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  • PTJ: Research on Computer Gaming's Effectiveness in Physical Therapy Needs to Level Up

    Playing active computer games (ACGs) may increase older adults’ physical activity, but authors of a recent article published in Physical Therapy (PTJ) say that current data provide "little confidence" that such activity improves physical health or cognition. And it’s not yet clear whether it is safe for older adults to play ACGs unsupervised.

    Active computer gaming such as Nintendo Wii or Microsoft’s Xbox is being used in rehabilitation based in part on an assumption that sounds reasonable enough: because the games are fun and motivating, adherence to physical therapist interventions will improve, which will in turn have an impact on health outcomes such as falls. Authors of the PTJ review wanted to know if that assumption was supported by data.

    Authors analyzed 35 randomized controlled trials with 1,838 total participants to determine whether ACG improved balance, functional exercise capacity, functional mobility, fear of falling, and cognition. They also examined participant adherence to interventions and factors such as dose, frequency, setting, and whether interventions were supervised.

    What they found: playing ACGs had a "significant moderate effect" on cognition and balance, and on functional exercise capacity when participants played more than 120 minutes per week. But ACG had no effect on functional mobility or fear of falling. Researchers interpret the findings with caution, as all of the studies were low or very low quality.

    The fact that ACG had a moderate effect "on one outcome associated with falls risk yet no effect on another…highlights the importance of tailoring ACG interventions to older adults’ specific needs for daily function," authors write. The ACG interventions employed a variety of mechanisms to improve function, they explain, and facing forward while standing in one spot may have helped participants improve balance but not functional mobility.

    Authors also raise safety as an issue for ACGs, which they say hold "promise for self-led exercise interventions for even the most frail." But determining which ACGs are safe to use unsupervised was impossible to determine, as only 3 studies used unsupervised interventions. Further, only 9 studies included individuals with balance impairments—making them less likely to be unable to engage in traditional exercise. This makes it difficult to evaluate effects of ACG for this population, authors say.

    "Findings of this review suggest that ACG may provide positive physical and cognitive health benefits greater than those observed following no treatment, traditional exercise, or rehabilitation interventions for balance, functional exercise capacity, and cognitive function," authors conclude, but higher-quality, "robust" randomized controlled trials are needed "in order to state with confidence" that ACG is effective.

    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.

    Government Affairs and Public Service Awards Nominations Due January 12, 2018

    Do you know of an APTA member who in 2017 has gone above and beyond to advocate on behalf of the physical therapy profession at the federal level? Is there a member of Congress, staffer, or public figure who has championed physical therapy causes this year? Nominate them for APTA’s Federal Government Affairs Leadership Award or the Public Service Award.

    The Federal Government Affairs Leadership Award is presented annually to an active APTA member who has made significant contributions to the association’s federal government affairs efforts and shown exemplary leadership in furthering the association's objectives in the federal arena.

    The Public Service Award is presented annually to an individual who has demonstrated distinctive support for the physical therapy profession at a national level. Individuals from the following categories are eligible for nomination: members of Congress, congressional staff, federal agency officials, health and legislative association staff, and celebrities or other public figures.

    Recipients will be selected in February by the APTA Board of Directors, and the awards will be presented during APTA's Federal Advocacy Forum set for April 29–May 1 in Washington, DC. Winners' expenses to attend the award event will be paid by APTA.

    Nominations must be submitted by Friday, January 12, to Jennica Sims at jennicasims@apta.org.

    The Good Stuff: Members and the Profession in Local News, December 2017

    "The Good Stuff," is an occasional series that highlights recent, mostly local media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    Is squatting the new standing? Jasmine Marcus, PT, points out some of the advantages. (mother nature network)

    Rachel Tavel, PT, DPT, writes for Huffington Post on the importance of seeing a pelvic health PT. (Huffington Post)

    A concussion forced Sarah Urke, SPT, to set aside her hopes of being an Olympic athlete; now she's preparing for a career as a physical therapist. (USC News)

    Rebecca Kilgore, PT, combines her knowledge of physical therapy with her training as a behavioral therapist to serve children with disabilities. (Jacksonville, Florida, Welcome to Sacksonville)

    Michaela Main, PT, DPT, is a cheerleader for the New England Patriots. (Boston University Today)

    Casie Danenhauer, PT, DPT, explains vaginismus and physical therapy's role in treatment. (Self magazine)

    Tracy Smith, PT, discusses the importance of prehab. (Palm Beach, Florida, Post)

    HIIT is hot. But is high-intensity interval training also dangerous? Aaron Hackett, PT, DPT, explains how to minimize the risks. (Shape)

    Fortino Gonzalez, PT, provides tips on training for a marathon. (McAllen, Texas, Monitor)

    “I owe my ability to walk to the physical therapy team I had. I saw them five or six days a week for six months. They had a lot of patience and pushed me a lot,” -Lee Springer, stroke survivor who has returned to competitive running. (Fremont, Ohio, News-Messenger)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    Analysis: The 'Big 5' Insurers Are Increasingly Dependent on Medicare and Medicaid for Revenue

    The degree to which the "big 5" private health insurers have come to rely on Medicare and Medicaid for their revenues may surprise you—but that reliance may be the key to increasing their involvement in the Affordable Care Act's individual marketplaces, according to authors of a new analysis in Health Affairs.

    The analysis looked at annual corporate filings with the Securities and Exchange Commission between 2010 and 2016 for the nation's 5 largest insurers—UnitedHealthcare, Anthem, Aetna, Cigna, and Humana—to analyze how revenue streams have shifted, and whether the ACA's marketplaces have had an impact on that shift. Combined, the insurers cover 43% of the total US insured population, or about 125 million people.

    Authors of the study focused on where revenues were coming from: the private group market (including administrative services-only arrangements); the individual market; and federal programs including Medicare Advantage, Medigap supplemental plans, Part D drug plans, and claims payment and network management in Medicaid programs. Here's what the study found:

    Growth was significant—especially in Medicare and Medicaid.
    Overall, membership in the companies' offerings grew by 23% from 2010 to 2016—twice the increase from 2005 to 2010. Between 2010 and 2016, the number of Medicare and Medicaid-related members nearly doubled, from 12.8 million to 25.5 million.

    The revenue landscape has shifted.
    In 2010, total revenue for the 5 insurers was $209 billion, with 44% of those revenues from government-related offerings. By 2016, revenues had increased to $360 billion, with 60% coming from Medicare and Medicaid.

    The individual market—including ACA marketplaces—account for a fraction of membership.
    Between 2010 and 2016, the number of members in individual plans experienced a 72% increase, from 2.3 million people to 3.8 million. But those numbers represent a small segment of the big 5's overall membership numbers—just 2% of the overall members in 2010, and 3% in 2016.

    Medicare and Medicaid programs seem to yield better benefit ratios for the companies.
    Among the 3 companies that reported on medical benefit ratios—the average revenue retained by the company per member given claims that are made—the government-related programs were more lucrative. The companies reported that they retained between 13% and 19% of Medicare and Medicaid premiums for administrative expenses, overhead, and profits, or about $1,500 to $2,000 per year, per member. The rate for commercially insured members was $624 to $912 per year per member. Overhead expenses were higher for Medicare Advantage operations than for the commercially insured, however.

    "In effect, these national insurers have become significant agents of publicly sponsored programs, acting on behalf of the federal government and states to purchase and arrange medical care on behalf of beneficiaries," authors write. Whether that's a good or bad thing by itself they don't say, but what they do believe is that there's a flipside to the situation: a private insurance industry so deeply dependent on public programs for revenue may offer an opportunity to shore up the ACA marketplaces.

    According to the authors, that opportunity is "tying," which would require any large insurance carrier wishing to do business with Medicare or state Medicaid programs to sponsor individual-market plans in those areas as well. "Requiring insurers that participate in Medicare Advantage in a given area to also serve the area's Marketplaces would strengthen state-level efforts to grapple with market stability and enhance the viability of the insurance Marketplaces," they write.

    Authors note that the idea comes with a certain amount of risk. After all, the companies' participation in Medicare and Medicaid is voluntary in the first place, and it's entirely possible that some insurers would back out of government-related programs altogether. Given that the insurance marketplace is increasingly consolidated, such a move by a dominant insurance company could have significant effects. "Without viable alternative insurance choices or a publicly sponsored insurance program, such as traditional Medicare, the threat of exiting could hold public programs hostage to increasing plan payments to retain insurer participation," authors write.

    The analysis was supported by a grant from the Commonwealth Fund.

    APTA offers a wide range of resources for members who want to learn more about the workings of private insurance at the association's Private Insurance webpage

    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.

    President Signs Law Allowing PTAs in TRICARE; Implementation May Not Be Immediate

    Physical therapist assistants (PTAs) are on their way to officially joining the TRICARE payment program used throughout the Department of Defense (DoD) health care system. President Donald Trump's signature on the National Defense Authorization Act enacts a change long advocated by APTA, but what happens next isn't entirely clear.

    One thing that's certain: the change won't take effect immediately. APTA Senior Congressional Affairs Specialist Michael Hurlbut says PTAs should keep themselves updated on the progress of implementation.

    "This is a huge step forward for PTAs, but the law itself simply directs DoD to make the change—it will take some time for actual regulations to be created and put in place," Hurlbut said. "APTA staff are monitoring progress, and will keep members informed of the timeline for the changeover to the expanded TRICARE system."

    The first glimmers of a possible change in TRICARE came in June 2017, when a US House of Representatives committee requested that the Secretary of Defense come up with a plan for bringing PTAs, occupational therapy assistants, and other support personnel into the TRICARE system. From there, action on the idea moved relatively rapidly from the House to a Senate committee, and then on to a vote in the full Senate in November.

    "We're very pleased that this APTA-backed change has been achieved," Hurlbut said. "This addition will make a difference for patients in TRICARE who deserve access to the valuable services provided by PTAs."

    APTA Board Recommends Further Exploration of Education Reform Through Education Leadership Partnership

    Mandatory residency that integrates specialty certification? Staged licensure? Someday, physical therapist (PT) education could include any or all of those things, as education inevitably evolves to meet the needs of society, the profession, and the health care system.

    But APTA will not be pursuing any of those paradigm-changing options right now.

    That much is clear after APTA’s Board of Directors (Board) adopted multiple motions related to the pursuit of best practice in clinical education at their November meeting. The motions were the result of recommendations from a task force appointed to respond to a 2014 charge from APTA’s House of Delegates (House) to investigate the future of physical therapist education (RC 12-14 and RC 13-14).

    The Board’s actions in November, which included amendments to the task force’s original recommendations, were the byproduct of months of extensive stakeholder engagement opportunities designed to generate feedback, including multiple in-person and virtual town halls, an online survey, and a collection of resources at APTA.org about the task force recommendations.

    “What we heard loud and clear from our stakeholder engagement is that the profession isn’t convinced that a highly integrated system of staged licensure and clinical-and-residency education, as originally recommended by the task force, is in the profession’s and ultimately our patients’ best interest right now, and we responded to that feedback,” said APTA President Sharon Dunn, PT, PhD, board-certified orthopaedic clinical specialist.

    “The task force recognized that some of their recommendations would mean massive changes that would take many years to implement, and it was always a priority to ensure that student debt wouldn’t increase as a result," Dunn explained. "Even so, there are too many unknowns in need of further investigation, and too many factors beyond APTA’s direct control, to commit right now to that kind of massive reform. But these conversations on advancing practice and education must continue in order to continue to meet our professional obligations to society.”

    So what happens now?

    Several things, but most simply and most significantly: the Board recommended that the Education Leadership Partnership (ELP) continue to explore the issues and concepts that were proposed as part of this multiyear exploration of PT education.

    The ELP comprises representatives from APTA, the Education Section of APTA, and the American Council of Academic Physical Therapy (ACAPT). It was formed in 2016 to help reduce unwarranted variation in practice by focusing on best practices in education.

    The Board recognized that the ELP is best positioned to pursue concepts identified by the task force, including:

    • Inclusion of clinical education inquiry into the profession’s data management plan and prioritized education research agenda
    • Development of a framework for formal partnerships between academic programs and clinical sites to include defined accountabilities for all parties
    • Development of a structured PT clinical education curriculum that could include elements such as universal definitions for entry-level competencies, the enhancement of the residency and certification process to better complement the standard clinical education experience, and the development of standardized measurement tools to evaluate student competencies at all phases of education
    • Creation of a long-term strategic plan for professional and postprofessional education informed by engagement with relevant stakeholders

    The Board does not have authority over the ELP and thus cannot formally charge the ELP to take specific actions. But by adopting motions to forward various recommendations to the ELP, the Board is demonstrating its trust in that partnership.

    “This whole process is a wonderful illustration of APTA’s ability to bring stakeholders together to examine our present and imagine our future,” Dunn said. “From the original member-generated motions in the House to the outstanding engagement around the task force recommendations, thousands of APTA members and nonmembers provided input that will inform the ELP’s ongoing efforts to achieve best practice in physical therapist education.”

    Move Forward Radio: Former NBA All-Star Grant Hill Discusses Pain Management and Alternatives to Opioids

    As a 19-year player in the National Basketball Association (NBA), Grant Hill was no stranger to injury, both major and minor. Experiencing "aches and pains, bumps and bruises is kind of par for the course," he says.

    Now available from APTA's Move Forward Radio: a conversation with Hill, who describes his experience with injury, managing pain, and what he would do differently today. "We all have pain in some fashion. The most important thing is to educate yourself…about pain—how do you handle postsurgery? What are your rights as a patient?" With regard to opioids, he explains, "You have options."

    The 7-time all-star retired in 2013 after numerous ankle injuries and surgeries—and painful recoveries—over the course of his career. Hill is a strong proponent of nonopioid alternatives to pain management and is a spokesperson for Plan Against Pain, a national campaign that educates the public on the availability of nondrug approaches to pain treatment postsurgery. As a player, he was prescribed opioids after surgery and for very painful injuries but says, "I didn’t like the way I felt." Hill tried to find alternative ways to treat his pain, including physical therapy. "Physical therapy has been an integral part of my career and my longevity" as a player, he says.

    He tells listeners: "Listen to your body. This is your body. This is your health. You don’t have to rely on opioids to deal with pain."

    Like Hill, APTA is raising public awareness about the risks of opioids and the benefits of physical therapy via its #ChoosePT campaign, which includes TV and radio public service announcements, national advertising, and free resources at MoveForwardPT.com/ChoosePT.

    Move Forward Radio is archived at MoveForwardPT.com, APTA's official consumer information website, and can be streamed online or downloaded as a podcast via iTunes.

    Other recent Move Forward Radio episodes include:

    Recovery From Debilitating Abdominal Pain Inspires a New Career Path
    Michelle Griffith had severe abdominal pain that was undiagnosed—until she saw a PT, who discovered her nerve damage and guided her recovery. Now she is an aspiring PT student.

    Pain Does Not Discriminate, Even in Hollywood
    Karen Joubert, PT, DPT, shares some insights into the needs of her famous clients, how they benefit from physical therapy, and her universal, back-to-basics approach in treating all of her clients.

    Neonatal Abstinence Syndrome
    Bertie Gatlin, PT, DSc, Divya Rana, MD, and Kalyani Garde, OTR, discuss signs and symptoms, treatment in the hospital, and aftercare for infants born with neonatal abstinence syndrome (NAS), which occurs when an infant who was exposed to opiates through his or her mother experiences withdrawal after birth.

    Diastasis Recti Abdominis: The Likely Cause of "Mummy Tummy"
    Carrie Pagliano, PT, DPT, discusses diastasis recti abdominis during or after pregnancy, including misconceptions about the condition and her perspective on how women can work with PTs to correct the condition.

    Amplified Pain Syndromes: Treating a Pediatric Population
    Brandi Dorton, PT, DPT, and Misty Wilson, OTR/L, discuss the variety of tools and interventions they use to effectively treat individuals with increased sensitivity to pain, and help them improve and reclaim their lives.

    APTA members are encouraged to alert their patients to the radio series and other MoveForwardPT.com resources to help educate the public about the benefits of treatment by a physical therapist. Ideas for future episodes and other feedback can be emailed to consumer@apta.org.

    APTA Fellowship Opportunities Focus on Education Research

    APTA has opened its search to fill a fellowship position that will help to define the body of knowledge that drives physical therapist education.

    The APTA Visiting Scholar Research Fellowships program is looking to fill a position for either an early-investigator research fellowship or a postdoctoral research fellowship. The early-investigator fellowship will be awarded to the most highly qualified applicant who currently holds a faculty appointment at an accredited US academic institution and is embarking on his or her sabbatical year, while the postdoctoral research fellowship is targeted at the most highly qualified postdoctoral physical therapist applicant who intends to pursue a career in education research.

    A complete description of the fellowships, including responsibilities, requirements, terms, and application instructions, can be found on the APTA website (postdoctoral fellowship here, early-investigator fellowship here). The deadline for submission of applications is January 12, 2018, with in-person and virtual interviews conducted on a rolling basis with an opportunity for in-person interviews to occur in February 2018, during the APTA Combined Sections Meeting in New Orleans. A final decision on the position will be announced in April.

    Questions about the fellowship should be directed to the APTA Research Department.

    Study: Even Small Amounts of PA Can Reduce CVD Risk Among the Elderly

    It's no secret that physical activity (PA) can decrease the risk of cardiovascular disease (CVD) in middle-aged adults, but researchers in England have found that the relationship also applies to the elderly, and that even small amounts of PA can markedly lower the chances of CVD hospitalization and death in this age group.

    Researchers used data from the EPIC study, a 10-country prospective population study, to track CVD-related hospitalizations and deaths among 24,502 participants, aged 39-79 years, and compare those with participants' self-reported PA. This isn't the first study of its kind, but authors believe it is notable because of its focus on participants 65 and older, and its 18-year median follow-up duration—a relatively long time span that allowed researchers to follow some participants into old age. Findings were published in the European Journal of Preventive Cardiology.

    Participants were divided into 3 age groups: 54 and younger, 55-65, and over 65. Individuals were then placed into a category of "inactive," "moderately inactive," "moderately active," and "active" based on self-reported levels of PA. Researchers tracked the participants for CVD-related hospitalizations and deaths that included events related to coronary heart disease (CHD) as well as stroke.

    A CVD event occurred in 5,240 of the 24,502 participants, with 4,450 events related to CHD and 1,231 events related to stroke. Among age groupings, the under-55 group experienced 874 CVD events, the 55-65 group experienced 1,650 events, and the over-65 group experienced 2,716 events.

    When researchers compared the data with reported levels of PA, they found that among the over-65 group, the chances of experiencing a CVD event were reduced by 12% for the active participants, 13% for the moderately active individuals, and 14% among the moderately inactive, compared with the inactive group. The 55-65 group showed reductions of 16% for the active, 1% for the moderately active, and 11% for the moderately inactive. In the youngest group, active, moderately active, and moderately inactive resulted in a reduction of 5%, 15%, and no reduction, respectively. The results were adjusted for socioeconomic status, age, sex, smoking status, blood pressure, diabetes, BMI, and cholesterol levels.

    "Elderly people appeared to benefit at least comparably from PA compared to middle-aged individuals regarding the risk of CVD," authors write, adding that "even those participants who were moderately inactive had a substantially lower CVD risk than those who were completely inactive." They believe the findings point to the possibility that "even modest engagement in PA may be associated with a substantially lower CVD risk in the elderly."

    The researchers believe the data support World Health Organization recommendations for at least 150 minutes of moderate-intensity PA per week, or 75 minutes of vigorous-intensity PA per week, but add that the nature of the self-reports used in their study widens the lens through which PA is viewed. Because the EPIC study asks about PA during leisure, work, and transportation, authors were able to obtain a more comprehensive perspective and, from that perspective, were able to see the effects of even small levels of PA.

    "These observations suggest that in order to achieve cardiovascular health benefits from PA, elderly people should be encouraged to engage in at least some PA of low level," authors write. "These findings indicate that health benefits are not restricted to those engaging in vigorous intensity PA."

     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.

    New Webpage Maps APTA's Coalition Connections

    "Better together"—the idea that more gets done when everyone's pulling in the same direction—has been a key theme within APTA for a few years now. But the association extends that idea far beyond its own members and components, and now you need look no further than a new APTA webpage for proof.

    Now available at APTA.org: a new resource that lists the coalitions, alliances, and other shared interest groups in which the association participates to help highlight important issues and bring the profession's voice to the table. The listings are grouped as "advocacy," "payment," and "practice," and include links to the coalitions themselves whenever possible.

    It's not a short list. As of the publication of the page, APTA lists no fewer than 30 groups in which it has involvement, including the Therapy Cap Coalition, the Coalition to Preserve Rehabilitation, the Disability and Research Rehabilitation Coalition, the Joint Commission, and the Academy of Nutrition and Dietetics, to name a few.

    The association's involvement in shared interest groups has played a significant role in some clear gains for patients and the physical therapy profession, including the Alliance for Integrity in Medicare Coalition's work in debunking of the "improvement standard" myth brought to light through the Jimmo v Sibelius settlement agreement, and the National Physical Activity Plan Alliance efforts to focus attention on the importance of physical activity as a way to improve public health.

    Want more information on APTA's involvement in other groups? Email advocacy@apta.org or practice@apta.org.