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  • Registry to Collect Torticollis Data Through Collaboration With Academy of Pediatric Physical Therapy

    APTA's Physical Therapy Outcomes Registry (Registry) has taken another step in the development of resources that will provide "a continuous feedback loop" for the physical therapy profession—this time, by way of a clinical "module" focused on torticollis.

    Recently the association signed an agreement with the Academy of Pediatric Physical Therapy to collaborate on the creation and integration of a congenital muscular torticollis module within the Registry. The module will be based on the academy’s clinical practice guideline on the topic.

    In Registry terminology, a “module” is a set of data elements that describe and risk-adjust process-of-care and clinical outcomes for a defined patient population. These condition- or disease-specific data elements are based on evidence-based clinical practice guidelines and will help refine the way outcomes data is analyzed and interpreted for specific populations. Modules will build on the current functions of the Registry, which collects a core set of patient and outcomes data from an electronic health record.

    The torticollis module will include more granular information, such as description of the type of cranial deformity, right side or left side of the head, and torticollis severity, among other factors. Analyzing a large amount of this data will help describe typical physical therapist practice patterns, variations in care, and the effectiveness of physical therapy interventions in different types of patients—all key elements in the Registry's mission to amass outcomes data to inform practice and enhance research.

    “This is the Registry’s first module agreement with an APTA section, and we look forward to more such collaborations in the future,” said James Irrgang, PT, PhD, ATC, FAPTA, scientific director of the Registry’s Scientific Advisory Panel. “The process of care and clinical outcomes data from modules will provide a continuous feedback loop not only for physical therapists but for guideline developers.”

    APTA is working with other sections to develop guideline-based modules in other areas, such as shoulder pain and neck pain.

    For more information about participating in the Physical Therapy Outcomes Registry and how sections can play an integral role in module development, visit www.ptoutcomes.com.

    APTA Resource Makes it Easy to Deliver Personalized Comments On Proposed Home Health Rule

    If a rule from the US Centers for Medicare and Medicaid Services (CMS) is adopted as proposed, physical therapists (PTs) and physical therapist assistants (PTAs) who work in home health could find themselves in a very different payment environment as early as 2019. That new environment could include a shift from 60- to 30-day episodes of care, and the startup of a new way to make case-mix adjustments that removes physical therapy service-use thresholds from the mix. All told, the changes being proposed could result in a $950 million payment reduction to home health, according to CMS.

    But the rule won't be finalized until later this year, and CMS is asking for public comments on its proposal. Ready to fire up your computer?

    APTA offers a template letter for PTs and PTAs who want to comment on the proposed 2018 home health prospective payment system (HH PPS) and the plans for changes to the case-mix adjustment methodology being considered for 2019. Among other positions, the letter encourages CMS to approach the new case-mix model, part of what's known as the Home Health Grouping Model (HHGM), in a budget-neutral manner and to audition the program by way of a limited demonstration project before making system-wide changes.

    Posted as a Microsoft Word file, the letter was created with the technical formatting that CMS is accustomed to, but it also includes areas that can be personalized with details and examples from the individual PT's or PTA's practice. Those personal touches can help to underscore the messages that the letter's shared elements deliver to CMS with a unified voice—namely, the concern that the HHGM "severely devalues the clinical importance of physical therapy" and negatively affects the most vulnerable patients who have the greatest need for rehabilitation.

    APTA outlined the basics of the proposed rule in a PT in Motion News story and will submit its own comments to CMS by the September 25 deadline. More information on the proposed rule is available through a CMS fact sheet.

    APTA just completed a live webinar on the proposed home health changes. PT in Motion News will alert readers when a recording of that session becomes available.

    APTA, Women's Section Help Clear Up Misinformation in NPR 'Mummy Tummy' Report

    Despite what you may have heard, if the idea of a single, daily, 10-minute exercise being the solution to diastasis recti, aka "mummy tummy," seems too good to be true, that's because it probably is. APTA and its Section on Women's Health, attempted to set the record straight.

    During the August 7 broadcast of NPR's Morning Edition, correspondent Michaeleen Doucleff reported on her experiences with a daily 10-minute abdominal exercise whose proponent, Leah Keller, a personal trainer, claims will close separated abdominal muscles often associated with women postpartum. The text version of the story that appeared on NPR's website under the rosy headline: "Flattening The 'Mummy Tummy' With 1 Exercise, 10 Minutes a Day."

    According to the story, Michaeleen reduced the separation in her abdominal muscles from 1.2 inches to .6 inches over 6 weeks, and other women in her exercise group did the same or better through the exercise. NPR reported that the program was supported by a pilot study of 63 women who all saw their diastasis recti fixed after 12 weeks.

    Not so fast, said APTA and the Section on Women's Health (SOWH). After the story aired, SOWH Vice President Carrie J. Pagliano, PT, DPT, contacted APTA with a suggestion that the section and the association point out some of the misinformation in the story. Together, SOWH President Patricia Wolfe, PT, MS, and APTA President Sharon Dunn, PT, PhD, drafted a letter to NPR describing several elements of the story that were "misleading to women seeking out help for diastasis recti." Pagliano also holds clinical specialist certifications in both orthopaedics and women's health; Dunn is a board-certified specialist in orthopaedics.

    The letter explained that besides the idea that a single short-duration exercise could be the quick-fix solution to diastasis recti, the story also contained factual errors about the kinds of exercises women postpartum should and shouldn't do. In the story, Keller tells these women to "please don't ever again in your life do crossover crunches or bicycle crunches," claiming that "they splay your abs in so many ways."

    In reality, the opposite could be the case, according to Dunn and Wolfe: contracting the rectus abdominis with a curl-up exercise has been shown to decrease muscle separation, while the exercise described in the story—a contraction of just the transverse abdominal muscle—has been associated with increased muscle separation while potentially improving how well the abdominals handle load. "It's not as simple as the '1 muscle-1 exercise approach' proposed by Keller," they write.

    Further, the authors point out, the study on which the program is based has several flaws, including the fact that only 29 of the 63 women in the study were postpartum, no explanation was provided for how diastasis recti was measured initially, and no control group was used.

    "Diastasis recti is not well understood and more research, including standardization of assessment, etiology, and clinical practice guidelines, is required," write Dunn and Wolfe. "In the meantime, a women's health physical therapist trained in the assessment and treatment of patients concerned about diastasis recti can be beneficial both during and after pregnancy to guide participation in exercise."

    In a follow-up report aired August 20, NPR acknowledged that the story received a "huge" response and included quotes from the Dunn and Wolfe letter. In that story, NPR described the criticism it had received, provided more information on the exercise in question, and included descriptions of other exercises that could be helpful, as well as advice from Dunn and Wolfe that "if done properly, the crossover crunches and bicycle crunches would actually help a woman restore the strength to all of her abdominal muscles."

    CMS MAC Claims Review Process Will Move to More Targeted System

    The US Centers for Medicare and Medicaid Services (CMS) will move away from its current practice of randomly selecting claims for audit in favor of a more targeted approach that it hopes will streamline the process and result in fewer appeals.

    The program, dubbed Targeted Probe and Educate, directs Medicare administrative contractors (MACs) to select claims for items or services "that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate," focusing only on "providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers." The program was piloted in 1 MAC jurisdiction in 2016, and expanded to 3 more in July of this year. All MAC jurisdictions will be following the procedure "later in 2017," according to a CMS fact sheet.

    Once a claim and provider have been targeted, MACs will begin a multiphase process by probing 20-40 claims per provider. If the provider is found to be noncompliant, the provider must participate in education on meeting requirements. After the education phase, the MAC must wait 45 days or more before reviewing another batch of 20-40 claims. At that point, the MAC can either determine that the provider is in compliance or submit the provider to another round of education and later review. Should a third review round not make a difference in compliance, the provider will be referred to CMS for possible further action.

    The new process moves away from the "Probe and Educate" program, a less-targeted process that resulted in more reviews—and more appeals from providers. According to an article in Modern Healthcare, CMS has 667,000 pending appeals and expects that number to rise to 687,000 by the end of 2017, and more than 1 million by 2021.

    2017 ELI Fellows Graduate From APTA Education Leadership Institute

    Eighteen seasoned physical therapy educators have deepened their knowledge and skills over the past year, thanks to the APTA Education Leadership Institute (ELI) Fellowship. These physical therapists (PTs) made up ELI's sixth cohort of ELI Fellows when they graduated in July after completing a yearlong higher education program that consisted of:

    • 9 online modules provided by content expert faculty;
    • 3 2-day face-to-face mentorship sessions and ongoing mentorship provided by experienced physical therapy program directors;
    • higher-education mentorship provided by physical therapy education leaders; and
    • implementation of a personal leadership plan and an institution-based leadership project.

    The ELI Fellowship strives to provide new and aspiring program directors in physical therapist and physical therapist assistant education programs with the skills and resources they need to be innovative, influential, and visionary leaders who can function within a rapidly evolving, politico-sociocultural environment.

    Partners who help promote and support the ELI Fellowship include the American Physical Therapy Association, American Council of Academic Physical Therapy, Education Section, and PTA Educators Special Interest Group. See who graduated from this year's class and find more information about the ELI Fellowship on APTA's website, and view video testimonials of previous ELI graduates.

    The program was first accredited by American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE), the accrediting body for postprofessional residency and fellowship programs in physical therapy, in 2012 and reaccredited in 2017 for a 10-year period.

    What's the Latest at CMS? Your Guide to Recent Proposed and Final CMS Rules

    The US Centers for Medicare and Medicaid Services (CMS) spent its spring and summer issuing proposed and final rules on areas ranging from the Medicare physician fee schedule, to what skilled nursing facilities will be paid and what they'll have to report, to inpatient reimbursement and home health episodes of care.

    Here's a quick guide to where some of these rules stand, and resources available from APTA—including an August 23 webinar focused on big changes CMS is eyeing for home health beginning in 2019 (11:30 am – 1:00 pm, ET). To register for the webinar email advocacy@apta.org.

    Medicare Physician Fee Schedule (MPFS)
    Status: Proposed; comments due September 11
    Resources: CMS fact sheet; PT in Motion News coverage
    The big news from the proposed MPFS for 2018 is that values for current procedural terminology (CPT) codes will be maintained—and a few even increased—after talk of the possibility that some of these codes were "misvalued." APTA is preparing comments on the proposed rule and has created a template letter for individual physical therapists (PTs) to send to CMS that covers both the proposed MPFS and more general Medicare issues.

    Home Health Prospective Payment System (HH PPS)
    Status: Proposed; comments due September 25
    Resources: CMS fact sheet; PT in Motion News coverage; August 23 webinar
    The fact that CMS will further reduce payment in 2018 by an estimated $80 million isn't exactly news—that cut is part of a series of reductions mandated by the Affordable Care Act (ACA). What is news is the CMS plan to reduce the unit of home health payments from 60-day to 30-day episodes of care, and to remove therapy service-use thresholds to make case-mix adjustments to HH payments in favor of "clinical characteristics and other patient information." Both of those changes would begin in 2019 under the proposed rule. APTA is preparing comments and is offering a webinar on August 23 from 11:30 am – 1:00 pm (ET) to outline the basics of the proposal and how to engage with CMS on the rule. To register for the webinar email advocacy@apta.org.

    Inpatient Prospective Payment System (IPPS)
    Status: Final; effective October 1, 2017
    Resources: APTA summary; CMS fact sheet; PT in Motion News coverage
    Acute care hospitals (ACHs) will see an estimated $2.4 billion increase in fiscal year 2018 (which begins October 1, 2017), while long-term care hospitals (LTCHs) will see a $110 million drop. Other highlights of the final rule include a CMS announcement that it will make medical record reviews a "low priority" when it comes to the requirement that physicians must certify that a patient admitted to a critical access hospital (CAH) will be discharged or transferred within 96 hours of admission, and the implementation of a 1-year moratorium on a policy that ties LTCH payment rates to ACH rates if an LTCH admits more than 25% of its patients from a single ACH. Another change: beginning in fiscal year 2019, CMS will include dual-eligibility status as a component in calculating penalties under the readmissions reduction program.

    Skilled nursing facility prospective payment system (SNF PPS)
    Status: Final; effective October 1, 2017
    Resources: APTA summary; CMS fact sheet; PT in Motion News coverage
    The final SNF PPS includes an overall 1% payment increase, changes to reporting requirements, and updates to the list of quality measures related to skin integrity, self-care, and mobility. CMS also will expand the window for its review of claims data related to potentially preventable 30-day readmissions. Previously CMS used a single year's worth of claims data; the rule expands that window to 2 years, an increase that CMS says will increase the number of SNFs with sufficient numbers of cases for public reporting.

    Inpatient Rehabilitation Facility Proposed Payment System (IRF PPS)
    Status: Final rule – effective October 1, 2017
    Resources: APTA summary, CMS fact sheet, PT in Motion News coverage
    Like SNFs, IRFs will see a 1.9% payment increase—about $75 million—for fiscal year 2018. The "60% rule"—a requirement that for an IRF to receive payment, 60% of its patients must require treatment for 1 or more of 13 conditions—has been adjusted to address diagnoses for patients with traumatic brain injury and hip fracture, as well as multiple trauma codes that didn't translate between ICD-9 and ICD-10. The new rule also requires IRFs to report standardized patient assessment data across 5 categories: functional status; cognitive functions; impairments; medical conditions and comorbidities; and special services, treatments, and interventions. Additionally, beginning in FY 2020, CMS will replace the current pressure ulcer measure with an updated version of the measure, an action that APTA supported in its comments.

    CMS Wants to Scale Back CJR Bundling Program for TKA, THA; Proposes Cancelling Bundle Program for Cardiac Care, Eliminating Expansion of CJR to Hip, Femur Fractures

    In brief:

    • Proposed rule would reduce the number of geographic areas required to participate in the Comprehensive Care for Joint Replacement (CJR) bundling model from 67 to 34
    • Low-volume and rural hospitals in all 67 areas would not be required to participate in CJR, but could do so voluntarily
    • Plans to implement a bundling model for cardiac care have been shelved, as are plans to expand CJR to include care of hip and femur fractures
    • Requirements for becoming a qualified provider in the CJR as an advanced alternative payment model would be broadened to include clinicians who don't have a financial arrangement with a facility but who are employed by the facility or have a contractual agreement

    The US Centers for Medicare and Medicaid Services (CMS) wants to significantly scale back the knee and hip joint replacement bundled care model and plans to cancel expansion of bundled care models to cardiac care and hip/femur fractures. The announcements were made as part of a package of proposals unveiled on August 15 that also includes some loosening of requirements for a provider to be considered as a "qualifying provider" under the joint replacement bundle program.

    The hip and knee bundle program, known as the Comprehensive Care for Joint Replacement (CJR) model, launched in 2016 as the first-ever attempt by CMS to mandate bundled care—in the case of CJR, that requirement applies to 67 different geographic areas covering some 800 hospitals. Under the proposed rule change, the number of geographic areas required to participate in CJR would drop to 34, leaving participation voluntary for all hospitals in the other 33 areas, or about 350 facilities. CMS estimates that 60 to 80 hospitals will choose to voluntarily participate. Hospitals that can and do decide to opt out of the program will have episodes beginning at any point during 2018 cancelled.

    In addition to reducing the number of geographic areas required to participate in the CJR, CMS is proposing that low-volume and rural hospitals in the remaining 34 areas also be switched from mandatory to voluntary participation.

    Per the same proposed rule, CMS would cancel a planned expansion of mandatory bundling to cardiac care, as well as expansion of the CJR to include care for hip and femur fractures. Those expansions originally were set to be put in place in February of this year but were later delayed until October 1, and then pushed back again to a January 2018 startup date. The proposed rule effectively would cancel the programs.

    As CMS taps the brakes on the CJR, it also proposes making it easier for clinicians to be included as qualifying participants in the bundling program. Under the proposed rule, providers—including physical therapists—who don't have a financial arrangement with a facility in the CJR program, but who are either directly employed or contractually engaged with a participating hospital, would be accepted into the program. It would be up to the hospitals to supply CMS with an "engagement list" of those providers, and CMS would take it from there, using Medicare Part B claims data to decide whether a clinician can be considered an advanced alternative payment model qualifying provider. Clinicians who get the nod from CMS would not be required to report to under Merit-Based Incentive Payment System (MIPS) and could be eligible for payment bonuses up to 5%. (Because physical therapists are solely voluntary participants in MIPS as of now, they wouldn’t be subject to the MIPS reporting requirement even if they don’t participate in an advanced APM—but that could, and is expected to, change in future years.)

    CMS has issued a fact sheet on the proposal. APTA staff are reviewing the proposed rule and will provide comments by the October 15 deadline.

    The Good Stuff: Members and the Profession in Local News, August 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!

    Ashleigh Dalton PT, DPT, cofounder of Camp Cliffview, talks about how the program provides opportunities for children with special needs. (BlueRidgeNow.com)

    Jessica Dufault, PT, explains how addressing separation of abdominal muscles in women post-birth requires more than an exercise or 2. (Offspring.lifehacker.com)

    Jan Dommerholt PT, DPT, gives Good Morning Washington a glimpse of what exergaming is all about. (Good Morning Washington)

    Tom Hulst, PT, MHS, and Jen Kurnowski, PT, discuss dry needling for back pain. (West Michigan Fox 17 News)

    The Brenau University physical therapy program's pro-bono physical therapy clinic in Georgia, is benefitting students and patients. (Gainesville, Georgia, Times)

    Caitlin Jones, PT, DPT, talks about the progress of a remarkable 5-year-old recovering from a gunshot wound. (WSB-TV2, Atlanta, Georgia)

    Eric Robertson, PT, DPT, provides insight on how exercise can help keep back pain from becoming chronic. (Oprah.com)

    University of Mary, North Dakota, PT students work with engineering students to create adaptive cars inspired by the Go Baby Go program. (Bismarck, North Dakota, Tribune)

    "Jonathan continues to recover from his accident, and Laura continues to stand beside him as he does. One day, Laura was shadowing Jonathan's physical therapy session when his therapist invited her to help lift him out of his wheelchair. 'As soon as we got him up, he started kissing my neck,' Laura said. 'We hadn't been able to stand and hold each other since before the accident ... It gave me the chills. You don’t realize how much that means until it’s almost taken away from you.'" - Laura Browning Grant, whose husband, Jonathan, is recovering from an automobile accident, on the viral video of their first kiss in months. (Self.com)

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

    Study: Prevalence of Knee OA Today Twice What It Was 75 Years Ago

    Knee osteoarthritis (OA) has more than doubled among Americans since 1940, say researchers, and the increase can't be explained by longer lifespans or a higher prevalence of obesity and overweight in recent decades. Instead, the real culprit could be physical inactivity, which authors describe as "epidemic in the postindustrial era."

    The study, appearing in the Proceedings of the National Academy of Sciences, compared knee joints of 2,756 skeletons from 3 groups of individuals: those who lived in the 1800s and early 1900s ("early industrial," N=1,581), those who lived during the late 1900s through the early 2000s ("postindustrial," N=819), and prehistoric hunter-gatherers who lived between 6,000 and 300 BCE (“prehistoric,” N=176). Researchers were looking for knee joint eburnation—the ivory-like result of bone-on-bone contact that occurs after cartilage erodes—as the indicator for moderate to severe OA.

    Here's what they found:

    • The prevalence of knee OA in the postindustrial skeletons was about 16%, a rate 2.6 times higher than the early industrial group, which had a 6% incidence rate. Knee OA prevalence among the prehistoric sample was 8%.
    • After controlling for body mass index (BMI) and age when that information was available (1,859 of the 2,756 skeletons), researchers were unable to establish a correlation between these factors and prevalence of knee OA—instead, rates remained 2 times higher for the postindustrial group even when compared with early industrial skeletons with similar ages and BMIs. BMI for the prehistoric sample could not be estimated.
    • In the postindustrial individuals with knee OA, 42% had the disease in both knees. Bilateral occurrence was 30% among the early industrial samples with knee OA, and 17% among the prehistoric group.

    "Although knee OA prevalence has increased over time, today's high level of the disease is not, as commonly assumed, simply an inevitable consequence of people living longer and more often having a high BMI," authors write. "Instead, our analyses indicate the presence of additional independent risk factors that seem to be either unique to or amplified in the postindustrial era."

    The researchers believe that risk factor could have to do with "environmental changes"—namely, the reduced levels of physical activity associated with the postindustrial era, despite the human body's need for regular exercise. It's a phenomenon known as a "mismatch disease," when the human body can't easily or rapidly adapt to changes in the lived environment.

    "Although altered loads generated by walking more frequently on hard pavement … or with certain forms of footwear … might be factors, another possibility that merits more study is physical inactivity, which has become epidemic during the postindustrial era," authors write. "Less physically active individuals who load their joints less develop thinner cartilage with lower proteoglycan content … as well as weaker muscles responsible for protecting joints by stabilizing them and limiting joint reaction forces."

    The good news, according to the researchers, is that their findings point to the possibility that knee OA is a largely preventable condition—providing there's a widespread "reappraisal of potential risk factors that have emerged or intensified only very recently."

    "As with other mismatch diseases, it is likely that any effective prevention strategy will involve adjusting physical activity patterns and diets to approximate more closely the lifestyle conditions under which our species evolved," authors write.

    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.

    Technological Possibilities, Practical Challenges: Report Looks at Assistive Technologies in the Workplace

    Assistive technologies to help individuals in the workplace are developing at a rapid rate, but if the promise of these technologies is to be fully realized then thinking around access, user training, reimbursement, and other barriers needs to catch up. That conclusion echoes throughout a new report from the National Academies of Science, Medicine, and Engineering.  Authors of the study include Physical Therapy (PTJ) Editor-in-Chief Alan Jette, PT, PhD, MPH, FAPTA, and Linda Resnik, PT, PhD, FAPTA, and executive director of the Center on Health Services Training and Research (CoHSTAR).

    "The Promise of Assistive Technology to Enhance Activity and Work Participation" is the result of an extensive review of the literature pertaining to assistive products and technologies, a series of public meetings on the topic, and a public teleconference that invited expert comment. The purpose: to develop an analysis of the adult use of assistive technologies including wheeled mobility devices, upper-extremity prostheses, and technologies designed to assist with hearing, speech, and communication.

    The report, available to download for free, isn't just an account of what's out there and how far assistive technology has come—it's also an examination of the challenges of putting these technologies to their most widespread and effective use.

    "The committee's review of the literature and the expert opinions of its members and others who provided input for this study made clear that appropriate-quality assistive products and technologies … may mitigate the impact of impairments sufficiently to allow people with disabilities to work," authors write. "In some cases, however, environmental and personal factors create barriers to employment despite the impairment-mitigating effects of these products and technologies. In addition, maximal user performance requires that individuals receive the appropriate devices for their needs, proper fitting of and training in the use of the devices, and appropriate follow-up care."

    That concept of barriers and training needs colored most the committee's conclusions, which include recommendations that point to the importance of proper fit, ongoing follow-up, better training for providers, and an understanding among employers and others that a device that may be useful to an employee today may become less useful over time.

    Authors also addressed the lag-time that can exist between effective technologies and a payer's willingness to provide reimbursement for those technologies.

    "The provision of assistive products and technologies … is contingent largely on reimbursement policy rather than patient need," authors write. "In some cases, the products and technologies that are covered by Medicare and other insurers as medically necessary are not those that would best meet the needs of users to enhance their participation in life roles."

    Funded by the Foundation for Physical Therapy , CoHSTAR is a multi-institutional, multi-disciplinary center dedicated to advancing health services and health policy research capacity in physical therapy.