• Tuesday, March 03, 2015RSS Feed

    Many PT Programs Describe Their Pain Management Education as Not 'Adequate'

    While it appears that physical therapist (PT) education programs have increased the amount of time spent on pain education over the years, only 63% of faculty respondents to a recent survey believe that today's students are receiving adequate instruction in pain management, according to study published recently in The Journal of Pain (abstract only available for free).

    Authors Marie Hoeger Bement, PT, PhD, and Kathleen Sluka, PT, PhD, surveyed accredited PT programs on a range of issues around pain education, including how much time is spent on pain instruction, whether that instruction is delivered in a standalone course, what areas were covered, and whether the education reflected Institute of Medicine (IOM) and International Association for the Study of Pain (IASP) recommendations and guidelines for curriculum development. The survey was conducted between October 2012 and January 2013, and was sent to all PT programs listed in APTA's Physical Therapist Centralized Application Service.

    In the end, 167 programs (76%) answered the first portion of the 10-part survey—the section that focused on time spent in pain education—while 137 (62%) completed the remaining sections, which focused on specific content covered and respondent perceptions about the adequacy of instruction.

    Among the findings:

    • On average, programs spent about 31 hours on pain, but this average accounted for a wide range of reporting, from 5 to 115 hours. The most-frequently cited time estimate (modal) was 10 hours.
    • Only 11 of 167 programs (6%) reported having an independent pain course; all other programs reported that content was integrated into courses through blocks of time devoted to pain issues. At the time of the survey, 2 programs reported plans to create an independent pain course within the next year.
    • Most time was devoted to interventions and management (average of 27.2 hours), followed by the science of pain (9.5 hours) and assessment (4 hours).
    • Within intervention, manual therapy and "electrical agents" for pain control were reported to receive the most attention, with averages of 4.4 hours and 4.9 hours, respectively. Other topics, including exercise therapy, thermal agents, psychological management, and multidisciplinary management, received less time, ranging from averages of 2.2 hours (physician management) to 3.9 hours (both exercise therapy and thermal agents).
    • Nearly all programs responding (99%) teach various subjective pain intensity rating scales.
    • Only 68% of programs responding covered pain assessment across the lifespan.

    Authors describe a lack of data on how pain curriculum has evolved in PT programs, but they cite a 2001 survey that reported a modal of 4 hours. Although the current and earlier studies are not directly comparable, they write, the recent results "appear to be an improvement."

    Still, despite increased hours and range of topics covered, only about 6 in 10 respondents felt that their programs offered sufficient instruction in pain management (63%), with 69% reporting that their programs provided inadequate education on pain across the lifespan. "These results suggest that not all PT programs adequately provide pain education in their curriculum, especially pain assessment and management in the young and old," authors write.

    Authors also reported that less than half of the respondents were aware of IASP curriculum guidelines, or an IOM report calling for increased education on pain across health disciplines. Among the elements in the IASP guidelines is the recommendation that pain curriculum be taught as a freestanding course.

    "Ensuring that PT students receive adequate instruction in pain mechanisms and management would likely result in improved patient outcomes and lower health care costs," authors write. "To stay current in pain education, PT programs should be aware of the latest educational advancements, including the IOM report, IASP guidelines, and pain competencies."

    APTA has been a strong advocate for the ways in which physical therapy can be a transformative agent in the treatment of chronic pain. The APTA Orthopaedic Section sponsors a special interest group in pain management, and the PT's role in chronic pain management was featured in the September 2014 issue 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.

    Monday, March 02, 2015RSS Feed

    March PT in Motion: PTs Innovate to Take on Obesity

    Need more proof that physical therapy is all about transformation? Look no further than this month's issue of PT in Motion magazine and its feature story on how the profession is helping to address obesity and overweight.

    In the March issue of the magazine, associate editor Eric Ries explores how several innovative physical therapists (PTs) are establishing the profession as a key resource in a battle against obesity and overweight through a variety of approaches, from new research initiatives to real-world action.

    Through a series of interviews, Ries traces the beginnings of PT involvement in treating obesity—at a time when some PTs themselves didn't understand how the profession could help—to the latest efforts to investigate new models of care in which PTs are an integral part of a medical home team for children who are overweight or obese, a project funded through an APTA Innovation 2.0 grant.

    Along the way, the article touches on several emerging issues, including the development of an annual PT evaluation, the possibility of offering cash-based services, and the need for PTs to embrace their own power to transform society.

    The PT in Motion article on physical therapist treatment of obesity and overweight appears in the March issue of the magazine. Hard copy versions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.

    Monday, March 02, 2015RSS Feed

    Swedish Study: Reduced Hospital Stays After Hip Fracture Increase Risk of Post-Discharge Mortality

    Researchers in Sweden are questioning the general trend toward reduced hospital stays after a hip fracture, concluding that for patients whose hospital stays are 10 days or fewer, every 1-day reduction in stay increases the odds of death within 30 days of discharge by 16%.

    The study, published in the British Medical Journal, tracked length-of-stay and later mortality of 116,111 patients 50 and older (mean age 82) who experienced a hip fracture and were admitted to hospitals in Sweden from 2006 to 2012. During that period, 30,052 individuals (25.9%) died within 1 year after admission for hip fracture; of those, 5,863 died during the initial hospital stay, and 6,377 died within 30 days of discharge. Researchers in this study focused on the individuals who died within that 30-day mark.

    The most common cause of death within 30 days of discharge was listed as "expos[ure] to non-specified factor—home" (21.5%), followed by myocardial infarction (13.2%), cancer (10%), dementia (7.2%), falls 5.9%), and stroke (3.7%). Authors acknowledge the low frequency of autopsies conducted may affect the accuracy of these figures.

    Researchers found that patients who were released 10 days or fewer after admission were not only significantly more likely to die within 30 days of release, but this risk increased in relation to the number of days of reduced stay, and seems have grown over time—from an 8% per-day increased likelihood in 2006, to the 16% increased likelihood recorded in 2012. Mean length of stay for hip fracture in Sweden over that time period decreased from 14.2 to 11.6 days.

    When authors compared groups at either end of the study spectrum, they found that patients whose hospital stay was 5 days or fewer had twice the risk of death within 30 days of discharge than patients whose stay was 15 days or more.

    Although researchers were able to identify a linear increase in risk as inpatient days were reduced, they weren't able to extend that trend in the other direction—stays longer than 11 days didn't seem to decrease the likelihood of death within 30 days of release at rates corresponding to length-of-stay.

    Authors theorize that the connection to length-of-stay and mortality at the 10-day mark may have something to do with the time it takes to provide a full geriatric assessment of a patient. "Shorter length of stay … reduces the time available for comprehensive evaluation of medical conditions during hospitalization," authors write. "A growing body of evidence suggests that comprehensive geriatric assessment decreased the risks of complications after hip fracture and death after discharge in elderly patients."

    According to the study's authors, future research should not only focus on how diagnoses in addition to hip fracture play into mortality rates, but also "evaluate whether early discharge to rehabilitation centers or nursing homes is associated with a worse outcome."

    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.

    Friday, February 27, 2015RSS Feed

    CMS Appears Ready for ICD-10—Claims Submitters, Maybe Not So Much

    If grades were being handed out, the first real test of how well the new ICD-10 system integrates with the US Centers for Medicare and Medicaid Services (CMS) resulted in a solid B—but the problems that stood in the way of a top score seem to have more to do with the claims submitters than the agencies receiving the claims.

    In a February 26 announcement (.pdf) CMS reported that 81% of claims were accepted as part of its first "end-to-end" test of the new codes. The test involved 661 volunteer providers and all Medicare administrative contractors (MAC), as well as the durable medical equipment MAC common electronic interchange contractor, in a practice session to spot potential glitches in the submission of claims according to coding in the International Classification of Diseases, 10th Revision, or ICD-10. CMS is set to implement the new codes on October 1.

    CMS reported that of 14,929 claims received between January 26 and February 3, 12,149 were accepted. Of the 19% of claims rejected, 3% were turned down because of invalid submission of ICD-9 codes, and another 3% for problems with ICD-10 codes. The rest were denied because of "non ICD-10 related errors, including setting up the test claims, health insurance claim number, submitter ID, dates of service outside the range of testing, invalid HCPCS codes, invalid place of service," according to CMS.

    In other words: problems with the ICD-10 system had more to do with the submitters than the agency processing the submissions—at least for this round of testing.

    "It's good that this testing is taking place well before the October 1 implementation date," said Matt Elrod, PT, DPT, MEd, NCS, senior specialist in APTA's Department of Clinical Practice. "Right now, it seems that the biggest challenge rests with the providers and those submitting the claims. It's crucial that they have a very clear understanding of how the system works. At this point, education is key." APTA offers multiple resources on the new system at its ICD-10 webpage.

    Two more end-to-end testing windows are scheduled over the spring and summer—one April 27–May 1, and another July 20–24. Information on the tests is available in a Medicare Learning Network bulletin (.pdf).

    Thursday, February 26, 2015RSS Feed

    'Bionic Reconstruction' Restores Hand Function in 3 Patients

    Researchers in Austria say that they've successfully completed "bionic reconstruction" procedures that allow individuals to use their minds to control a prosthetic hand that can engage in complicated motor control activities such as unfastening buttons, picking up coins, and pouring water from a cardboard carton. All 3 patients who received the prosthesis suffered brachial plexus avulsion injuries and elected to have the injured hand amputated.

    The prostheses are controlled through 2 "cognitively separate" electromyographic signals in the forearm—one from nerves and muscles already present in the patient's damaged forearm, and another surgically transferred into the affected arm from the leg. After the signal sites were established, the patients underwent cognitive training by, at first, controlling a graph on a computer screen via electrodes attached to the sites, and then through the operation of a "virtual hand" on the screen.

    The final phase of the cognitive training involved a "hybrid hand" that was attached to the nonfunctional hand by way of a "splint-like" device. "As crude as it seems, the device provided direct proof for patients that better hand function could be achieved using the prosthesis than with their denervated hand," authors write.

    After the patients completed cognitive training, they underwent amputation of the damaged hand, and were fitted with the bionic prosthesis. Patients completed 3 assessments of global arm function before and after the intervention—the Action Research Arm Test (ARAT), the Southampton Hand Assessment Procedure (SHAP), and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire—and recorded significant improvement in all areas.

    Results were published the Lancet (abstract only available for free), accompanied by free videos that show hand function in the patients before the intervention, during the "hybrid" stage, and after being fitted with the prosthesis. The videos show the patients using the prostheses to unscrew a jar lid, unfasten buttons, pick up coins, and pour water, among other activities. News of the research was also featured in major media outlets including theNew York Times and CNET.

    "Pre-interventional testing showed that all patients had dismal hand function," authors write. "The patients did not use the impaired hand in daily life, even when the bimanual tasks were specifically requested." After becoming accustomed to having 2 functional hands, the patients engaged in bimanual tasks, and were able to wear their prostheses 8-12 hours a day. Tests of overall psychological wellbeing also showed improvement—another positive sign for the researchers who had purposefully selected patients "who had had great psychological harm as the result of the injury."

    "The loss of hand function after global brachial plexus injury with lower root avulsions poses a reconstructive challenge that is difficult to overcome," authors write. "Present surgical techniques for such injuries are crude and ineffective." However, they argue, the technique they pioneered presents "no technical or surgical limitations that would prevent this procedure from being done in centers with similar expertise and resources."

    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.

    Thursday, February 26, 2015RSS Feed

    Repeal of Therapy Cap Back in Congress

    Legislation calling for the repeal of the Medicare outpatient therapy cap has been reintroduced in both the US Senate and House of Representatives.

    This week, Sens Ben Cardin (MD) and Susan Collins (ME) introduced the Medicare Access to Rehabilitation Services Act (S. 539), which calls for an end to Medicare's payment ceiling for certain outpatient services including physical therapy. A companion version of the bill was introduced in the House in early February (H.R. 775).

    The introduction of the legislation in the Senate comes during a busy week on Capitol Hill for APTA advocates and staff, who not only spoke with legislators and policymakers on the therapy cap, but participated in meetings at the White House, the Federal Trade Commission, and the National Institutes of Health to bring the profession's voice to the table on a variety of issues.

    The therapy cap issue remains a policy priority for APTA, which sent out an action alert this week to encourage members to contact their representatives about the legislation now in Congress. Additionally, Mandy Frohlich, APTA vice president of government affairs, was featured in an episode of Comcast Newsmakers explaining why repeal of the therapy cap is a crucial to transforming health care for consumers and providers.

    APTA will continue to monitor the progress of the legislation and provide members with updates.

    Wednesday, February 25, 2015RSS Feed

    Physical Therapy's Prominence in $64 Million Research Funding Program Reflected in Awards to Delitto, Duncan

    Physical therapy is front-and-center in a high-profile $64 million program that seeks to anchor research to real-world practice: this week, the Patient-Centered Outcomes Institute (PCORI) announced that 2 of its 5 inaugural funds have been awarded to projects led by prominent physical therapy researchers Pamela Duncan PT, DPT, FAPTA, and Anthony Delitto , PT, PhD, FAPTA. Combined, the researchers will receive nearly $28 million in support.

    Both projects are focused on getting physical therapists (PTs) involved in patient care early-on, and both will be conducted as "pragmatic clinical studies"—research that analyzes a care option’s effectiveness in real-life practice situations, such as typical hospital and outpatient care settings, with diverse patient populations. According to a PCORI news release, unlike standard clinical trials that "test whether a care approach works under optimized conditions with carefully selected patients in research centers," the findings from pragmatic studies "are more likely to be applicable to a wide variety of patients."

    Duncan is professor of neurology at Wake Forest Baptist Medical Center. Delitto is associate dean of research at the University of Pittsburgh School of Health and Rehabilitation Sciences.

    PCORI awarded $14 million for Duncan's project, which will involve stroke patients in 50 hospitals in North Carolina to find out if early discharge with ongoing support by PTs and other providers results in better daily function outcomes than longer hospital stays and standard transitional care. The study "will also consider caregiver strain, hospital readmission rates and mortality, use of health care, consistency of physician care, use of transitional care services, and death," Duncan writes in her summary of the project.

    Delitto received $13.9 million in PCORI funding to look at the individual's transition from acute low back pain (LBP) to chronic LBP by focusing on 2 approaches in the outpatient primary care physician (PCP) setting—one "usual care" approach, and a second approach that would team up PCPs with PTs to provide cognitive behavioral therapy (CBT). Patients who have LBP and risk factors for moving from acute to a more persistent state of LBP will be the targeted population for the project, which will involve 12 PCP clinics in 5 different areas across the country. Delitto hopes to recruit 2,640 patients and acquire data on 2,400 over 6 months after enrollment.

    "This study is designed to look at the value of a stronger partnership between primary care and physical therapy, particularly for painful musculoskeletal conditions," Delitto said. "A number of studies have come out detailing the success of the PCP plus PT-CBT approach, but they've all been conducted in Europe. Before we can recommend any approach, it should be thoroughly and rigorously tested in the US, with its unique health care system."

    The program, with its focus on pragmatic trials, is intended to encourage exactly that kind of approach, according to PCORI Executive Director Joe Selby, MD, MPH.

    "A critical feature of these studies is that they will involve all major stakeholder groups as partners, increasing the chances that the studies will be implemented in a useful way and analyzed with an eye toward implementation," said Selby in the news release. "And, if warranted, their results will be put to use in practice much more quickly than most research."

    "We are extremely pleased that APTA member PT researchers are among those selected," said Paul A. Rockar Jr, PT, DPT, MS, APTA president in an association news release. "With improved patient outcomes based on evidence, we will be closer to achieving APTA's vision of transforming society by optimizing movement to improve the human experience."

    PCORI is an independent, nonprofit organization authorized by Congress in 2010. Besides the Duncan and Delitto projects PCORI will also be funding research on breast cancer screening, the intensity of CT surveillance needed to detect lung cancers, and how a standing-order entry system advising physicians when to prescribe a medication to prevent infections reduces over- and underuse of this medication among patients with breast, lung, or colorectal cancer.

    Wednesday, February 25, 2015RSS Feed

    For PT in Motion News, Wednesday is the New Friday

    PT in Motion News has shifted its weekly blast to Wednesdays to make room for a series of newsletters designed to deliver more customized information to members.

    Called Friday Focus, the newsletter series will target 1 of 4 areas each week. The 4 areas that will be covered on a rotating basis are:

    • Payment (debuts February 27, then every fourth Friday of each month)
    • Professional issues (debuts March 6, then every first Friday of each month)
    • Evidence and care (debuts March 13, then every second Friday of each month)
    • APTA & You (debuts March 20, then every third Friday of each month)

    To get Friday Focus, members need only to select which topics they'd like to receive. They can do this by logging in to My Profile on www.apta.org and making their choices, as well as review all APTA communications and choose options that best suit their needs and interests.

    Tuesday, February 24, 2015RSS Feed

    APTA Delivers Profession's Vision, Perspectives During a Busy Week in DC

    Ending the Medicare therapy cap and repealing the flawed sustainable growth rate (SGR), contributing to a White House discussion on aging, supporting research on rehabilitation and child health, and staying on top of the latest issues in health care competition are all part of what is turning out to be a very busy week for APTA advocates and staff on Capitol Hill.

    This week in Washington, DC, association representatives are bringing the profession's transformative vision for health care to multiple fronts by speaking with legislators and policymakers, and seeing to it that physical therapy has a place at the table for some of the most important discussions around the future of health care.

    "The events happening this week are a fantastic opportunity for APTA to bring its message of the power of physical therapy to transform society," said Justin Moore, PT, DPT, APTA executive vice president of public affairs. "The association's vision is on point with many of the issues being discussed, and we're fortunate to have so many advocates who are passionate about sharing that vision. We're very excited about being able to contribute in these varied ways."

    APTA is bringing its voice to:

    • The therapy cap, SGR, and locum tenens . A special legislative "fly in" is bringing members of APTA and its Private Practice Section (PPS) to Capitol Hill to speak directly with legislators and staff on the importance of ending the Medicare cap on physical therapist services, as well as repeal of the flawed sustainable growth rate, and support for the extension of Medicare locum tenens provisions to physical therapists. Over 100 members representing 40 states are participating in nearly 200 meetings with legislators, staff, and other policymakers.
    • Physical therapy and aging. APTA has been invited to meet with representatives from the White House Conference on Aging to discuss the role of physical therapy in the aging population, and they ways APTA may be able to collaborate with the conference on future events and policy recommendations. APTA President Paul A. Rockar Jr, PT, DPT, MS, CEO Michael Bowers, and Moore are attending the February 24 meeting.
    • Rehabilitation and child health research. APTA is joining other members of a coalition that supports the National Institutes of Health's National Institute of Child Health and Human Development (NICHD) for a meeting with NICHD Director Alan Guttmacher, MD, and other institute staff. NICHD houses the National Center for Medical Rehabilitation Research (NCMRR), the office responsible for coordinating rehabilitation research at NIH. The Friends of NICHD Coalition advocates for NICHD priorities during annual congressional appropriations and budget processes.
    • Health care competition. APTA representatives are attending a 2-day Federal Trade Commission (FTC) workshop on health care competition in a post-Affordable Care Act market. Speakers at the event include economists, policy analysts, researchers, and attorneys from the FTC, the US Department of Justice, the US Centers for Medicare and Medicaid Services, Blue Cross Blue Shield, the Brookings Institution, and several major universities. APTA met with FTC representatives in the fall of 2014 to help plan the workshop, and will provide comments afterwards.

    In an APTA video dispatch recorded at the start of the week, Rockar described the current activities as part of a "really important week" that is allowing APTA to bring physical therapist issues to the fore. "If we're really going to transform society, we have to influence and educate people about policy that's going to help us provide care to our patients in this evolving health care environment," he said.

    Terry Brown, PT, DPT, president of the PPS, stressed the importance of broad participation, both in-person and by way of participation through action alerts and other communications from PPS and APTA. "It's enormously important that other people get involved," Brown said. "We need each and every therapist at home to become involved."

    There's more work to be done in Washington for the profession and the public it serves: make plans to join hundreds of other APTA members for PT Day on Capitol Hill, June 3–4. The event coincides with the 2015 NEXT Conference and Exposition being held in nearby National Harbor, but attendance at NEXT is not required for participation.

    Tuesday, February 24, 2015RSS Feed

    Physical Therapy Plays Role in Artificial Heart Development

    Physical therapy has been playing a role in the rehabilitation of patients fitted with a new type of artificial heart.

    The bioprosthetic heart, developed by the French company Carmat, is designed to replace the patient’s original heart over the long term, mimicking nature using biological materials and sensors.

    In December 2013, a patient with terminal heart failure was fitted with the artificial heart. Two months later, the Georges Pompidou European Hospital in Paris issued a statement that said, "The 76-year-old man is eating normally, no longer needs constant respiratory assistance, and is able to walk a little further every day thanks to physical therapy."

    More recently, in January 2015, a 68-year-old recipient of the artificial heart was discharged from the hospital and "is living a completely normal life now," according to Alain Carpentier, the French surgeon who invented the device. Carpentier added that the man has been "pedaling like crazy" on a stationary bicycle.