Delaware physical therapists (PTs) have a new scope of practice that includes telehealth, dry needling, and an updated definition of the practice of physical therapy now that a significantly revised PT licensing law has been signed by Gov Jack Markell. Markell signed the bill on August 12.
Advocated for by the Delaware Physical Therapy Association, the legislation (HB 359) faced opposition from other provider groups, including acupuncturists who were opposed to the inclusion of dry needling in the new definition for physical therapy. In addition to the dry needling and telehealth provisions, the new law includes temporary exemptions to licensure for PTs licensed in another state who are in Delaware for educational purposes, accompanying travelling sports team or performance groups, or responding to declared emergencies.
“The legislative process was very arduous, and I am grateful for all of our chapter members who attended hearings, met with legislators, and sent emails or made phone calls in support of HB 359," said George Edelman, PT, OCS, MTC, president of the Delaware Chapter, "We are thrilled that Delaware now has a physical therapy statute that reflects 21st century practice."
"APTA congratulates our Delaware Chapter on this significant legislative achievement," said APTA President Paul A. Rockar Jr, PT, DPT, MS, "Our vision of transforming society by optimizing movement to improve the human experience begins with transforming our state licensure laws to ensure physical therapists can practice within their full scope."
The Delaware State Examining Board of Physical Therapists and Athletic Trainers—the state's licensure board—is expected to begin work on developing board rules related to the new law this fall.
The old saying about how "it's the journey, not the destination" may have particular relevance for recipients of total knee arthroplasty (TKA): according to a new study, when it comes to levels of function, TKA recipients whose preoperative condition was mild enough to deem the procedure "inappropriate" ultimately arrive at the same place as patients with more severe preoperative symptoms.
The research (abstract only available for free), e-published ahead of print in the August 6 issue of Arthritis Care & Research, builds off a previous study that applied a modified Escobar classification system developed in Spain to label TKA recipients as "inappropriate," "appropriate," or "inconclusive" based on radiographic evidence, knee motion and laxity, and scores on the Western Ontario and McMaster Universities Arthritis Index (WOMAC). That study found that 34.3% of the TKAs studied were performed on patients whose presenting conditions were judged to be inappropriate for the procedure.
In the follow-up study, researchers led by Daniel L. Riddle, PT, PhD, FAPTA, looked at outcomes for 167 patients with primary TKA. Of those TKAs, 47.9% were identified as "appropriate," and 31.3% were classified as "inappropriate," with the remaining 20.8% labeled "inconclusive." Researchers monitored scores from the WOMAC as well as Knee Injury and Osteoarthritis Outcome Scores (KOSS) for both pain and symptoms at 2 months postprocedure, and again at the 1- and 2-year marks. The aim was to quantify both the "journey" to improvement and the ultimate "destination"—exactly how much function related pain and activity limitation was present one and two-years after surgery.
Researchers hypothesized that because they underwent TKA with less severe symptoms, the inappropriate group would have smaller changes in pain and function, and experience better outcomes at the 1 and 2 year "destination" points than patients whose TKA was deemed appropriate. What they found was nearly the opposite.
"Persons who were classified as inappropriate had no significant change in pain, function, and knee symptoms over the 2-month postoperative period relative to the preoperative assessment," authors write. "This contrasts to the substantial improvements over the same time period in the appropriate and inconclusive groups. In addition, despite having higher functioning and substantially less pain preoperatively, the destination outcomes … were not statistically different. Overall, improvements in the group classified as inappropriate were small and in some cases did not reach clinical significance 1 year following surgery."
Authors write that while the study design cannot establish with certainty whether the appropriateness criteria is valid for US patients or whether patients receive TKA only when needed, "our study does … provide evidence to suggest that one or the other (or both) of these inferences is likely to be false." The need at this point, they write, is for further study and "consensus building efforts … to define eligibility criteria for TKA with the goal of reducing variation in patient characteristics and maximizing outcome."
"To me, the real standout feature in this study was the small amount of improvement in the inappropriate group," Riddle said. "Both groups had essentially the same final outcome, but it was fairly striking how small the actual amount of improvement was for the inappropriate group."
Riddle acknowledged that the appropriateness logarithm used in the study is "grounded in the notion that TKA is optimal for those that have severe or end-stage knee osteoarthritis," saying that because "TKA has evolved, and rightly so, it makes sense that the potential window for possible candidates would be wider than it used to be."
Still, Riddle said, as effective as the procedure is, "there needs to be some additional clarity" around who are the best candidates for TKA. "That's why we argue for the need for consensus around clinical standards for TKA, now that the bar has been lowered somewhat," he said.
Although the study has more to do with appropriateness for a surgical procedure than it does for physical therapy afterward, Riddle believes that there are lessons here for physical therapists (PTs).
"It's important for PTs to recognize that there are larger variations in the types of patients selected for TKA, and large variation in surgical decisions," he said. Perhaps even more important, he added, is what the study can tell PTs about the dynamics of recovery. "PTs should look at studies like this one as an important reminder to think about outcomes in terms of both the journey and the destination," Riddle said. "They need to think about where their patients end up, and how they get there. Both approaches to outcome assessment are important."
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.
Despite what your mom may have told you, hanging out can be a very productive use of time: at least that will be the case for the PTNow Google Hangout on August 28, when you can learn about PTNow's clinical summary on Down syndrome directly from the summary's author.
Kathy Martin, PT, DHS, author of the clinical summary, will answer your presubmtted questions along with Tracy Stoner, PT, DPT, PCS, a pediatric physical therapist in the Department of Physical Therapy at University of Delaware and a research coordinator at Drexel University. The hangout will be moderated by Mary Tischio Blackinton, PT, EdD, CEEAA, GCS, PTNow associate editor for social media.
The PTNow Google Hangout will not be live, but a recording will made available shortly afterward, allowing users to access the content whenever they want. Because of this, questions need to be submitted in advance.
There are several ways to forward your questions to the hangout—just be sure to get them in before August 25. You can:
After remaining relatively unchanged for the past few years, running blades are undergoing redesign efforts that could help more athletes than ever participate in the Olympics, according to a recent article in co.Exist.
The article describes a joint effort by Altair, a design company, and Eastman, a chemicals and plastics manufacturing supplier, to rethink the blade-shaped prosthetics used by athletes—most famously by Oscar Pistorious in the Summer 2012 Olympics. According to reporter Ariel Schwartz, the project was taken on by the companies after Paralympian runner Blake Leeper challenged designers to move the concept forward.
The blades now in testing employ curved bottom plates to better accommodate track corners, "twists" in the blade that can decrease drag force by 57%, and a new attachment system that includes a "fabric shroud" that helps to lock the prosthetic into place. According to the article, the new design meets Olympic regulations and could be seen in the 2016 games.
The largest recorded cyber-attack on a health care operation has succeeded in stealing information on 4.5 million patients associated with Community Health Systems (CHS), a Tennessee-based company that owns, operates, or leases 206 hospitals in 29 states. Although CHS maintains that the information does not include payment or clinical information, hackers were able to access names, addresses, social security numbers, and other data.
In an August 18 filing with the US Securities and Exchange Commission (SEC), CHS reports that hackers successfully accessed confidential files in April and June of 2014 through the use of malware that was able to bypass the company's security systems. According to reports from Reutersand the Chicago Tribune, a Chinese group known as "APT 18" is suspected of conducting the attack. CNN reports that the FBI is working closely with CHS to investigate the theft.
In addition to names, addresses, and social security numbers, stolen information includes birthdates, telephone numbers, and employer or guarantor information on patients who were treated by or received referrals from CHS-affiliated doctors during past 5 years.
CHS posted a media notice on its website stating that individuals whose information was taken in this cyber-attack "will be mailed a letter informing them about the data breach and how to enroll in free identity theft protection and credit monitoring services." The Health Insurance Portability and Accountability Act (HIPAA) requires companies to notify patients of suspected breaches of health care information.
The National Institutes of Health (NIH) has announced 2 research funding opportunities aimed at developing and testing approaches to increasing physical activity in ways that might be applied broadly across the US.
"Developing Interventions for Health-Enhancing Physical Activity" will provide 2 years of support for research into interventions that increase physical activity, while "Testing Interventions for Health-Enhancing Physical Activity" will provide up to 5 years of support for research into how to test multi-level intervention programs. Applications are due October 4 and October 1, respectively.
Want to get the latest on Medicare and Medicaid Service's (CMS) final 2015 rules on acute care, inpatient rehabilitation, and skilled nursing facilities? APTA has you covered.
APTA members can now access detailed summaries of the latest set of final rules issued by CMS pertaining to payment and other issues related to physical therapist practice.
For information on acute care and inpatient rehabilitation, visit the association's Medicare Payment and Policies for Hospital Settings webpage (look for the latest summaries under "Acute Care" and "Inpatient Rehabilitation" headers); for a summary of prospective payment system rules for skilled nursing facilities (SNFs), visit the Medicare Payment and Policies for Skilled Nursing Facilities webpage (look for the "APTA Summaries" header).
The physical therapy profession's preeminent guide to practice has taken on a new format, added new information and resources, updated others, and is now ready for use. The new online-only APTA Guide to Physical Therapist Practice 3.0 offers more dynamic content while continuing to deliver the most comprehensive description of an evolving profession—and it's free to the public for a very limited time.
"It was a long process, but we did want to get it right," said Lisa Saladin, PT, PhD, who contributed to the revision of the Guide as former chair and current member of the Board Oversight Guide Work Group. In an APTA video dispatch, Saladin describes how the revisions moved from staff to volunteer subject matter experts to the work group. The end result: a "really dynamic" experience that will deliver current information, and allow users to dive more deeply into evidence-based practice resources and in-depth visual supports through direct online access to PTNow and other offerings. Users will "feel the similarities, but they're going to see the differences," Saladin said.
The newest version of the Guide is focused on the physical therapist (PT) and physical therapist assistant (PTA), and has moved away from content targeted at policy makers, administrators, third-party payers, and other professionals, who now have access to other resources. An overview of other important similarities and differences between the previous version and Guide 3.0 is included on the Guide webpage.
The APTA Guide to Physical Therapist Practice, 3.0 is available for free to the public until September 30. After that, the Guide will be free to APTA members and available to nonmembers via an annual subscription. The software supporting the Guide requires no installation, and updates will not have to be downloaded to individual users' computers.
A recent Medscape article promoting the use of in-office ancillary services (IOAS) by physicians as a way to "boost your income" has prompted a pointed response from APTA that describes how self-referral can increase health care costs and hinder patient access to the most appropriate care.
"In an era when policy makers, providers, and patients are all looking for ways to bring down health care costs, it appears that your article is advocating the opposite approach by encouraging referrals for the purpose of profit," writes APTA President Paul A. Rockar Jr, PT, DPT, MS. "Respected policy organizations, researchers, and budget analysts continue to provide evidence that show the abusive financial impact of self-referral."
APTA's comments were in response to a Medscape article titled "9 Ancillary Services That Can Boost Practice Revenue," a how-to piece that encourages physicians to consider adding in-house services including physical therapy to their practices. One health care accountant and business advisor quoted in the article advises doctors that "you could be making money on each service you've been referring out."
The article describes physical therapy as a service that could be added at an estimated cost of $25,000 "plus the cost of extra space," but could earn "about $500,000 per year." One consultant commenting on the idea of adding physical therapist services warned Medscape readers that "the high investment in equipment and staffing make for low profits," while another countered that the services could be useful "if you had a sports medicine practice or treated a lot of elderly patients."
APTA's response reiterates the association's opposition to self-referral in general and in particular to physical therapist services being included in the IOAS exception under the physician self-referral prohibition (the Stark self-referral law). The letter goes on to cite Office of Management and Budget estimates that closing these self-referral loopholes under Medicare could save the health care system $6 billion over 10 years.
"The expansive use of the IOAS exception by physicians in a manner not originally contemplated by the law undercuts the purpose of the law and substantially increases costs to the Medicare program and its beneficiaries," Rockar writes. "Physical therapy is not a same-day service. Your own article points that out when referencing the fact that physical therapy is often provided in multiple follow-up visits."
The Medscape article concludes by advising its readers that "none of these services is a slam dunk" in terms of potential profits, and that physicians considering adding any service be "ready to be challenged by specialists … who feel that others may not be qualified to provide the service."
APTA takes a different perspective on self-referral in its response. "APTA's foremost goal is to see patients continue to receive the highest-quality, most appropriate care while protecting limited Medicare resources,"
Rockar writes. "Closing the self-referral loophole will ensure that both goals are met without hurting true interdisciplinary collaboration."
In addition to physical therapy, the consultants recommended that physicians consider adding allergy therapy, urgent care, cosmetic services, medication dispensing, radiography, lab testing, weight loss services, and diabetes counseling.
A new study on concussions in high school football has found that the location of the impact on the head may not have much to do with clinical outcomes, but it could have a lot to say about the need for safer tackling.
A recently published article in Pediatrics describes efforts to examine whether the location of a concussion—front, back, side, or top of head—was linked to the number or prevalence of symptoms, symptom resolution, and return-to-play times for high school football players. Authors write that much like studies that found no links between neuropsychological function and impact location, their study of 1,975 concussion incidents "suggest[s] that impact location is likely of little use in predicting clinical outcomes."
Researchers used data from the National High School Sports-Related Injury Surveillance System, High School Reporting Information Online (RIO), a system based on reports from high school athletic trainers over 5 seasons, from 2008 to 2013. The reports include data on impact location, symptomology, and symptom resolution.
The only factor that did seem to be influenced by the location of the concussion was related to loss of consciousness, which was experienced at twice the rate (8.8%) of concussed players sustaining top-of-the-head impacts compared with all other areas (3.5%).
The findings underscore the need to emphasize "heads up" tackling, authors write, given that 70.7% of all concussions caused by player-to-player collisions were the result of head-to-head contact. "Concussions from top-of-the-head impacts, and the resulting risks associated with such impacts, may be reduced by enforcing rules prohibiting players from leading with their head," authors write. "Players must never initiate contact with the helmet or make contact while head-down."
Among other findings in the study:
Concussion prevention and management—particularly in youth sports—has been a particular focus of APTA over recent years, and APTA continues to educate policymakers on how physical therapists are qualified to detect and manage concussions. For information on federal and state legislation, and APTA's position on the role of physical therapists in concussion management, visit APTA's Concussions webpage. Find more resources on the Traumatic Brain Injury webpage, and direct patients to the Physical Therapist's Guide to Concussion, located on APTA's MoveForwardPT.com consumer website.
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