• Wednesday, July 29, 2015RSS Feed

    For Medicare and Medicaid's 50th, a Look at Physical Therapy's Role

    When it arrived as signed legislation 50 years ago, Medicare and Medicaid was far from the system we know today—especially when it comes to physical therapy. APTA is marking the program's half-century birthday by highlighting how its evolution affected the profession, and vice-versa.

    Just in time for the July 30 anniversary of Medicare and Medicaid, the association has released an infographic (.pdf) that lays out the timeline for physical therapy's involvement in a program that covers an estimated 124,000,000 people (55 million via Medicare and 69 million through Medicaid). The program, controversial at the time of its implementation, now is credited with increasing life expectancy and reducing poverty in the United States.

    Today's Medicare and Medicaid are significantly different from their original forms. Medicaid, for example, was tied to welfare, and Medicare didn't cover prescription drugs. Initially, private insurance played a far less prominent role than it does today, and hospitals and nursing homes were racially segregated (something Medicare and Medicaid helped to eliminate).

    The physical therapy profession became part of this evolution in 1968 and has remained integral to the program ever since. Like almost every other element connected to Medicare and Medicaid, however, the relationship between the programs and physical therapy has changed over time.

    It's a relationship that, judging from the APTA timeline, has had its share of ups and downs. But it generally has trended toward increased patient access to physical therapist services. Among the notable developments listed in the infographic:

    • Reimbursement for physical therapists became possible in 1968 when the definition of outpatient physical therapy services was added to the Social Security Act of 1967.
    • In 1983, the Centers for Medicare and Medicaid Services (CMS) fueled the rise in postacute care by enacting the prospective payment system based on diagnosis-related groups. Prospective payment systems for skilled nursing facilities, home health agencies, and inpatient rehabilitation facilities were added in 1997.
    • The Balanced Budget Act implements a $1500 cap on outpatient therapy in all settings except hospitals beginning in 1999; APTA successfully lobbies Congress to impose a 2-year moratorium on the cap.
    • The number of physical therapist practices participating in Medicare and Medicaid grows rapidly after 2000, when CMS eliminates certain conditions of participation.

    Many more details appear on the timeline, including more recent developments such as the repeal of the flawed sustainable growth rate formula and the signing into law of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act.

    "It's nearly impossible to underestimate the effects Medicare and Medicaid have had on the overall population health of the United States," said APTA President Sharon L. Dunn, PT, PhD, OCS. "The physical therapy profession has had a relationship with these programs for nearly as long as they've existed. We should take pride in the ways our commitment to patient health and transformation has, in turn, helped Medicare and Medicaid evolve."

    Interested in more history and real-world accounts of the ways in which Medicare and Medicaid have made a difference in people's lives? Check out the CMS webpage devoted to the anniversary.

    Tuesday, July 28, 2015RSS Feed

    Evidence on Hamstring Rehab Supports Exercise; Platelet-Rich Plasma Found Ineffective

    Results of a new systematic review and meta-analysis point to stronger evidence that when it comes to acute hamstring injuries, rehabilitation exercises work—and platelet-rich plasma (PRP) injections don't.

    The study, which updated an earlier review published in 2012, analyzed 10 randomized clinical trials—6 of which were new since the previous publication—that focused on conservative interventions for acute hamstring injuries. A total of 526 participants were included in the trials (mean of 65 per study) with an average age of 20. All participants had some connection to sports, and most (86%) were male.

    The interventions used in the trials included lengthening and loading exercises, stretching and strengthening (STST) exercises, progressive agility and trunk stabilization (PATS), and PRP injections. Authors of the systematic review compared the interventions by way of return-to-play (RTP) times and re-injury rates. Results were e-published ahead of print in July 21 online edition of the British Journal of Sports Medicine (abstract only available for free).

    The analysis showed that in terms of reducing RTP times, evidence supports the addition of lengthening exercises. Authors also found a link between PATS exercises and reduced re-injury rates, although evidence supporting that relationship was described as "limited." Researchers weren't able to identify any evidence that supported PATS as a way to speed up RTP, nor were they able to point to evidence that lengthening exercises reduced re-injury rates. Studies of STST exercises did not produce evidence supporting their effectiveness in RTP, and showed what authors described as a "remarkably high" re-injury rate, at 70%.

    What the evidence definitely doesn't support, according to the authors, is the use of PRP injections.

    "Our meta-analysis and descriptive synthesis show that there is no superior efficacy for PRP injections," authors write. "Considering our quantitative and qualitative findings, higher levels of evidence are now available to discourage the use of PRP injections in the rehabilitation of hamstring injuries."

    While authors believe that their new review helps to create a clearer intervention path, they cite the need for more studies or higher quality. Most current studies, they write, are weakened by a lack of blinding among patients and therapists, and poor comparability between trials (mostly due to variation in what was used as the "standard therapy" control). Another issue: RTP measures "varied greatly" between studies.

    Still, they write, evidence is sufficient to point to the positive role of both lengthening exercises and PATS "for daily practice" to treat acute hamstring injuries.

    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.

    Monday, July 27, 2015RSS Feed

    Rapid—and Recent—Developments in Robot-Assisted Rehab Point to Burgeoning Industry

    We're not quite in Iron Man territory yet, but new developments in mobility assistance through robotics have been occurring at a fairly fast clip over the spring and summer of 2015, and financial forecasters expect the rehabilitation technology market to take off over the next 5 years.

    A few of the latest developments:

    A Lego-friendly prosthetic arm. Developers in Colombia have created a prototype prosthesis that can accommodate creations made from the popular interlocking plastic building system. The device reacts to movements from muscles at the arm stump and delivers signals to a motor that accepts standard prosthetic attachments and Lego-based creations. It's a project they hope will help break down barriers for children with disabilities. "The idea erases that line between disability and ability," says Carlos Torres, developer of the IKEO Prosthetic System.

    The first-ever US commercial insurance reimbursement for a ReWalk exoskeleton. The first company to receive US Food and Drug Administration approval for a robotic exoskeleton reached a milestone when an unnamed commercial insurance company approved reimbursement for the device, which has a retail price of $71,000.

    A lightweight walking assistance device from Honda. The Walk Assist system built by the car manufacturer is worn like a belt, with attachments that can be strapped on to the thighs of the wearer. Walk Assist weighs about 6 pounds and has a 60-minute battery life. Honda says the device is based on "the inverted pendulum model" and is intended to be used under the guidance of a physician or therapist. Leasing begins in Japan in November.

    A robotic assistant that senses small muscle contractions and interfaces with video games. The Luna rehabilitation robot uses electromyography to sense muscle movement at nearly undetectable levels, and then translates those into mechanically assisted arm movements that in turn interact with video games to make rehabilitation sessions more interactive and entertaining.

    An upper-body exoskeleton that feels "weightless" to wearers. Researchers at the University of Texas – Austin have developed HARMONY, an upper-body exoskeleton with extensive adjustment capabilities that works with the entire upper body, rather than a single arm at a time. "HARMONY’s shoulder mechanism assists in a range of motions that are very close to those required for daily activities, and the eventual incorporation of a screen or gaming environment to simulate such activities may lead to successful relearning," according to a UT-Austin news release.

    A rehabilitation robotics market poised to grow rapidly. A new financial analysis estimates that rehabilitation technology will grow from a $200 million global industry to a $1.1 billion one by 2021. According to a summary of the analysis from medGadget, "all the products that are now commercially viable are positioned to achieve significant staying power in the market long term, providing those companies that offer them with a possibility for long-term leadership position in the market."

    Check out APTA's resources on technology and patient care as well as an audio course on robotics and physical therapy.

    Monday, July 27, 2015RSS Feed

    PT Bainbridge Featured in ESPN Coverage of Special Olympics

    Many physical therapists (PTs) and physical therapist assistants (PTAs) have been involved with the Special Olympics over the years, but Donna Bainbridge, PT, EdD, ATC, has elevated that involvement in ways that stretch beyond the actual World Games now taking place in Los Angeles.

    As part of its coverage of the event, ESPN.com correspondent Stephania Bell, PT, OCS, CSCS, caught up with Bainbridge to find out more about FUNfitness, the screening program Bainbridge developed with APTA that is now a central part of the Special Olympics' Healthy Athletes Program.

    Bainbridge, former director of practice at APTA, explains how FUNfitness was developed and implemented at the 2001 games in Alaska, and how the program has grown from a 6-consultant program to a global operation that includes between 75 and 80 programs. This year, Bainbridge says in the interview, there could be as many as 200 volunteers at the games, working together to reach a goal of providing screenings to 60%-65% of all participating athletes.

    For Bainbridge, the benefits of the program stretch beyond the immediate needs of the athletes at the games, and reach physical therapists and their home communities.

    "I feel like we're changing the lives of the volunteers we train because even though all these physical therapists work with people with disabilities, this is not necessarily a group they would solicit," Bainbridge says. "I've heard many times that they go back much more aware and seek out working with these people in their practices and their communities."

    Friday, July 24, 2015RSS Feed

    Anthem's Acquisition of Cigna Continues Insurer Consolidation Trend

    Health insurer Anthem's recent announcement that it will acquire Cigna in a $54.2 billion deal is continuing a consolidation trend that could reduce the number of major insurance companies in the US from 5 to 3. And while the nuts and bolts of the deal are plain enough, when it comes to speculation on what it will mean for consumers and providers, there's less consensus.

    What's known is this: the multibillion dollar acquisition will make the Anthem-Cigna combination the country's largest private health insurer in terms of members, with an estimated 53 million people covered. Revenues for the new company are projected at $115 billion annually.

    Anthem's acquisition comes on the heels of a July 3 merger announcement from insurance giants Aetna and Humana, meaning that if federal regulators approve both deals, the country's 5 major private insurance companies will be reduced to 3, United Healthcare being the third. Pending regulatory approvals, the Anthem-Cigna deal will close in late 2016.

    Media coverage of the acquisition generally pointed to pressures applied to insurance companies from the Affordable Care Act (ACA), which put caps on profits that could be made by insurance companies, as the big motivator for the consolidations.

    Aside from that, reports on the deal highlighted different aspects of the acquisition and its possible effects. Here's a quick take on how the deal was reported in news media outlets:

    "The merger between Aetna and Humana was a major change for the Medicare Advantage marketplace, whereas the Cigna and Anthem merger will have the biggest ripple effects for the commercial insurance market." The Washington Post

    "Anthem's combination with Cigna will result in a company with a much broader base over which to spread costs and expenses, and it could make technology investments over the industry's biggest customer pool.." Associated Press

    "Health insurers are seeking to consolidate to gain greater scale to reduce costs and capitalize on growing opportunities in the government and individual markets." New York Times

    "Anthem said it expects the deal to close in the second half of 2016, indicating a long regulatory road ahead." Reuters

    "Bigger insurers with more clout could raise premiums and reduce the number of doctors and hospitals in network coverage plans. But health insurers have defended their position." CNN Money

    Visit APTA's webpage on private insurance to access information, tools, and resources that can help you navigate the physical therapist-insurance company relationship.

    Thursday, July 23, 2015RSS Feed

    PCORI Devotes Additional $142 Million to Expansion of Clinical Research Network

    The Patient Centered Outcomes Research Institute (PCORI) plans to invest $142.5 million to expand its clinical research network—another facet of a broad initiative that includes major grants supporting physical therapy research.

    According to a PCORI news release, the money will be used to establish a second-phase expansion of the National Patient Centered Clinical Research Network (PCORnet), a project that links various health data research networks. The funding will be used in part to expand the number of PCORnet participants from 27 to 34, and will include both clinical data and patient-powered research networks.

    The 34 PCORnet partner networks encompass more than 150 conditions, including Alzheimer’s disease and dementia, autism spectrum disorders, heart disease, obesity, Parkinson disease, behavioral health disparities among low-income populations, and health disparities among sexual and gender minorities, all drawn from a wide variety of population groups.

    "Having key stakeholders--researchers, patients, clinicians, and health systems—working together to co-create PCORnet has been a tremendous step forward in how we approach health research," PCORI Executive Director Joe Selby, MD, MPH, stated in the news release. "We're proud of the achievements of the participating individuals and organizations that have worked so diligently to prepare PCORnet to begin conducting robust and efficient patient-centered research."

    PCORI is an independent, nonprofit organization authorized by Congress in 2010. Besides creating PCORnet, PCORI is funding specific research projects. Earlier this year, the institute announced that it will devote $28 million to support 2 research efforts led by prominent physical therapy researchers Pamela Duncan PT, DPT, FAPTA, and Anthony Delitto , PT, PhD, FAPTA.

    Duncan’s project will look at treatment of patients poststroke to find out whether early discharge with ongoing support by physical therapists (PTs) and other providers results in better daily function outcomes than do longer hospital stays and standard transitional care. Delitto's research will focus on low back pain, comparing 2 approaches in the outpatient primary care physician (PCP) setting. One is the "usual"care approach, and the other teams PCPs with PTs to provide cognitive behavioral therapy.

    Wednesday, July 22, 2015RSS Feed

    Study: Early Supervised Exercise Reduces Fatigue, Improves Strength for Women After Breast Cancer Diagnosis

    A new study from the Netherlands is lending more support to the value of exercise during the early stages of adjuvant treatment for breast cancer. Researchers say that a combination of supervised strength and aerobic training not only reduces fatigue, but helps patients actually increase muscle fitness during the first 18 weeks of treatment.

    For the project, 204 breast cancer patients were divided into 2 groups of 102—one receiving usual care and the other participating in physical therapist-supervised resistance and aerobic exercise as soon as possible after diagnosis. By design, all participants received chemotherapy at some point between baseline and by an 18-week assessment.

    The exercise program was conducted at the patient's treating hospital, and consisted of 2 aerobic and 2 resistance exercise sessions per week, with each type of session lasting 25 minutes. Muscle training was targeted at all major muscle groups and designed to reach 1 set of 10 repetitions at 75% of 1-repetition maximum by the end of the 18-week period. Results were published in a recent issue of BMC Medicine (.pdf).

    Although the intervention and control groups both reported fatigue, at 18 weeks, the exercise group reported levels of fatigue 1.3 times lower than the control group, though no significant differences were noted at the 36-week assessment. Other measures related to quality of life showed no differences between groups, with the exception of the exercise group's perception of a positive "change in health" at 18 weeks.

    While researchers had anticipated that fatigue levels would drop for the exercise group, they were surprised to find that the exercise program not only offset the deconditioning effect of chemotherapy and other adjuvant treatments, but actually increased muscle strength. Authors write that most of the noted strength improvements at the 18-week point occurred at the submaximal level, an important improvement "since most daily activities are performed at the submaximal level."

    Researchers believe that engaging in exercise early in the breast cancer treatment process helps to change physical and emotional dynamics at a critical time, both by breaking the "vicious cycle" of "a self-perpetuating detraining state" that induces fatigue, and by increasing feelings of "general self-efficacy and mastery" among patients in treatment.

    The findings echo APTA's understanding of the important role that activity should play in the lives of cancer survivors. The association offers continuing education on physical therapy for cancer survivors, and visitors to APTA's website can view a video on collaborative care and breast cancer rehabilitation. Additionally, the role of the physical therapist in cancer survivorship was the focus of an article in the July 2013 edition of PT in Motion magazine.

    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.

    Tuesday, July 21, 2015RSS Feed

    ADA Turns 25—Here's How You Can Help Celebrate

    Happy 25th anniversary to a law based on an idea that lies at the very heart of the physical therapy profession—that individuals should not face barriers of any kind based on disability.

    Signed into law on July 26, 1990, the Americans with Disabilities Act (ADA) altered everything from employment policies to building design, and from educational approaches to the ways information is made available to people across the US. Its legacy, including the ways in which it has been expanded and strengthened over the years, is one of transformation—not just toward accommodations in physical, employment, and educational environments, but toward a more inclusive society.

    In recognition of this important anniversary, APTA has signed the Proclamation to Recommit to Full Implementation of the ADA. This statement celebrates progress made through the law but acknowledges that "the full promise of the ADA will only be reached if we remain committed to continue our efforts to fully implement” it. Signing organizations can be viewed by state—look for APTA among the organizations from Virginia.

    APTA is urging its members to join in celebrating and recommitting to this important act by signing the ADA Pledge for Individuals and participating in other programs meant to draw attention to the positive change that has taken place since 1990. Here are some additional things you can do to help mark the ADA's anniversary:

    • Share your story. The ADA Legacy Project has established a repository for individual stories about how the ADA has impacted people’s lives. Take a few minutes to share what the law has done for you and your patients and clients.
    • Check out the DisabilityBlog. This series of moving blog posts by individuals whose lives have been changed by the ADA is a great reminder of why this anniversary is worth celebrating.
    • Follow the ADA on Twitter. #ADA25 will keep you connected.
    • Join the celebration! Many local recognition events already have taken place, but there are more to come—particularly between July 24 and 26, and especially in Washington, DC. Check out this list of events to see what's up in your area.

    Need to get up to speed on the ADA? Time for an ADA refresher? Check out APTA's Americans with Disabilities Act webpage, a resource that features guides for employers, rules on mobility access rights, notes on ADA amendments, and more.

    Monday, July 20, 2015RSS Feed

    Medicare Extends 5-Star Ratings to Home Health Agencies

    Home health agencies are now part of the Centers for Medicare and Medicaid Services (CMS) 5-star rating system, which incorporates evaluations of patient mobility in its assessment of an agency's overall effectiveness.

    Released through its Home Health Compare website, the star ratings are based on 9 of the 27 quality measures included in that program. The measures included are patient wait for a first visit, thoroughness of explanations of drugs to a patient or caretaker, administration of a flu shot, hospital stays, and improvements in walking, getting in and out of bed, breathing, and movement with less pain.

    Of the 9,359 agencies rated (out of 12,261 total agencies), only 239 received 5 stars, while 2,218 received 4 or 4.5 stars. Nearly half of all agencies—46%—landed in the middle of the pack, receiving 3 or 3.5 stars, with 28% receiving lower ratings of 1.5 to 2.5 stars. Of all agencies rated, 6 received a single star.

    The 2,902 agencies not included in the rating system either had low patient volume, did not provide enough data, or had recently opened for business.

    In a state-by-state analysis conducted by Kaiser Health News, Rhode Island and Florida reported the largest percentages of 4- to 5-star rated agencies—albeit based on markedly different volumes. While Rhode Island, with 46% of its agencies earning 4-5 stars, technically had the best rate, those numbers reflected 24 rated agencies. The 43% of facilities that earned 4 to 5 stars in Florida were identified from a pool of 949 rated agencies.

    States with the highest percentages of agencies with 2.5 stars or lower include Arkansas (45%), Wyoming (48%), Texas (52%), and Minnesota (52%). Other states and territories with high percentages in this category included the District of Columbia, Alaska, and the US Virgin Islands, but relative numbers of agencies rated were small.

    The ratings were drawn from data from fall 2013 through the end of 2014. Medicare will update the ratings quarterly.

    Friday, July 17, 2015RSS Feed

    Meta-Analysis Backs Use of Electrical Stimulation on Patients Posttroke

    Editor's note: this republication corrects an earlier version of this story that identified pulse duration in minutes instead of milliseconds.

     Authors of a review and analysis of studies on neuromuscular electric stimulation (NMES) in the treatment of patients poststroke say they've taken a step toward settling some of the debate about the technique's effectiveness. Bottom line: it's an option that they recommend to reduce spasticity and increase range of motion.

    The study, which appears in the August edition of Stroke (abstract only available for free), examined 29 randomized clinical trials that were focused on the use of NMES either alone or in combination with other treatment techniques, compared with a control group that did not receive NMES. Application sites were limited to lower or upper extremities, but researchers did not put upper or lower limits on NMES dosage. A total of 940 individuals were included in the combined trials.

    Authors of the analysis evaluated pre- and posttreatment spasticity by looking at participant scores on the Modified Ashworth Scale (MAS). Range of motion (ROM) was analyzed through Goniometer data. Treatment time varied (although studies that involved fewer than 3 days of intervention were excluded), as did the amount of time that passed between stroke and first treatment—from 1.5 months to more than 1 year.

    Despite the variation, what they found was that on average, use of NMES resulted in a significant .30 improvement on the MAS (14 of the 29 studies reviewed), and a 2.87 average increase in ROM (15 of the 29 studies reviewed). The most notable improvements came when NMES was used in conjunction with other interventions.

    "NMES combined with other intervention modalities is a treatment option that provides improvements in spasticity and range of motion in stroke patients," authors write. "This data provides support for further NMES use as an additional therapy technique," though they note more study is needed.

    In terms of actual frequencies used in the studies, in 22 trials, NMES frequencies ranged from 18 to 50 Hz, and pulse duration from .1 to .4 milliseconds; 3 studies used frequencies from 80 to 100 Hz with durations of .1 to .3 milliseconds; 4 of the studies did not describe the frequencies and durations. Intervention time across the studies was averaged to 3038.7 minutes, with all but 1 study occurring in an outpatient environment.

    Authors see the control of spasticity as a precursor to the application of any therapies that target motor control, and recognize NMES as an effective way of meeting that challenge.

    "From our findings, the application of NMES to reduce spasticity in these patients can be recommended," authors write. "It would lead to a bigger benefit from the motor control programs and a better improvement in the functional activity. The use of NMES could not inhibit the use of the unaffected hand, but it could enhance and facilitate the patient to use the affected hand for day-to-day tasks, resulting in improvements in [ROM]."

    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.