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  • From PTJ: Electrodiagnostic Testing Sheds Light on 'Bioscaffolding' Procedure for VML

    Researchers believe electrodiagnostic testing may be a useful way to predict just what kind of improvement to expect from an experimental approach that uses material from pig bladders and intestines to grow new muscle in patients with severe muscle loss.

    According to an April 2016 article in Physical Therapy (PTJ), APTA's science journal, presurgical electrodiagnostic testing may help predict increase in muscle strength after a process known as extracellular matrix (ECM) implantation, a procedure that uses pig tissue cells to act as "scaffolding" that draws a patient's own stem cells to the site of volumetric muscle loss (VML). The procedure has been successful in regrowing tissue in preclinical testing, but research has been lacking on patient functional outcomes.

    In the longitudinal case series, authors wanted to find out how the surgery would change preoperative and postoperative electromyography (EMG) and nerve conduction study (NCS) results, as well as whether these tools could identify the best candidates for ECM implantation. They hypothesized that both electrophysiologic activity and muscle strength would improve.

    Researchers implanted 8 patients with severe muscle loss due to trauma. Three of the patients had VML in the anterior tibial compartment, 4 in the quadriceps compartment, and 1 in the biceps brachii. The average percentage of muscle loss was 66.1%.

    All participants completed a preoperative physical therapy program until they reached what authors describe as "a plateau in strength and function." One day prior to surgery, researchers performed needle EMG and NCS testing, and a physical therapist (PT) measured muscle strength using a handheld dynamometer. EMG testing measured muscle recruitment and abnormal spontaneous activity; the latter can indicate instability of muscle fibers.

    Within 48 hours after surgery, each patient began a 6-month physical therapy regimen, after which the same testing was performed. Four had significant improvement in strength (20% or more), 2 had minor improvement, and 2 experienced no increase in strength.

    Authors concluded that electrodiagnostic testing could be beneficial in predicting suboptimal outcomes. Five of the participants had improvements in either NCS or EMG results while also showing clinical improvements in muscle strength. Two participants showed no EMG activity or strength at baseline; they had no improvement in strength.

    "These findings suggest that muscles judged to have no electrical activity at baseline are unlikely to display improved strength following ECM implantation," authors note.

    The researchers attribute the wide variability in response to ECM implantation in part to degree and type of initial injury causing the muscle loss. For example, 1 participant showed increased compound muscle action potential (CMAP) amplitude of 80% but no increase in strength. Another had a 33.3% improvement in strength but no electrophysiologic improvement. Two others showed a "dramatic increase" in strength but decreased CMAP amplitude.

    Authors suggest the possibility "that the increased strength was a result of a restoration of mechanical integrity, rather than electrical conductance, of the muscle." However, the improvement in CMAP amplitude in 4 of the participants "is encouraging," they write, because it indicates an increased number of muscle fibers after implantation. These findings, the researchers contend, could not only inform surgical decisions in the future but also help PTs in designing regenerative rehabilitation protocols.

    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.

    'Red Book' Author, Direct Access Advocate Marilyn Anderson Dies

    Marilyn Anderson, PT, former member of the APTA Board of Directors, strong advocate for direct access to physical therapist services, and coauthor of the association's first-ever extensive analysis of physical therapist practice, died on April 22. She was 89.

    Anderson spent much of her career in the Army physical therapy program, where she served as director of the 6H-35B program, retiring as a Colonel. She has been described as a "driving force" behind the Army's decision to enact direct access to physical therapists, and she pressed for similar changes in civilian health care. An article about the US Army Program Alumni Association describes her as a devoted instructor whose "indomitable spirit was infectious."

    At APTA, Anderson served a term on the Board of Directors from 1974 to 1977. Among her most noted achievements for the profession was coauthorship of Competencies in Physical Therapy: An Analysis of Practice in 1979. Often referred to as "the red book," Competencies was the association's first attempt to capture the full spectrum of current physical therapist practice, and helped lay the groundwork for the first edition of APTA's Guide to Physical Therapist Practice.

    After retirement from the Army, Anderson spent many years on Orcas Island, in Washington state, where she became an active supporter of the local school system and its elementary music program. In 2012, the Orcas Island Elementary School renamed its music room in honor of Anderson, who led an effort to raise $100,000 for its rehabilitation.

    Bill to End Physician Self-Referral Reintroduced in the House

    Welcome back: APTA and a coalition of medical groups are applauding the reintroduction of a bill in the House of Representatives that would close up Medicare self-referral loopholes. Those loopholes allow physicians to refer patients for certain services—including physical therapy—to a business that has a financial relationship with the referring provider.

    Titled the Promoting Integrity in Medicare Act (PIMA), the bill seeks to eliminate exceptions to the federal law originally intended to prohibit self-referral. That law, known as the Stark law, does prohibit most self-referral practices, but it also contains language that allows physicians to self-refer for several "common sense" or same-day treatments. Unfortunately those exceptions also include services that are rarely provided on the same day—physical therapy, anatomic pathology, advanced imaging, and radiation therapy.

    PIMA would eliminate those loopholes not only as a way to ensure that the exceptions are used according to their original intent, but to reduce overutilization and overall health care costs. According to the latest estimates from the Congressional Budget Office, enacting the changes contained in PIMA would save Medicare an estimated $3.3 billion over 10 years, mostly due to what research points to as overuse of referrals among providers who can direct patients to services with a financial connection. The bill is sponsored by Rep Jackie Speier (D-CA14), who introduced a similar bill in 2014.

    "How many [Government Accountability Office] studies outlining the abuse and billions of dollars of Medicare reimbursement to doctors for unnecessary services that are driven purely for personal profit does it take to shut this activity down?" said Speier in a statement on the bill. "This is a golden opportunity to put patient health and program health over profits. We should always work to improve the quality and cost-effectiveness of government programs—this bill will save taxpayers money and help seniors who depend on Medicare for their quality of life."

    APTA is a strong supporter of the legislation, and is a member of the Alliance for Integrity in Medicare (AIM), a coalition of professional groups opposed to their services' inclusion in the Stark exceptions. AIM isn't alone in the fight: in 2014, the American Association of Retired Persons (AARP) issued a statement in support of PIMA.

    "The exceptions in the Stark law were intended to allow a limited number of common services such as lab tests and x-rays to be performed during office visits," said Michael Hurlbut, APTA senior congressional affairs specialist. "PIMA doesn't change that, but it does remove physical therapy from a list of exceptions that it should never been a part of in the first place."

    "Reforming the … exception through the passage of [PIMA] will ensure Medicare recipients receive the highest quality and safest health care appropriate to their needs," AIM says in a statement on the bill, adding that the estimated savings "is in the best interests of beneficiaries, providers, and our nation's health care system overall."

    Find out more about this issue on APTA's self-referral webpage, and take action now by asking your legislators to close the self-referral loophole. Contact the APTA advocacy staff for more information.

    APTA-Supported Youth Sports Opioid Education Bill Moves Ahead

    A bill supported by APTA that recently passed US House of Representatives Energy and Commerce Committee could help to bring needed education on the dangers of opioids—and the benefits of alternative, nonopioid approaches to pain treatment, such as physical therapy—to youth sports.

    On April 27, the committee reviewed the John Thomas Decker Act (H.R. 4969), proposed legislation that would direct the Centers for Disease Control and Prevention (CDC) to develop and provide educational materials specifically targeted at teenagers who have been injured playing youth sports. The bill is sponsored by Republican Reps Patrick Meehan (PA-7) and Thomas Rooney (FL-17), and Democrats Ron Kind (WI-3) and Marc Veasey (TX-33).

    "APTA believes it is crucial to provide teenagers and adolescents injured in sports with appropriate educational materials related to the costly and addictive nature of opioids and to safe and effective treatment alternatives, such as physical therapy," stated APTA President Sharon L. Dunn, PT, PhD, OCS, in an APTA letter in support of the bill. "The John Thomas Decker Act will play a critical role in helping to curb this epidemic [of opioid abuse and heroin use] by ensuring adequate knowledge for our nation's youth."

    The CDC is well-positioned to provide education that supports alternatives to opioids for pain, having issued a set of high-profile prescription guidelines that cite nonopioid approaches, including physical therapy, as the recommended first-line treatment.

    The bill was forwarded to the House for a full vote.

    Consumer Reports Includes Physical Therapy in Pain Relief Feature

    The national dialogue on pain treatment has now been highlighted by Consumer Reports in an article that promotes physical therapy as an effective alternative to opioids and other painkillers.

    The cover story of the June 2016 issue of Consumer Reports magazine, "Pain Relief Now!" takes readers through the basics of pain treatment and the epidemic of painkiller overuse, and provides guidance on different approaches to pain relief, as well as tips on what to do to respond to different kinds of pain.

    Although just 1 of several professional and medication approaches mentioned in the article, physical therapy is well-represented. The article begins with the story of a woman who experienced a sudden onset of back pain that was relieved through physical therapy, and includes a brief description of physical therapy's history and proven effectiveness.

    In an accompanying "Soothing Strategies" article, Consumer Reports suggests physical therapy for low back, neck and shoulder pain, writing that in cases of neck and shoulder pain, "studies show that relief can happen in as few as 1 to 3 sessions [of physical therapy]."

    Dutch Study Finds Positive Long-Term Outcomes for Multidisciplinary Treatment of Chronic Pain

    Authors of a new observational study from the Netherlands say that taking a multidisciplinary approach to chronic musculoskeletal pain (CMP) can not only result in short-term improvements, but seems to be beneficial even 2 years after a rehabilitation program has ended—particularly in terms of reducing health care provider usage and increasing patient working hours.

    For the study, published online in Musculoskeletal Care (abstract only available for free), researchers followed a group of 165 patients with CMP who participated in a 15-week multidisciplinary rehabilitation program that involved cognitive behavioral therapy (CBT), education, individual and group exercise, relaxation, and hydrotherapy. The program was provided by a team that included a rehab physician, an occupational therapist, a physical therapist, a social worker, and a psychologist.

    According to authors, an earlier study of the program had already established positive outcomes for pain and function at discharge; their study was focused on assessments of pain, function, fatigue, and other factors 12 and 24 months postdischarge. Participants were 87% female, with an average age of 44.1. The most-cited location of CMP was the back (71%), followed by shoulders (60%), neck (52%), and upper legs/knees (48%).

    Here's what researchers found:

    Mean ratings for pain were lowest at discharge; increased at 3 and 12 months, and then dropped slightly by 24 months but still showed moderate differences from baseline ratings. Ratings for fatigue followed the same pattern.
    At baseline, the mean participant rating for "pain in the previous week" was 6.6 on a 10-point scale. That number dropped to 5.2 at discharge and averaged 5.3 at 24 months. Ratings for the level of pain experienced on the worst days in the previous week averaged 8.2 at baseline, dropping to 7.1 at discharge and to 6.8 after 24 months. A 10-point fatigue scale (10 being "completely exhausted" over the previous 7 days) showed an average rating of 7.3 at baseline, 5.8 at discharge, and 6.3 at 24 months.

    Quality-of-life ratings rose at discharge, and by 24 months hadn't dropped off dramatically.
    Average scores on the Rand 36-Item Health Survey, which uses a 0-100 rating scale, showed the same general pattern of improvement that seemed to be maintained, for the most part, at 24 months. Increased average scores were recorded for Mental health (from 61 at baseline to 70 at 24 months postdischarge), physical functioning (from 46 at baseline to 53 at 24 months postdischarge), vitality (from 36 at baseline to 46 at 24 months postdischarge), and role-physical functioning (from 15 at baseline to 31 at 24 months postdischarge).

    Health care usage decreased, and hours worked increased.
    The number of health care providers participants reported seeing in the past year dropped from an average of 4 at baseline (range 1-13) to 2 at 24 months (range 0-9). The percentage of patients who reported working from 1 to 24 hours a week dropped from 62% to 53%, and the percentage of patients who reported working 25 or more hours a week increased, from 16% to 48%. The percentage of patients who reported no hours of work dropped to 0 at 24 months.

    One thing didn't change much: use of pain medications.
    The percentage of patients who reported using pain medication on at least a weekly basis was 75% at baseline and 69% at 24 months, a reduction that authors describe as not significantly different from rates at baseline.

    "The positive effect on pain in the present study was observed with the interventions [that targeted] the regain of activities and participation rather than on pain reduction," authors write. "The favorable effect on work status, as well as the significant reduction in health care usage seen in the present study suggests that the intervention may be cost-effective from the societal as well as health care perspective."

    The researchers acknowledge limitations to the study, including the lack of control group and the fact that the underlying causes of the CMP were not recorded—data that would have made it theoretically possible to make connections between specific conditions and the effectiveness of the multidisciplinary program.

    Still, authors write, the results show "promising" results for multidisciplinary approaches to treatment of CMP.

    "Multidisciplinary treatment is effective … especially taking into account that most of these patients were seeing many health professionals and were partly or totally out of work," authors write. "Furthermore, even 2 years later, the benefits were still present, with a sustained effect on health care usage and employment."

    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.

    Get more on the possibilities for physical therapy in the treatment of pain at the upcoming NEXT Conference and Exposition, June 8-11 in Nashville. Sessions related to pain include "The Physical Therapist as a Primary Care Provider for Patients With Low Back Pain," "A Sequential Cognitive and Physical Treatment Approach for Patients with Patellofemoral Pain Syndrome," "Pain Care Innovation in Rehabilitation," and "The Language of Pain: Define It, Speak It, Integrate It." Advance registration ends May 4.

    In the News: Tech-Driven Approaches Improve TKA, THA Surgery and Recovery

    Rehabilitation from total knee arthroplasty (TKA) or total hip arthroplasty (THA) may be a constant, but the time needed for rehab could be shortened, thanks to new ways of performing TKA, THA, and joint restoration surgeries.

    In an April 21 article in the Miami Herald, reporter Caitlin Granfield writes about approaches to surgery that rely on technologies such as robotics and 3-D modeling to help create procedures that, among other recovery-enhancing qualities, minimize impact on surrounding muscles. Techniques include what Granfield describes as "quadriceps-sparing knee replacement, where surgeons lift the muscle and the knee-replacement surgery is performed from the side, with the incision much shorter than traditional knee replacement surgeries."

    "Over time, we've realized that certain muscles and tissues can simply be moved out of the way and don’t need to be detached," one orthopedic surgeon says in the article.

    In addition to the "quadriceps sparing" approach, the article describes other ways orthopedic surgery is focusing on techniques that improve recovery and function, including hip preservation surgery, and the use of a 3-D model of a patient's leg that is uploaded to a computer that in turn directs a robotic arm to make precise cuts and accurately position the joint implant. Granfield also touches on custom-made implants and an even newer approach that uses "cooled radiofrequency energy" to provide pain relief for patients for whom surgery isn't an option.

    Attention to new approaches could well increase, now that the Centers for Medicare and Medicaid Services (CMS) has launched its Comprehensive Care for Joint Replacement (CJR) bundled care program in 67 metropolitan areas. That program requires hospitals performing TKA and THA to participate in payment systems based on an entire episode of care, from admission to 90 days postdischarge, rather than billing on a fee-for-service basis. The CJR system has ramifications for physical therapists (PTs) and physical therapist assistants (PTAs), and APTA has created a CJR resource page to help members stay informed on the program.

    New Wisconsin Law Allows PTs to Order X-Rays

    Physical therapists (PTs) in Wisconsin now have a big addition to their licensing law: the ability to order x-rays. The change, signed into law by Gov Scott Walker on April 25, marks the first time any state has specifically authorized PTs to make the decision.

    Under the new law, to be able to order x-ray imaging, the PT must hold a clinical doctorate degree or a specialist certification, or have completed a board-approved residency or fellowship, or a formal X-ray ordering training "with demonstrated physician involvement."

    The law also requires the PT to communicate the x-ray order to the patient's primary care physician "or an appropriate health care practitioner" to ensure coordination of care. That communication is not required if the patient doesn't have a primary care physician or was not referred to the PT by another practitioner, or if the radiologist doesn't identify a significant finding.

    According to Angela Shuman, APTA's director of state government affairs, the Wisconsin law is historic because it's the first time a state PT licensing law has specifically listed ordering x-rays as within a PT's scope of practice.

    "No other state PT practice acts specifically say that PTs can order x-rays—the laws are mostly silent on the matter," Shuman said. "This lack of specific language can make it difficult for PTs to understand just what they can or can't do, but Wisconsin has taken the step to make things very clear." The state has also changed the licensing law for the individuals who perform radiologic procedures such as x-rays, specifying that they can now accept orders from licensed PTs, she explained.

    APTA, the Wisconsin Physical Therapy Association, and supporters worked for more than 2 years to advocate for the new law.

    The bill was sponsored by Rep Joe Sanfelippo in the Wisconsin State Assembly, with a companion bill in the state senate sponsored by Sen Van Wanggaard. The bill becomes effective the day after it is electronically published by the state's Legislative Reference Bureau.

    Legendary Physical Therapy Leader Charles Magistro Dies

    Charles M. Magistro, PT, DPT (hon), DrSci (hon), FAPTA, a passionate physical therapy leader whose contributions spanned education, research, policy, and community involvement died on April 21 at age 91.

    Magistro's pioneering legacy has shaped not just APTA, but the entire physical therapy profession in ways that directly affect every physical therapist, physical therapist assistant, and student of physical therapy. In a statement on behalf of APTA, President Sharon L. Dunn, PT, PhD, OCS, described Magistro as "a truly historic figure" whose "soul is woven into who we are as a profession."

    Magistro served as president of APTA 1973-1976, after completing a term as treasurer of the association. During his term as president Magistro oversaw the first formal, professionally managed Combined Sections Meeting, and led the launch of Chapters (later renamed Component Bulletin), the association's vehicle for communication with its components. Magistro was awarded the Lucy Blair Service Award and the Henry O. Kendall and Florence P. Kendall Award, and was named a Catherine Worthingham Fellow in 1990. He delivered the 22nd Mary McMillan lecture in 1987.

    An early proponent of evidence-based practice, Magistro also played a key role in the establishment of the Foundation for Physical Therapy, where he served as its first chair. The Magistro family remained involved with the Foundation throughout his life through, among other contributions, the Magistro Family Foundation Research Grant program.

    Magistro was an impassioned advocate for the continued professionalization of physical therapy, and helped to guide the shift of physical therapy education accrediting from American Medical Association control to oversight by APTA. At the time, Magistro was quoted as saying "If you cannot control your own education, how can you possibly control your destiny?"

    Community involvement was also extremely important to Magistro, whose family foundation remains involved with the Pomona Valley Hospital (California) Medical Center, where he served as director of physical therapy. In 2015, the medical center renamed its rehabilitation center the Charles M. Magistro Physical Therapy & Rehabilitation Center in honor of his work to promote physical therapy and his dedication to his patients.

    "Every physical therapist and physical therapist assistant practicing today is part of a profession that was shaped by [Magistro's] vision, his heart, and his unwavering commitment to always doing the very best for his patients and his community," Dunn said. "The physical therapy profession has lost a legend."

    APTA has created a memorial page that includes an area for comments on his passing and contributions to the physical therapy profession.

    Donations made in memory of Charles Magistro will be directed to the Foundation for Physical Therapy's Charles M. Magistro Endowment Fund. A card will be sent to the Magistro family informing them of any contribution.

    SNF and IRF Proposed Rules Continue CMS Push Toward Quality Reporting, Value-Based Payment

    Continued emphases on quality reporting and new payment models are at the center of the Centers for Medicare and Medicaid Services’ (CMS) proposed 2017 rules for skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs), along with an $800 million increase in payments to SNFs, and a $125 million increase for IRFs.

    CMS is proposing an overall payment increase of 2.1%, or an estimated $800 million, but the rule also includes notice that CMS is continuing its push for quality-reporting measures required by the Improving Post Acute Care Transformation (IMPACT) Act. The 2017 proposed rule adds to the list of quality measures that will be required of SNFs beginning in 2018 to include data on discharge to community, Medicare spending per beneficiary, and potentially preventable 30-day readmissions. The proposal also stipulates that by 2020, SNFs will be required to supply reports on drug regimen reviews with follow-up.

    The rule also provides a few more details on how CMS intends to create a value-based purchasing program (VBP) for SNFs as it continues to research different models. According to a fact sheet from CMS, the agency will seek public comment on performance standards, performance periods, scoring methodology, and the development of confidential feedback reports. APTA will advocate for a physical therapy representative to serve on the technical expert panel that will review input.

    Next year's payment increase for IRFs is proposed to drop slightly from this year's overall 1.6% increase, down to 1.45% overall (estimated $125 million), though the final amount may be updated "if more data becomes available," according to a CMS fact sheet.

    Like the SNF proposed rule, the IRF proposal also establishes more quality-reporting requirements around many of the same areas that will be required of SNFs (discharge, spending, readmissions, drug regimen review, etc). Additionally, the IRF rule would add 4 new measures to the facilities' public reporting requirements, including reports to a publicly accessible CMS website, such as Hospital Compare.

    APTA will submit comments on both proposed rules by the June 20 deadline. In addition, the association will develop fact sheets on the rules to help members understand what's being proposed.