group differences in maternal age, BMI, number of live children, or education; and all infants included in the study were born healthy and full-term with no congenital abnormalities.
    • In the exercise group, compliance averaged 83%, with 81% of the exercising mothers reaching at least 70% compliance during pregnancy.

    Why it matters
    With childhood obesity and overweight rates continuing to rise, the pressure is on to promote healthy rates of physical activity (PA). Authors of this study point to previous research that links better motor skills in infancy to higher rates of PA through childhood and adulthood, and write that "the promotion of exercise during pregnancy may positively impact childhood health outcomes."

    More about the findings
    Authors aren't sure what exactly is happening through aerobic exercise in pregnancy, but they speculate that it may have to do with the release of growth hormone and intrauterine growth factor-1, which do not cross the placenta but can increase the supply of nutrients to the fetus. Additionally, they believe that the improved blood flow and oxygenation associated with aerobic exercise may also contribute to the differences.

    Keep in mind…
    The research involved only healthy women and didn't control for other factors that contribute to mother and infant health, including sleep, diet, sedentary behavior, occupation, and the infant's environment after birth.

    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.

    Study: Knee, Hip OA May Increase Risk of CVD-Related Death, Underscoring Need for Emphasis on Physical Activity in OA Treatment

    In this review: Cause-specific mortality in osteoarthritis of peripheral joints
    (Osteoarthritis and Cartilage, June 2019)
    Abstract

    The message
    Researchers from Sweden found that among individuals studied, those with hip or knee osteoarthritis (OA) died from chronic ischemic heart diseases and heart failure at a greater rate than both the non-OA population and those with OA in other peripheral joints. No other significant correlations were found between the presence of OA and other causes of death, including diabetes, dementia, neoplasms, or diseases of the digestive system.

    The study
    Researchers tracked 469,512 health records from individuals in southern Sweden who were between the ages of 25 and 84 in 2003, including individuals who received an OA diagnosis between 1998 and 2003. Authors of the study then compared causes of death among the OA and non-OA group reported over an 11-year span, from 2004 to 2014. The researchers wanted to find out the degree to which the presence of OA in a peripheral joint (or joints) increased the hazard risk for various individual causes of death.

    Findings

    • Among all individuals studied, the most common causes of death were neoplasms and cardiovascular diseases (CVD), accounting for 66% of all deaths.
    • Compared with the non-hip/knee OA groups, those with hip OA were 1.13 times as likely to die from CVD, while the knee OA group was found to be 1.16 times as likely to die from CVD. Those differences increased as the individuals aged.
    • The CVD-related deaths among the hip and knee OA groups were primarily related to heart failure and ischemic heart disease, and rates didn't differ significantly between men, women, and when adjusted for other demographic variables.
    • Researchers found no correlation between OA and other causes of death studied: diabetes, hypertension, cerebrovascular disease, neoplasm, dementia, and liver disease.
    • Among the knee OA group, 26% underwent knee replacement during the study period. Of the hip OA group, 55% had a joint replacement procedure; however, the mortality results were similar even when both replacement groups were excluded from the hazard ratio analysis.

    Why it matters
    The bulk of research related to OA and causes of death tend to focus on all-cause mortality. This large-scale study took a more granular approach to identify possible relationships between types of OA and specific causes of death. Authors believe the findings further underscore the importance of emphasizing physical activity in the treatment of OA.

    What APTA's doing
    APTA is a strong supporter of the importance of physical activity in the treatment of OA. The association offers resources on encouraging healthy, active lifestyles at APTA's Prevention, Wellness, and Disease Management webpage as well as information on arthritis management through community programs. Members also can dive deeper into the issues by joining APTA's Council on Prevention, Health Promotion, and Wellness in Physical Therapy, and by checking out evidence-based resources such as this clinical practice guidelines on hip pain mobility deficits, available at the association's PTNow website. Patient-focused resources are available through APTA's MoveForwardPT.com website; additionally the Osteoarthritis Action Alliance offers a free booklet to help consumers participate in its "Walk With Ease" program.

    Keep in mind…
    Researchers were unable to adjust for body mass, a factor related to both the presence of OA and higher all-cause mortality. Additionally, the individuals with OA included those at all stages of the disease, and were limited to those who received an OA diagnosis—authors acknowledge it's likely that the non-OA group included individuals with undiagnosed OA.

    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.

    Military System Study: PTs in Primary Care Provide Safe Treatment and Are Less Likely to Order Ancillary Services or Make Referrals

    While civilian health care policymakers and stakeholders in the US continue to debate whether physical therapists (PTs) should be included as primary care providers, the country's military health systems have marched ahead with the concept. A new study adds to the evidence that the idea is working, both in terms of patient safety and reduced health care utilization.

    Authors of the study, published in Military Medicine (abstract only available for free) and first presented as a poster at the 2019 APTA Combined Sections Meeting, frame their research as an exploration of the potential for PTs to address the nationwide physician shortage by lowering costs and increasing access to care. They assert that the potential for more team-based, effective care could be at least partially realized if civilian PTs were treated like their military counterparts and included as primary care providers. It's a position that APTA strongly supports in its strategic goals and is consistent with APTA's own investigations into the PT's role in primary care settings. In addition, in 2018 the association conducted a practice analysis aimed at determining the feasibility of primary care as a specialty area recognized by the American Board of Physical Therapy Specialties and the American Board of Physical Therapy Residency and Fellowship Education.

    The study tracked 3 years' worth of patient data from the Malcom Grow Medical Clinic and Surgery Center (MGMC), a facility at Maryland’s Andrews Air Force Base that treats active-duty personnel and their families. MGMC patients with musculoskeletal complaints can choose their care pathway, receiving care through either a family health clinic (FHC) or the facility's physical therapy clinic (PTC). Authors describe the PTC as engaging in "advance practice" physical therapy that, in addition to its direct access status, allows PTs to order diagnostic imaging and lab studies, make referrals, and prescribe a limited range of medications.

    Researchers were interested in answering what they say is 1 of the main reservations about the PT as primary care provider—that patients would face increased risk of harm—and along the way wanted to find out what they could about the PT's use of ancillary services such as imaging and referrals. They analyzed data from nearly 250,000 provider encounters (207,241 from the FHC and 41,656 from the PTC), including information from an internal patient safety reporting database (PSR) that tracks "safety events" in which patients were exposed to or experienced various degrees of harm. Here's what they found:

    • Over the 2015-2017 study period, the FHC recorded 56 documented safety events, compared with 16 reported in the PTC. Adjusting for overall caseload, patients in the FHC were determined to be 1.9 times as likely to experience an actual or "near-miss" safety event (a potential safety event that never reaches a patient) as were the PTC patients.
    • While both clinics reported the majority of their safety events as near-miss, the PTC's near-miss events made up 75% of its total safety events during the study period, compared with a 50% rate at the FHC. A 72% near-miss rate is the MGMC’s benchmark.
    • Imaging was the most frequently used ancillary service in the PTC, but use rates were still significantly lower than the FHC rate, with 1 study per every 37.13 encounters in the PTC and 1 per 4.99 encounters in the FHC. Because of the frequency of imaging use in the PTC, authors believe that "pursuing diagnostic imaging authority may be of utmost importance if pursuing advanced practice physical therapy within a practice act or within a health care organization."
    • No adverse events were associated with the 1,817 thrust manipulations (197 in FCH, 1,621 in PTC) or the 2,910 dry needling procedures (PTC only) provided to patients during the study period.
    • Referrals to other providers were lower among PTs, with a rate of 1 per every 51.88 encounters, compared with 1 per every 3.06 encounters at the FHC.
    • Both the rate of prescriptions and orders for lab studies were dramatically lower among PTs, who wrote prescriptions at a rate of 1 per every 1,487 encounters and ordered lab studies at a 1 per 1,301 rate. Providers in the FHC had rates of 1 per 0.99 for prescriptions and 1 per 2.91 for lab work.

    Authors warn against interpreting the lower PT rates of additional service use as an endorsement of PTC superiority; instead, they are an indication of differences in necessary care pathways in the 2 clinics. Providers in the FHC, they write, must order lab tests "for other functions such as tracking disease progression or identifying proper [pharmaceutical] dosages," something that's not done as frequently in the PTC. Similarly, they write, "the number of images ordered by the PTC may be deflated if the patient had already received the imaging at the FHC."

    Setting aside those factors, they argue, the data show what they hypothesized—"that [physical therapy] has a similar safety profile to primary care within the specified domains of advanced practice [physical therapy]." Additionally, they write, their study supports findings from earlier research that found "significant reductions in health care utilization including pharmaceuticals and imaging services when patients accessed physical therapy first."

    APTA members Lt Col. Lance M. Mabry, BSC, USAF (Ret.), PT, DPT; Jeffrey Notestine, PT, DPT, ATC; Col. Josef Moore, MSC USA, PT, PhD; and Jeffrey Taylor, PT, DPT, PhD, were among the authors of the study.

    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.

    #Fail? Study Says Physical Therapy's Reach on Social Media Comes up Short

    When it comes to using social media to promote the profession, physical therapy may be missing out: that's the conclusion of a recent study that analyzed physical therapy-related tweets and found that, for the most part, Twitter discussions about the profession are occurring in an "echo chamber"—if they even rise to the level of a discussion in the first place.

    The study, published in APTA's journal PTJ (Physical Therapy), looked at a random sample of 1,000 tweets from a collection of 30,000 tweets gathered over a 12-week period. Researchers sorted out each message according to its author, intended audience, tone, and theme, and—when it occurred—the "pattern" of the twitter conversation, which includes shares as well as actual online exchanges. The collection was based on 9 search terms: physical therapy, physiotherapy, physical therapist, physiotherapist, #physicaltherapy, #physiotherapy, #physical therapist, #physiotherapist, and #physio. Hashtags associated with "known physical therapy campaigns," such as APTA's #ChoosePT, were not included in the searches. [Editor's note: the article appears in the August edition of PTJ, which is the journal's 1,000th issue—help celebrate by checking out the PTJ website for original research, perspectives, podcasts, and more.]

    Here's what they found:

    • Of the tweets that generated shares and discussions, most were what the Pew Research Foundation calls "tight crowd" and "brand cluster"—discussions that "tended to cluster on the periphery, dominated by a small group of highly connected people with few isolated participants," according to authors.
    • A substantial number of tweets, authors write, were from "disconnected participants" whose messages "resulted in no interaction with anyone other than the tweet's original author." The exceptions tended to be when APTA, other national organizations, and celebrities tweeted about physical therapy. As an example, authors offered up a 2016 physical therapy-related tweet by wrestler and actor John Cena, which at the time of the study had 1,550 retweets and 4,403 likes.
    • Almost half the tweets (48.5%) were characterized as "marketing" in nature. Employment-related tweets were a distant second at 17.7% of the total, followed by patient experience (15.7%), education (15.7%), advocacy (14.6%), conversation (14.3%), opinion/editorial (13.8%), physical therapist (PT) education (11.3%), research (7.7%), and continuing education (3.2%).
    • Recruiters and corporations were responsible for 86% of all employment-related tweets. PTs, physical therapist assistants (PTAs), and clinics were the authors of the majority of messages related to patient education, continuing education, and marketing.

    The big takeaway, according to authors, is that if PTs and PTAs want to heighten the profession's profile on social media, they need to do more than just show up.

    "The results of the present study reveal that simply being present on social media may not be enough," authors write. "The power of social media is in the conversation, and information becomes influential through 'likes,' 'retweets,' 'shares,' and 'mentions.' Physical therapy professionals and the hospitals and clinics that employ them need to understand the function and structure of online health conversations so they may influence and effectively engage in these conversations."

    Moving physical therapy discussions beyond what the researchers describe as a social media "echo chamber" will require a more savvy approach, according to the authors. They suggest "leverage[ing] the power and reach of broadcast networks and popular events" such as the Olympic Games, and using more generic hashtags (#rehabilitation, for example), as well as hashtags that "infiltrate another distinct mode of professionals" (#sportsmedicine, for instance) as ways to increase the reach of their messages.

    Authors acknowledge that the samples they studied provide a "limited" and "superficial" view of the entirety of physical therapy-related social media activity, and further admit that the average of 300 physical therapy-related tweets per day is a drop in the bucket compared with Twitterverse activity as a whole. Still, they argue, the profession needs to understand—and leverage—the power of social media as a provider of health information.

    "Online health information seekers have a high level of trust [in information accessed online] and often use it to make health decisions," authors write. "Rehabilitation-related information is not immune to this influence."

    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.