According to a new study from New Zealand, a couple of things are clear: (1) exercise therapy for individuals with knee osteoarthritis (OA) tends to be more effective when some sessions are spread out over a year as "booster" sessions rather than held every few days over a shorter timeframe; and (2) manual therapy conducted in addition to exercise therapy increases overall treatment effectiveness—but only when it's part of sessions that are conducted in the compressed schedule. In fact, manual therapy actually seemed to decrease effectiveness when it was used in the booster program.
Weird, right? The authors of the study thought so, too. But they have some caveats about that particular result, which they describe as "perplexing."
The study, e-published ahead of print in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free), aimed to assess whether exercise therapy for knee OA was more effective when 12 45-minute exercise therapy sessions were provided over 9 weeks, or through a "booster" schedule that provided 8 consecutive sessions during the first 9 weeks, 2 booster sessions at 5 months, 1 booster session at 8 months, and a final booster session at 11 months. A second goal was to find out if the additional manual therapy improved outcomes. Reassessments took place 1 year after treatment began.
Researchers primarily relied on changes in Western Ontario and McMasters Universities Osteorarthritis (WOMAC) scores as the outcome measure for 66 participants with knee OA who were divided into 4 groups: a 9-week exercise therapy group (Ex), a 9-week Ex group that also received manual therapy (Ex+MT), a booster exercise therapy schedule group (ExB), and an ExB group that also received manual therapy (ExB+MT). Overall treatment success was also evaluated according to the Outcome Measures in Rheumatoid Arthritis Research Society International (OMERACT-OARSI) definitions, which rely on a combination of WOMAC scores, pain reduction ratings, functional improvements, and global rating of change.
At the 1-year mark researchers found that when it came to exercise therapy alone, individuals who participated in the booster program averaged scores on the 0-240 WOMAC scale that were 46 points lower than the average for individuals in the 9-week program (lower numbers are preferable). The effectiveness of the 9-week program improved when manual therapy was added, with the Ex+MT group averaging WOMAC scores 37.5 points below the Ex group.
But strangely enough, the addition of manual therapy to the booster group resulted in WOMAC scores that were, on average, almost the same as the scores registered by the group that received only exercise therapy in the 9-week timeframe—a result that seemed to show that adding manual therapy to a booster regimen actually decreased WOMAC scores for this group.
"The finding of an adverse interaction effect between manual therapy and booster sessions … was perplexing," authors write. Though they describe it as "conjecture," they speculate that "the simplest and therefore most likely explanation" is that small group sizes—18 or 19 participants per group—may have introduced instability to the study, which was intended to test main effects for the larger groups (Ex vs ExB, and manual therapy vs no manual therapy).
Authors acknowledge that although the study's findings are strong, the results do not concur with a similar study that found lower-than-expected treatment effects in the Ex group and contradictory interaction effects in the ExB+MT group. These variations underscore the need for more research on the incremental effectiveness of the various approaches, they write.
Authors of the study include J. Haxby Abbott, DPT, PhD, FNZP, G. Kelley Fitzgerald, PT, PhD, FAPTA, Julie Fritz, PT, PhD, FAPTA, and John Childs, PT, PhD, MBA, FAPTA, OCS.
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.
Bipartisan legislation that will leave it to states to decide the cutoff number for what's defined as a "small employer" for purposes of health insurance coverage will likely be signed by President Obama, according to a recent story in the New York Times (NYT).
The NYT reports that although the administration "did not particularly like" the legislation that has moved out of the Senate, Obama is expected to approve a change aimed at saving businesses with between 51 and 100 employees from the "small employer" designation—and the designation's attendant "stringent insurance regulation" that would have started January 1 under the Affordable Care Act (ACA).
Instead, the Protecting Affordable Coverage for Employees Act will leave the issue to individual states to decide. The current cutoff for being designated a small employer is at 50 employees or fewer.
According to the NYT article, analysts predicted that employers with 51 to 100 employees would face premium increases averaging 18% next year if the numbers were changed as called for in the ACA.
A bill that would help physical therapists (PTs) in private practice improve continuity of care received supportive comments from several members of a House subcommittee during a hearing that featured the testimony of Sandra Norby, PT.
Norby's comments were provided during a House Energy and Commerce Subcommittee on Health hearing on the Prevent Interruptions in Physical Therapy Act (HR 556) and 2 other health care-related bills. The bill, which has companion legislation in the US Senate, would extend locum tenens provisions to PTs, allowing those therapists to bring in another licensed physical therapist to treat Medicare patients and bill Medicare through their Medicare national provider identifier (NPI) during temporary absences for illness, pregnancy, vacation, or continuing medical education.
APTA and the association's Private Practice Section collaborated on pressing for the legislation, which is one of the goals of the association's public policy priorities.
In her testimony, Norby described the legislation as a change that would provide "needed regulatory relief" through "a simple technical fix."
"Physical therapy is part of the comprehensive care model, therefore it is high time that the PT receives the same protections against unavoidable absences that are available to [other health care providers]," Norby said in her statement.
Norby outlined the safeguards that would prevent fraud and abuse of the provision, and provided her own personal example of the problems now faced by private practice PTs—a time when one of her staff PTs, the only one for that particular clinic, was off for maternity leave. As the only PT certified by Medicare to continue service at that particular clinic, Norby had to make the long trip to the rural Iowa clinic, often sleeping at the facility so that she could be on hand to see patients the next day—all in addition to her regular duties.
In questions that followed witness testimony Norby explained why the continuity opportunities provided by locum tenens were of particular value for physical therapy by using rehabilitation after a total knee replacement as an example. "Any interruption…is going to be very very detrimental to the progress of their care," she explained. "If continuity is interrupted, "[Patients] are literally going to have more visits to achieve that goal we set up in the first place."
Subcommittee members included Rep Gus Biliraikis (R-FL) and Ben Ray Lujan (D-NM), who introduced the bill and are leading the House efforts for passage. At the hearing, Billiraikis described the bill as "pro-patient and pro-physical therapists," while Lujan characterized the change as "common sense legislation."
Billirakis showed the real-world effects of the current system by sharing a letter from constituent Alicia Nixon, PT, DPT, BCA, PMDB, who wrote to Billirakis telling him that it was "almost impossible to take a vacation to attend seminars because of my need to be onsite at the clinic," and that "I was recommended to have surgery 6 years ago that I still have not had because it would require me to be away from my practice for over 6 weeks for recovery." Nixon also described an instance in which, in order to respond to a court summons, she had to close her clinic for the day, resulting in lost wages for her staff.
In later remarks, Lujan spoke out in more detail about his personal connection to physical therapy and his understanding of the importance of care continuity. Describing a head-on automobile accident that left him severely injured, he said that "it was physical therapists … that really put me back together to being able to move, and to be able to just walk."
If there had been an interruption in his care, he said, "I can't imagine what would've occurred."
APTA will monitor the progress of the bills and post updates to its locum tenens webpage. Resources on the website include a podcast on the importance of this legislation and information on how PTs can get involved in advocating for its passage.
Sandra Lee Norby, seated at far right, prepares to testify on locum tenens for physical therapists before the House Energy and Commerce Subcommittee on Health.
The Office of Inspector General (OIG) of the US Department of Health and Human Services (HHS) has turned its attention to skilled nursing facilities (SNFs), where it alleges that Medicare payments have "greatly exceeded SNF costs for therapy for a decade." Those increases in SNF billing resulted in $1.1 billion in Medicare payments during 2012 and 2013 alone, with about 80% of that increase attributable to the use of "ultrahigh" therapy, the OIG claims.
According to a report released September 30, the payment system for therapy in SNFs provides a "strong financial incentive" for facilities to bill for higher levels of therapies, even when those therapies may not be needed by certain patients. In particular, they write, the differences between the cost of therapy and Medicare payments for that therapy skew heavily toward providing ultrahigh levels of therapy—720 minutes or more a week per patient--for which facilities receive an average of $66 a day over costs, compared with $11 over costs for low therapy, according to CMS estimates.
Some of the OIG findings were reported in advance by the New York Times, which quoted Daniel R. Levinsion, HHS inspector general, as saying that the data collected for the report show that some nursing homes were attempting to "optimize revenues" by taking advantage of the payment system.
The OIG report asserts that between 2011 and 2013, the percentage of SNF resource utilization groups (RUGs) that received ultrahigh therapy increased from 21% to 34%, and RUGs receiving very high therapy rose from 12% to 22%. Meanwhile the percentage of RUGS receiving low therapy dropped from 14% to 12%.
The increasing use of higher therapy levels, coupled with annual increases to base payment rates based on the market-basket index, resulted in steady increases in SNF cost/payment margins from 2002—where the margin was 25%--to 2010, when the margin peaked at 42%. Since that time, the estimated margin has dropped and is estimated to have been 29% in 2012, the most recent year evaluated.
The OIG findings are consistent with results of an analysis conducted earlier this year by the Wall Street Journal, which found that the use of ultrahigh therapy has increased from 7% of patient days in 2002 to 54% of patient days in 2013.
The news stories and OIG report point to an even larger issue: the relationship between volume and value-based health care.
In a letter to the editor published in WSJ, APTA President Sharon L. Dunn, PT, PhD, OCS, writes that the challenges of delivering appropriate patient care in systems that incentivize volume "are, unfortunately, well known to those in the rehabilitation profession."
"Patient care decisions should be made by clinicians in accordance with their clinical judgment and ultimate professional responsibility to their patients," Dunn writes. "Value—the outcome of care relative to the cost or resources needed to provide that care—should be the primary indicator of performance."
The OIG report makes several recommendations to the Centers for Medicare and Medicaid Services (CMS), ranging from changing payment methodology and rates to strengthening oversight. CMS accepted the recommendations and agreed that the payment system needs to be reassessed for potential reductions that would improve payment accuracy. CMS is conducting a study to explore alternative therapy payment models.
The issue of productivity pressures is at the heart of a collaborative effort by APTA, the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASHA), which collaborated to produce a "Consensus Statement on Clinical Judgment in Health Care Settings (.pdf)." For more on productivity: check out the APTA Center for Integrity in Practice as well as "Measuring by Value, Not Volume," a recent feature article in PT in Motion magazine that takes a closer look at how some PTs are responding to the challenge.
Most Americans expect to live a long life but worry that when it comes to movement, it ain't gonna be pretty. That's the myth that APTA and its members are taking on this October through the #AgeWell campaign launched in recognition of National Physical Therapy Month (NPTM).
The campaign is built around the idea that while some effects of aging are inevitable, many symptoms and conditions commonly associated with growing older can be delayed—and in some cases prevented—and that physical therapists (PTs) and physical therapist assistants (PTAs) can play a vital role transforming the aging process.
Many of the tips and other information developed by APTA for the #AgeWell campaign are based on responses to a national survey that included questions on Americans' perception of the aging process and their own hopes and fears about aging. That survey found that while 68% of respondents believe they will be able to engage in "the same type" of physical activities at age 65 and older, about half expect to lose strength and flexibility with age. Similarly, while 42% hope to stay healthy as they age, fears loom large, including worries about not being able to live independently and being affected by debilitating disease and chronic conditions.
The benefits of physical therapy directly address many of these concerns, and APTA has created tools for members to spread the word about aging well. In addition, the association will launch a concurrent ad campaign in the press and on major health-related websites, including health.com, a site that receives over 1.6 million unique visits every month.
NPTM resources for PTs and PTAs include:
Other resources will be rolled out during NPTM, including podcasts that take a deeper dive into healthy aging.
Physical therapy has once again made it into a "top 10 jobs"-related list: this time as one of the "toughest jobs to fill in 2016."
According to a recent article in Forbes, employment forecasters crunched numbers from the US Bureaus of Labor Statistics (BLS) and other demographic data to create a list of the careers that employers will have a tough time fully staffing over the next year. Just as physical therapy often makes it into lists of the most in-demand jobs, so it shows up among the jobs that will most challenge employers.
Physical therapists (PTs) join registered nurses and home health aides as the health care jobs on the list, with the Forbes article cites retiring Baby Boomers (and the related need for care among this population) and the Affordable Care Act as the main drivers for the gaps between available jobs and individuals to fill them.
Rounding out the list were data scientists, electrical engineers, general operations managers, information security analysis, marketing managers, medical service managers, and software engineers.
The jobs report, created through a partnership between CareerCast and the Society for Human Resource Management, cites estimates from APTA that predict a potential physical therapist (PT) employment gap of about 33,000 in 2016. "Like other health care fields, demand is up due to greater accessibility to health insurance and the aging population," the report states.
Earlier this year, CareerCast ranked PTs as 17th in its list of the 200 "top rated" jobs in the country in terms of "work environment," "stress," and "hiring outlook." The findings echoed a similar study from late 2014, also reported on by Forbes, that listed physical therapy among the "top 10 jobs in high demand."
Want to go where the jobs are? Check out APTA's Red Hot Jobs website for regularly updated opportunities.
The sometimes stiff-legged running gait of toddlers compared with adults may be less about development and more about physics, and how size affects muscle activation demands, according to a new study.
Or, in the words of a headline for a commentary that accompanied the study, "Kids are clumsy runners because they are small."
For the study, appearing in the Journal of Experimental Biology, researchers analyzed the walking and running gaits of 18 children aged 1.1 to 4.7 years to find out why they moved like they did, with a more stiff-legged gait that involves less reliance on "work-minimizing strategies" compared with adults. Researchers tracked the movements of children as they ran and walked along a track by using a camera system and measuring the forces exerted on the floor.
What they found was that similar to small animals, children simply have less time to activate muscles sufficiently for the power necessary to push away from the ground in a gait pattern more akin to the way adults move. Instead, they leave their feet on the ground for a longer period of time, thereby spreading the duration of muscle action—a process that demands greater work, but lower power requirements. The result: a seemingly "undeveloped" gait.
Authors of the study believe that their findings, which incorporate the role of muscle and size into gait, challenge mechanical models that are based on the concept of the inverted pendulum.
And they also think their work gives kids credit where credit is due. In a video that explains the study's findings, co-author James R. Usherwood puts it simply.
"So it may be that children walk and run in an apparently uneconomical manner not because they are immature and underdeveloped, but because they are getting it right for their size," he says.
A recent small-scale study of veterans is adding support to the idea that the more people are exposed to telehealth—this time in the form of postoperative care—the more they like it.
In a research letter published in the September 23 edition of JAMA Surgery, authors share the results of a survey of 35 veterans receiving both in-person and telehealth-based postoperative care for "low complexity" surgeries including gall bladder removal, hernia repair, appendectomy (laproscopic), thyroid removal, or soft tissue excision. Authors of the letter described these surgeries as "amenable to postoperative telehealth evaluation."
After discharge, the veterans received 3 sequential follow-up visits: 1 by telephone, 1 in person, and 1 via videoconferencing that followed a standard rubric addressing general recovery, follow-up needs, wound care needs, and complications.
A total of 23 veterans completed all 3 phases of the postoperative visits, and among the mostly male, mostly white participants, 69% preferred the telehealth visits (phone and/or video) to the in-person session. Within that group, a little over half preferred the phone visit to the video visit, but both groups said that either telehealth approach would "be adequate" and preferable to an in-person visit.
Researchers looked at whether travel pay status affected preferences, but found no connection. There was, however, a tendency for veterans who had to travel farther for in-person appointments to prefer the telehealth visits.
In terms of effectiveness, researchers reported that detection of wound needs or complications was not hindered by the telehealth approaches; and that "there were no instances in which we failed to detect a wound or postoperative complication by telephone or video."
"The data suggest that telehealth visits … can identify veterans requiring in-person assessment or further care," authors write, adding that if planned follow-up studies support the initial findings, "this has implications for waitlist management, costs, and access to care for veterans and Veterans Affairs health care system."
In 2014, APTA's House of Delegates approved a resolution that supports the adoption of telehealth technologies in physical therapy as "an appropriate model of service delivery" when provided in ways that are "consistent with association positions, standards, guidelines, policies, procedures, Standards of Practice for Physical Therapy, Code of Ethics for the Physical Therapist, Standards of Ethical Conduct for the Physical Therapist Assistant, the Guide to Physical Therapist Practice, and APTA Telehealth Definitions and Guidelines; as well as federal, state, and local regulations." APTA offers resources on telehealth in physical therapy—including a link to Board of Directors definition and guidelines--on its telehealth webpage.
Fair physical therapy copays, direct access to physical therapist (PT) services, a complete overhaul of a state's practice act, leading a charge to eliminate a referral requirement for spinal manipulation, and a physical therapy advocacy record of over 25 years were among the accomplishments of this year's APTA State Legislative Leadership and Legislative Commitment award winners recognized at the association's recent State Policy and Payment Forum in Denver.
Marc Lacroix, PT, MBA, received the APTA State Legislative Commitment award for more than 2 decades of advocacy efforts on behalf of PTs in New Hampshire. During that time, Lacroix was involved in practice act revisions, title protection efforts, improvements to direct access, and the passage of fair PT copay legislation.
In her remarks at the awards presentation, APTA President Sharon Dunn PT, PhD, OCS, said that Lacroix exemplified the quality celebrated in the award—a long-term commitment to "build … chapters' resources, infrastructure, and overall state-level advocacy efforts."
Winners of this year's State Legislative Leadership awards were:
From left: Marc Lacroix, APTA President Sharon Dunn, Joe Donnelly, Mary Kay Hannah, and Don Blackburn.
The awards were part a State Policy and Payment Forum that drew more than 230 PTs, physical therapist assistants (PTAs), and physical therapy student advocates from across the country. The September 19-21 event, cohosted with the Colorado Chapter, was designed to increase participants' involvement in and knowledge of the state issues that have an impact on the practice of physical therapy, and improve their advocacy efforts at the state level.
This year's forum featured a mix of presentations on direct access and practice act revision legislative efforts, insurance transparency legislation, network adequacy and consolidation, dry needling, using press and social media in advocacy efforts, information on the proposed interstate licensure compact for physical therapy, Medicaid, and more.
In addition to a focus on providing inspiration for future advocacy efforts, the event was also a celebration of a successful year of state advocacy in 2015. Those successes have been captured in a new infographic that shows how work at the state level has affected the lives of patients, PTs, and PTAs. More information on individual state legislative efforts can be found at APTA's State Advocacy webpage (scroll down to "Briefs").
It's beginning to look like a dynasty: for the third year in a row, Utah has been declared the best state in which to practice physical therapy, this year followed by Virginia and Nebraska. The rankings—and the explanations behind the rating system—appear in the October issue of PT in Motion, APTA's member magazine.
The rankings were derived from an analysis of 8 factors: well-being and future livability, literacy and health literacy, employment and employment projections for physical therapy, business and practice friendliness, technology and innovation, compensation and cost of living, physical therapist/physical therapist assistant/student engagement with APTA, and—new this year—health and financial disparities.
"What's the secret of Utah's success? It had consistently strong scores across the board, with a particularly high rating (third) in 'well-being and future livability' and coming in first for its lack of health and financial disparities," writes PT in Motion Editor Donald E. Tepper in the article.
This year, both Virginia and Nebraska pushed out Colorado and Minnesota to take over the number 2 and 3 positions. Colorado dropped to fourth place, and Minnesota fell to fifth.
As Tepper explains in the article, the overall scores gave equal weight to each of the 8 factors used in the analysis—an assumption that may not be the case for an individual physical therapist or physical therapist assistant, who might feel that some factors are more important than others. To provide as complete a picture as possible, the article provides each state's individual rankings on all 8 factors for the top 20 states.
Rounding out the top 20 after Minnesota were North Dakota, South Dakota, Idaho, Iowa, Vermont, Washington, Alaska, Arizona, Wyoming, Oregon, Montana, Texas, Kansas, Wisconsin, and New Hampshire.
"The Best States in Which to Practice" is this month's open-access article in the online version of PT in Motion, which makes it easy to share with nonmembers. (Also available to share this month is “Facing True North From the Louisiana South,” a profile of APTA’s new president, Sharon Dunn, PT, PhD, OCS.)
Hardcopy versions of PT in Motion are mailed to all members who have not opted out and to subscribers; digital versions of the entire issue are available online ahead of print to members.
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