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  • Study: Return-to-Play Predictions for Hamstring Injuries Hamstrung by Variability

    Think you can predict how long it will take an athlete with a hamstring injury to return to play based on the athlete's history and an initial clinical examination? Some researchers say you probably can't—and magnetic resonance imaging (MRI) probably won't help.

    In a study published in the British Journal of Sports Medicine(pdf) researchers followed the progress of 180 male athletes with acute hamstring injury in an effort to analyze the predictive value of patient history and initial clinical examination, as well as any additional insight added by MRI. All of the athletes participated in a supervised physical therapy program, and were cleared for return to sport by either a physician or a physical therapist (PT).

    Using a more in-depth statistical analysis than in previous studies, the investigators calculated that patient history and clinical examination explained only 29% of the total variance in time to return to sport among the participants. Adding MRI increased that variance by just 2.8%—for a total of 31.8%.

    Based on their findings, the authors write, “Clinicians cannot provide an accurate time to return to sport” based on patient history, initial examination, or MRI. However, they add, “this is not a call to abandon MRI in clinical practice,” a resource that could be valuable for confirming the diagnosis and informing patients about their injuries.

    The initial examination included pain experienced during range-of-motion testing, manual muscle testing, the active slump test, and measuring length and width of the injury through tenderness to palpation. The variables that were correlated with length of time before return to sport included pain score at the time of injury, being forced to stop within 5 minutes of the onset of pain, painful resisted knee flexion, and length of injury.

    One of the limitations of the study is that the criteria for determining return to sport were determined by the individual physicians and PTs. But, the investigators note, while scientifically not optimal, this may better reflect the reality of patient care.

    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.

    Obama Budget, APTA Comments to Congress Converge on Elimination of Self-Referral Loophole

    For the fourth year in a row, the federal budget plan announced by President Barack Obama proposes that the so-called Stark law be tightened up to eliminate exceptions that allow physicians to self-refer for certain services, including physical therapy. And should Congress need an additional reminder of the importance of this change, it need look no further than APTA, which recently supplied Senate and House committees with comments outlining exactly why the loopholes should be closed.

    The $4.1 trillion FY 2017 budget plan is unlikely to be enacted by Congress, where Republican leaders have stated that they would break with tradition and not hold a hearing on the budget with the administration's budget chief. Still, Obama's budget has helped to emphasize issues that the administration believes are worth attention—and action.

    According to administration budget estimates, elimination of exceptions to the prohibition on referral to in-office ancillary services (IOAS) in Medicare would result in $4.98 billion in savings over 10 years. The current IOAS exception allows for self-referral for physical therapy, anatomic pathology, advanced diagnostic imaging, and radiation therapy.

    As in past years, the Obama proposal around IOAS was applauded by the Alliance for Integrity in Medicare (AIM) a coalition of organizations, including APTA, that has been advocating for removal of physical therapy and other services from the exception.

    "Since fee-for-service continues … the financial incentive remains for clinicians to exploit the IOAS exception[s]," AIM writes in a news release on the budget. "Alternative payment models … will not be successful if arrangements that allow overutilization continue to be incentivized in the Medicare program."

    Obama's emphasis on elimination of the IOAS exception was recently echoed by APTA, which supplied comments to the Senate Finance and House Ways and Means committees.

    In those comments, APTA writes that "care furnished under the IOAS exception is often degraded, raising serious quality concerns" and that legislators should support the "original intent of the IOAS exception," which was centered on same-day services.

    "This reform is in the best interests of taxpayers, patients, and the American health care system overall," APTA writes.

    Elimination of the IOAS exceptions remains one of APTA's public policy priorities, and has gained support from the American Association of Retired Persons (AARP), which announced its position against the exceptions late in 2014.

    APTA Names Physical Therapy Outcomes Registry Scientific Advisory Panel

    A game-changer in the physical therapy profession's efforts to document outcomes now has its scientific leadership in place.

    APTA recently announced the members of the Scientific Advisory Panel (SAP) to the Physical Therapy Outcomes Registry (Registry), the major APTA initiative to create the most comprehensive database of physical therapy outcomes in the country.

    The panelists include: James Irrgang, PT, PhD, ATC, FAPTA (Director); Kristin Archer, PT, DPT, PhD; Linda Arslanian, PT, DPT, MS; Janet Freburger, PT, PhD; Christopher Hoekstra, PT, DPT, OCS, FAAOMPT; Stephen Hunter, PT, DPT, OCS; Michael Johnson, PT, PhD, OCS; Christine McDonough, PT, PhD; and Linda Woodhouse, PT, PhD.

    The SAP will provide direction for the Registry on scientific integrity, clinical application, quality, public policy, and research.

    “The Scientific Advisory Panel represents excellence and a wide range of expertise — research scientists, front-line clinicians and managers, and administrators from the physical therapy business community,” said APTA President Sharon Dunn, PT, PhD, OCS in a news release.

    As one of the association’s top strategic priorities, the Registry will use the data contributed to show how physical therapy can transform the lives of patients through positive outcomes. Physical therapy practices and facilities can also use the Registry to benchmark their performance and justify services to payers, as well as meet quality reporting requirements.

    Data from the Registry is published in the Logical Observation Identifiers Names and Codes (LOINC) database, a worldwide universal coding system that provides standardized codes and names for more than 73,000 data elements.

    Why is the Registry such a big deal? Check out "The Physical Therapy Outcomes Registry Is Totally Into You," part of last year's "Transformation" series to learn more.

    Article Looks at Stem Cell Clinic Debate

    As the prominence of stem cell clinics has increased, so has attention from the US Food and Drug Administration (FDA)—along with more public debate on whether the techniques are useful interventions or a new form of "quackery."

    In a recent article in STAT, an online health care and science magazine, reporter Usha Lee McFarling looks at the arguments for and against therapies that involve injecting stem cells processed from the patient into an injured area. Proponents say it speeds healing and can help patients avoid surgery, while detractors question its effectiveness and legality.

    According to the STAT article, "federal regulators are preparing to crack down on scores of clinics" that perform the therapies, based in part on new FDA guidelines (.pdf) that define the stem cells used in most clinics as drugs that require "a rigorous approval process."

    The article includes interviews with critics who describe the stem cell approach as a "huge unproven human experiment," as well as with providers who perform the therapies and claim that the injections are not drugs but "simple outpatient surgeries that should not be regulated."

    This isn't the first time the rise of stem cell clinics has gained wider media attention: in September 2015, USA Today focused on the topic in a feature article. The topic of regenerative medicine in general, and the physical therapist's relationship to it, will also be the subject of a cover story in the March issue of APTA’s PT in Motion magazine.

    Rehab Research Bill Passes Major Hurdle in Senate

    APTA's efforts to support improvements in rehabilitation research just received a major boost by way of a US Senate Committee, which has completed the "markup" phase of a bill that would bolster research efforts at the National Institutes of Health (NIH).

    Next stop: the Senate floor.

    Titled the "Enhancing the Stature and Visibility of Medical Rehabilitation Research at NIH Act," (S. 800), the bill passed through markup by the Senate Committee on Health, Education, Labor, and Pensions (HELP) with only minor changes. The Disability Rehabilitation and Research Coalition (DRRC) worked with NIH and the office of Sen Mark Kirk (R-IL), the bill's sponsor, to develop the necessary compromises. APTA is on the steering committee of DRRC, which is composed of over 40 organizations committed to promoting rehabilitation research.

    If signed into law, the bill would help better coordinate rehabilitation research across all institutes at NIH in several ways, including statutorily defining medical rehabilitation research to ensure continuity in the use of the word, and standardizing reporting mechanisms to enhance the coordination of research.

    The bill is based in part on recommendations from an NIH blue ribbon panel that was co-chaired by Rebecca Craik, PT, PhD, with members that included Anthony Delitto, PT, PhD, and Alan M. Jette, PT, PhD. The panel's recommendations, issued in 2013, were supported by APTA, with then-APTA President Paul A. Rockar Jr, PT, DPT, MS, characterizing the findings as ones that reflect APTA's "core principles," and are "critical to meeting the NIH's mission and impacting society in a positive manner."

    The bill will join a package of Senate legislation that serves as a companion of the 21st Century Cures legislation (H.R. 6) on the House side that passed last year.

    Improvements to rehabilitation research and support of NIH work in this area are among APTA's public policy priorities.

    Jimmo Message Hasn't Sunk In; CMS Needs to Do More

    When theJimmo v Sebelius settlement was announced in 2013, patient advocates applauded what they saw as a landmark change for individuals who need care to maintain their medical conditions or slow their declining health. However, 3 years later, many providers and payment adjudicators are still making coverage decisions as if they're living in a pre-Jimmo world—mostly because the US Centers for Medicare and Medicaid Services (CMS) hasn't done enough to bring them up to speed, according to an advocacy group supported by APTA.

    Recently, APTA provided a supporting declaration to the Center for Medicare Advocacy's (CMA) efforts to get CMS to do a better job of making it clear that the "Improvement Standard"—the idea that Medicare coverage can only be extended if that care will actually improve the patient's condition—is a fallacy, and that skilled maintenance care can qualify for payment.

    "There are still many providers and contractors who do not know about, understand, or trust the change in the improvement policy," CMA wrote in a December 2015 letter to APTA and other stakeholders. "We believe this is largely due to the fact that CMS' Education Campaign was insufficient to make up for the rigor with which Medicare enforced the Improvement Standard—for decades." According to CMA, CMS conducted only 1 briefing for providers and adjudicators, in early December of 2013. Since that time, CMS "has refused to do more," CMA writes.

    APTA agreed with CMA's take on the situation and submitted a declaration of support, writing that the information provided by CMS is "introductory in nature and [has] not been sufficient in educating our members."

    "Approximately 2 years after the CMS National Education Campaign, APTA is still receiving inquiries from physical therapists regarding the coverage of skilled maintenance therapy under Medicare," APTA writes. "We have found that many providers have not received any information regarding the settlement … or remain confused about the proper application of the skilled maintenance therapy benefit." The association suggests posting answers to frequently asked questions, sharing information briefs on what to do in case of denials, hosting national calls, and sponsoring regional town halls.

    Patients and physical therapists do have recourse: CMA has created a "self-help packet" for appealing denials of outpatient therapy that may have been made based on a pre-Jimmo understanding of payment policy. The webpage featuring the packet also contains background information on Medicare coverage and the "improvement myth," therapy cap exceptions, and appeals processes.

    APTA engaged in an extensive effort to educate its members on the Jimmo settlement, and maintains a webpage on skilled maintenance that includes links to a podcast series, a recorded webinar, and several pages of frequently asked questions.

    Botox Approved for Lower Limb Spasticity

    Six years after gaining FDA approval for the treatment of upper limb spasticity, onabotulinumtoxinA—commonly known as Botox—has now been OK'ed for the same use in lower limbs.

    According to Medscape (free sign-in required) the FDA approval was based on a clinical trial of more than 400 individuals who were experiencing lower limb spasticity poststroke. Participants treated with Botox showed statistically significant improvements at weeks 4 and 6 in muscle tone and clinical patient benefit.

    The trials were focused on the ankle and toes, and didn’t confirm use in other areas of the lower extremities.

    In 2010, FDA approved the use of Botox for upper limb spasticity, but effectiveness was only confirmed for the elbow, wrist, and fingers. Five years later, effectiveness was confirmed for use in 2 thumb muscles.

    Zika Outbreak a 'Public Health Emergency,' Could be Linked to Guillain-Barré, Other Disorders

    The Zika outbreak has been elevated to a "public health emergency of international concern" by the World Health Organization (WHO) while health officials scramble to understand the disease, including its possible relationship to Guillain-Barré Syndrome (GBS) and other disorders that affect the nervous system.

    As of January 30, 26 countries had reported locally transmitted Zika infections across Central America, South America, the Caribbean, and the Pacific Islands. The list of countries treating these infections continues to grow. Travel-related cases have been identified in the continental United States. Puerto Rico, American Samoa, and the US Virgin Islands already are experiencing ongoing transmission of the virus.

    The new status from WHO may help affected countries better respond to the virus through stepped up research, surveillance, care, and follow-up.

    The virus largely has been transmitted via mosquito bites, but a US Centers for Disease Control and Prevention (CDC) report notes that infections have occurred through mother-to-fetus transmission, sexual transmission, blood transfusion, and lab exposure. This week, the first human-to-human transmission of the virus within US borders was reported in Texas, where a woman contracted the disease through sexual contact with her husband.

    Signs of Zika infection include fever, skin rash, conjunctivitis, muscle and joint pain, malaise, and headache, but health officials are also concerned about the infection's possible relationship to disorders of the nervous system. In addition to a rise in microcephaly recorded in Brazil since October 2015, both Brazil and El Salvador have observed a dramatic increase in cases of GBS coinciding with the 2015 Zika outbreak.

    In a January 18 statement, the Pan American Health Organization (PAHO) recommended that “countries in the Americas prepare their healthcare facilities to respond to a potential increase in demand for specialized care for neurological syndromes.”

    WHO does not recommend a travel ban to infected countries, and while health officials anticipate clusters of outbreaks in the United States due to infected travelers, CDC says that widespread transmission “appears to be unlikely.” The CDC has issued a set of travel tips for anyone visiting areas affected by the Zika outbreak.

    The CDC asks providers to report any suspected cases to their state health department to enable laboratory diagnostic testing and avoid further transmission.

    White House Proposes $1.1 Billion to Reduce Opioid Abuse

    In a proposal aimed in part at building on an initiative that includes APTA, President Barack Obama has designated $1.1 billion in new funding over 2 years to intensify the fight against the country's opioid use and heroin abuse epidemic.

    According to a White House fact sheet, Obama's proposal takes a "2-pronged approach" to address the drug problem: $1 billion in new mandatory funding for expanding treatment for individuals with an opioid use disorder, and $500 million to increase prescription drug overdose prevention strategies, including more funding for medication-assisted treatment. Some of the funds will be directed specifically to rural areas of the country, which have seen disproportionately high levels of abuse and overdose.

    The proposal, which requires congressional approval, further intensifies the administration's focus on the opioid abuse epidemic. That focus received national attention in October 2015, when Obama announced the creation of a public- private partnership to combat opioid abuse and heroin use. APTA is participating in the initiative along with 39 other health care provider groups that include the American Medical Association, the American Academy of Family Physicians, and the American Nurses Association.

    APTA has long advocated for the role of the physical therapist (PT) in pain management, using its MoveForwardPT.com website to educate the public, and featuring new approaches to pain treatment being used by PTs in a 2014 feature story in PT in Motion magazine. More recently, the August 2015 issue of Physical Therapy (PTJ), APTA's peer-reviewed journal, included a discussion of how to interpret the burgeoning effectiveness evidence from recent clinical trials and systematic reviews on pain treatment.

    APTA Adds Physical Therapy Perspective to Senate Work Group Report on Chronic Health Conditions

    The challenges of providing care to individuals with chronic health conditions are now the focus of a bipartisan working group in the US Senate, and APTA is helping to shape the group's policy proposals.

    In December 2015, the Senate Finance Committee's Bipartisan Chronic Care Working Group issued a 30-page "policy options document," the product of a 6-month investigation of possible ways to improve care delivered to Medicare beneficiaries with chronic health conditions. The information-gathering process included over 80 stakeholder meetings and 530 recommendations, with the final document including 24 policy proposals ranging from the changes to the Medicare Advantage (MA) program to expanded education and research initiatives.

    According to the work group, the policy changes listed in the document are aimed at increasing care coordination, streamlining Medicare payment systems "to incentivize the appropriate level of care," and establishing a chronic care system that "facilitates the delivery of high quality care, improves care transitions, produces stronger patient outcomes, increases program efficiency, and contributes to an overall effort that will reduce the growth in Medicare spending."

    On the whole, APTA's comments to the proposals were supportive, with the association focusing on 12 proposals that would most directly affect physical therapy. Among them:

    Expansion of the Independence at Home demonstration project into a "permanent, nationwide program." APTA supported the idea, but advocated for a careful approach.

    Continued access to MA special needs plans. APTA asserted that "all plans have access to physical therapy services."

    Provisions that would allow MA plans to vary benefit structures to meet the needs of chronically ill enrollees. APTA supported this idea, but called for care in the definition of "non clinical" professionals.

    Telehealth provisions that would expand opportunities for use in MA, accountable care organizations (ACOs), and for beneficiaries poststroke (3 separate policy proposals). APTA supported all 3 proposals, particularly in relation to physical therapy, writing that "telehealth will not replace traditional client care, but it will give [physical therapists] and [physical therapist assistants] the flexibility to provide services in a greater capacity."

    Ensuring accurate payment for individuals who are chronically ill. APTA wrote that it was "generally supportive" of the proposal, but suggested that to truly achieve a more effective payment system, additional regulatory changes need to happen—including a full repeal of the Medicare therapy cap.

    The association also commented on proposals to increase care coordination among ACOs, the development of quality measures for chronic conditions, and a suggestion to increase transparency at the CMS Center for Medicare and Medicaid Innovation (CMMI), a center that should create more grant funding opportunities "aimed at providers such as physical therapists," according to APTA.

    APTA highlights the role of the physical therapist and physical therapist assistant in the treatment of chronic conditions through its prevention, wellness, and disease management webpage. In addition, the 2015 House of Delegates adopted the position Health Priorities for Populations and Individuals (RC 11-15) "to guide [APTA's] work in the areas of prevention, wellness, fitness, health promotion, and management of disease and disability." The priorities include active living, injury prevention, and secondary prevention in chronic disease and disability management. The topic was also the subject of a popular presentation at the 2015 NEXT Conference and Exposition.

    Also available from the APTA Learning Center: "Disease Management Models for Physical Therapists: Focus on Diabetes and Cardiovascular Disease."