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  • APTA Weighs in on Opioid Use Disorder, Opioid Poisoning, Among People With Disabilities

    APTA has contributed to an effort that may help shed light on an often-overlooked facet of the opioid crisis—the impact of opioid use disorder on people with disabilities. While final directions have not been laid out, the comments are helping to shape further calls for research on some important considerations for this population, such as barriers to addiction treatment, difficulty in accessing nonpharmacological pain management, and the relationship between traumatic, disabling injury and opioid misuse.

    The project is the work of the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), a branch of the US Department of Health and Human Service's Administration for Community Living (ADL). The institute hopes to use comments it received from 50 invited respondents, including APTA, to define next steps in research and education. Other groups that responded included the American Association of Nurse Practitioners, the American Psychological Association, and the National Council on Independent Living. In addition, NIDILRR sought comments from consumers, research teams, clinicians, and community organizations.

    The effort is an attempt to address what NIDILRR describes as the "paucity of research focusing on people with long-term disabilities and their likelihood of developing an opioid use disorder." In an interim report, the institute identified 3 key themes that emerged from the initial call for comment. They are:

    People with disabilities are more likely than the general population to misuse opioids but less likely to receive treatment. NIDILRR authors cited one study's estimation that among Medicaid beneficiaries, people with disabilities had a higher incidence of opioid use disorder than did those without a disability (6.4% vs 4.2%) but a lower rate of receiving an approved treatment medication for opioid misuses (11% vs 32%).

    Barriers such as physical accessibility to treatment centers, limited insurance coverage, and policies that withhold opioid prescriptions without offering alternative pain management approaches are more prevalent among people with disabilities. In many rural areas, treatment facilities require long travel, and, once there, those with disabilities can find physical access challenging. Additionally, treatment that focuses primarily on denying or restricting the use of opioids creates treatment gaps that often can lead to secondary health issues, including blood pressure problems, heart palpitations, and falls.

    People with disabilities who have had a serious traumatic injury are at greater risk for opioid poisoning. Traumatic injuries that result in long-term disability can create secondary health conditions that often are treated with opioids. Such treatment exposes this population to an even greater danger of opioid misuse and death from opioid poisoning. One study cited by NIDILRR estimated that 70%-80% of all patients with traumatic brain injuries are discharged with a prescription for an opioid.

    NIDILRR says it is exploring funding opportunities "to generate new knowledge and promote its effective use to address the opioid crisis and its impact on people with disabilities." Future possible funding areas include more research on prevalence of opioid use disorder in this population, individual and environmental risk factors, factors associated with improved access to treatment, and the effects of government policies and programs on health care access and treatment.

    Advanced Cancer Patients Can Benefit From Structured Exercise, Say Researchers

    Incorporating structured exercise into supportive care can help improve the lives of patients with advanced cancer, say researchers in an article e-published ahead of print in the Archives of Physical Medicine and Rehabilitation (abstract only available for free). In an analysis of previous studies, authors found that both aerobic exercise and resistance training improved many cancer side effects.

    Authors evaluated 25 studies, for a total of 1,188 participants, that measured the efficacy of exercise interventions on physical function, quality of life, fatigue, body composition, psychosocial function, sleep quality, pain, and survival. All studies used more than 1 session of structured exercise as the primary intervention and specified the "frequency, intensity, time, or type" of exercise. More than 80% of participants in each study had been diagnosed with "advanced cancer that is unlikely to be cured." Some studies used control groups, and some did not.

    Their findings include:

    Physical function. In 83% of studies, participants who exercised experienced significant improvements in physical function, including exercise capacity, aerobic capacity, and muscle strength.

    Quality of life. In 55% of studies, exercise resulted in significant improvement in at least 1 measure of quality of life.

    Fatigue. Half of the studies reported that exercise improved at least 1 measure of fatigue.

    Psychosocial function. At least 1 measure of psychosocial or cognitive function was reported as having improved with exercise in 56% of studies.

    Body composition. In 56% of studies, exercise improved at least 1 measure of body composition, including lean body mass and body fat percentage, though not BMI, fat mass, or body mass.

    Sleep quality. In all 4 studies including this area, participants who exercised reported significant improvements compared with control groups.

    Pain.Of the studies measuring pain, 2 found significant improvements after exercise interventions.

    Survival. No studies examining survival rates found a significant improvement as a result of exercise.

    Because "decline in physical function has been reported as one of the most debilitating symptoms associated with advanced cancer," authors write, "interventions targeting improvements in this domain are of utmost importance."

    While authors note that exercise "appears to be an effective adjunct therapy in the advanced cancer context," they recommend that future studies use standardized protocols to report consistent outcomes measure assessment—one limitation they observed. Authors also suggest that future research should "compare different frequencies, intensities, durations, and types of exercise" to "determine the optimal exercise dose to enhance outcomes for specific cancer diagnoses."

    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.

    2018 House of Delegates Motions, Background Papers Posted

    Now available to APTA members: the complete first packet of motions, accompanied by background papers, to be considered by the 2018 APTA House of Delegates (House) when it convenes June 25-27, 2018, in Orlando, Florida.
    Called "Packet I With Background Papers," the compilation contains 57 motions to the 2018 House of Delegates, including 4 bylaws amendments. This packet replaces "Packet I Preview." Besides minor editing and formatting changes and the addition of background papers, the new packet does not differ from the earlier version in any ways that affect the scope of motions.
    Proposed amendments to APTA bylaws are:

    • RC 53-18 Amend: Bylaws of the American Physical Therapy Association, Article VIII. House of Delegates, Section 3: Voting Delegates, A. Qualifications of Voting Delegates, (1) Chapter Delegates
    • RC 54-18 Amend: Bylaws of the American Physical Therapy Association, Article VIII. House of Delegates, Section 4: Nonvoting Delegates, A. Qualifications of Nonvoting Delegates, (1) Section Delegates
    • RC 55-18 Amend: Bylaws of the American Physical Therapy Association, Article VIII. House of Delegates, Section 4: Nonvoting Delegates, A. Qualifications of Nonvoting Delegates, (2) PTA Caucus Delegates
    • RC 56-18 Amend: Bylaws of the American Physical Therapy Association to Allow Sections to Vote in the House of Delegates

    Delegates wishing to amend a motion within Packet I With Background Papers should schedule a virtual Reference Committee appointment on Friday, June 8, or schedule an onsite appointment for Sunday, June 24 or Tuesday, June 26. For more information, refer to Make an Appointment with the RC found in the House Hub file library.
    Contact APTA's Justin Lini with any questions.

    PTs From the US Selected to Speak at International Physical Therapy Congress

    A total of 13 physical therapists (PTs) from the US will be among the main speakers at the World Confederation for Physical Therapy (WCPT) Congress to be held in Geneva May 10–13, 2019.

    The American PTs will contribute to focused symposia on a wide range of topics including education research, the application of evidence to individual patients, improving mobility of hospital patients, big data, cancer survivor rehabilitation, and diversity in physical therapy. Each focused symposium is organized by a convener who leads an international group of speakers through linked research-focused presentations. A complete list of all symposia is available at the WCPT Congress website.
    "There were some very difficult choices; however, we are proud to present the focused symposia that we believe represent the best possible combinations of a range of timely topics with relevance to clinicians, educators and researchers, delivered by excellent speakers from all over the world," said WCPT International Scientific Committee Chair Charlotte Häger in a press release.
    Details about the symposia and the program for WCPT Congress 2019 may be found at the WCPT congress webpage.

    The Good Stuff: Members and the Profession in the Media, May 2018

    "The Good Stuff," is an occasional series that highlights recent 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!

    Bravery, persistence, DPT: Brandon Hsu, SPT, faced down leukemia and chemotherapy-induced encephalopathy but never lost his passion for the profession. Now he's a newly minted DPT. (University of Southern California News)

    Pitching good posture: Judy Seto, PT, DPT, helped New York Mets pitcher Robert Gsellman correct bad postural habits made worse through video-gaming. (New York Times)

    From North Dakota to Peru—and back again: Sierra Steckler, PT, describes what it was like to provide physical therapist services in Peru. (Wahpeton, North Dakota, News-Monitor)

    When it's time to go: Carrie Pagliano, PT, DPT; and Laurie Kilmartin PT, DPT, offer advice to new and expecting moms on relieving constipation. (Parents)

    This is your PT speaking: Amanda Brick, PT, DPT, passes along tips for sitting comfortably on long airplane trips. (Bustle.com)

    Shinful behavior: Heather Moore, PT, provides guidance on exercises to ease and prevent shin splints. (Philadelphia Inquirer)

    Mix it up, parents: Shondell Jones, PT, DPT, stresses the importance of children engaging in a variety of physical activities and not focusing solely on 1 sport. (KWX-TV10, Waco, Texas)

    Crack your back? Just…don't: Jeffrey Yellin, PT, warns about the dangers of "unskilled" back-cracking. (Elite Daily)

    Blood flow restriction basics: John Corbo, PT, DPT, explains how blood flow restriction is used in physical therapy. (WCCO4, Minneapolis)

    Sole searching: Robert Gillanders, PT, DPT, discusses how finding the right shoe can reduce foot pain. (Self)

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

    CDC: Falls-Related Deaths in the US Rose 31% in 10 Years

    Among US residents age 65 and older, the rate of death from falls continues to climb steadily, having increased by 31% between 2007 and 2016, and growing at a particularly rapid rate among those aged 85 and above. The latest statistics, included in a report from the US Centers for Disease Control and Prevention (CDC), point to a need for more widespread falls screening and prevention efforts including physical therapy, authors say.

    During the 10 years tracked in the study, falls-related deaths among US residents 65 and older rose from 18,334 to 29,668—in terms of rates of death from falls, that's an increase from 47 per 100,000 to 61.6 per 100,000 in that age group. Deaths climbed by about 3% per year, according to the report.

    In addition to overall totals and rates, CDC researchers looked at data in terms of demographics and state-by-state variables. Among their findings:

    • In 2016, falls-related deaths per 100,000 were highest among white non-Hispanic US residents (68.7) and the all-ethnicity 85-and-older group (257.9).
    • While death rates increased for all age groups, the 85-and-older category recorded the most dramatic rise between 2007 and 2016, from 9,188 deaths in 2007 to 16,454 in 2016. The 65-to-74 age group recorded 2,594 falls-related deaths in 2007 and 4,479 in 2016; the 75-to-84 age group saw an increase from 6,552 deaths in 2007 to 8,735 in 2016.
    • Men had higher rates of falls-related deaths than did women—73.2 per 100,000 men compared with 54 per 100,000 per women. Researchers believe the gap may be attributable to "differences in the circumstances of a fall," with men tending to experience falls that lead to more serious injuries, such as those sustained in a fall from a ladder or as the result of alcohol consumption.
    • Rates for deaths from falls in the 65-and-older age group varied among states, ranging from 142.7 per 100,000 in Wisconsin to 24.4 per 100,000 in Alabama. Authors aren't sure of the reasons for the variance but suspect that the numbers might be related to demographic variables including differing proportions of older white adults in various states. Another possible explanation cited in the report was the impact of who completes the death certificate: According to the CDC researchers, a 2012 study showed that coroners reported 14% fewer deaths from falls than did medical examiners.

    Authors of the report theorize that the rates of falls-related deaths may be climbing in part because of an aging population and longer survival rates after common diseases including heart disease, cancer, and stroke. Whatever the contributing factors, it's a trend that needs to be addressed, they write: even if the rate were to stabilize, an estimated 43,000 US residents would die from falls in 2030, and if the rate were to climb as it did from 2007 to 2016, some 59,000 individuals may die from falls in 2030.

    "As the US population aged [65 and older] increases, health care providers can address the rising number of deaths from falls in this age group by asking about fall occurrences, assessing gait and balance, reviewing medications, and prescribing interventions such as strength and balance exercises or physical therapy," the report states.

    Better prevention efforts also may result in health care cost savings as well: an earlier report estimated that expenditures on nonfatal falls in the US reached nearly $50 billion in 2015, with medical costs associated with fatal falls coming in at an estimated $754 million.

    APTA provides extensive resources on falls prevention at its Balance and Falls webpage. Offerings include consumer-focused information, online courses, and links to other sources of information, including the CDC and the National Council on Aging. In addition, APTA's PTNow evidence-based practice resource offers a unilateral vestibular hypofunction clinical summary, a summary on falls risk in community-dwelling elders, an osteoporosis clinical summary, and tests and measures such as a fracture risk assessment, a clinical test of sensory interaction and balance, and a self-paced walk test. The association's scientific journal, PTJ (Physical Therapy) has also published a clinical guidance statement from the APTA Academy of Geriatric Physical Therapy on management of falls in community-dwelling older adults.

    CMS Offers Alternative Dispute Resolution for Some Providers With Unresolved Medicare A or B Appeals

    Providers with Medicare Part A or B appeals that have been waiting for a decision are being offered the possibility of resolving those appeals through a new alternative dispute resolution program from the US Centers for Medicare and Medicaid Services (CMS). However, the requirements around just who can qualify for the service, and under what circumstances, are a bit complex—that's why CMS is urging interested providers to review online resources and register now for a May 22 conference call that will attempt to explain the details.

    Called the "Settlement Conference Facilitation" (SCF) program, the initiative is aimed at providers and suppliers who have claims appeals awaiting decisions in the Office of Medicare Hearings and Appeals (OMHA) or Medicare Appeals Council (Council). In the SCF, "a facilitator uses mediation principles to assist the appellant and CMS in working toward a mutually agreeable resolution" to a claims appeal, according to CMS. The facilitator can't make rulings on the merits of a claim, nor can the facilitator serve as a fact-finder; instead, says CMS, the facilitator "may help the appellant and CMS see the relative strengths and weaknesses of their positions."

    To qualify for the program, a provider must have a National Provider Identifier, cannot have or have had False Claims Act litigation pending against them, and cannot have filed for bankruptcy or expect to do so.

    But those are just the provider qualifications. Determining which appeals would qualify for the program is another somewhat more complicated matter, involving the total number of appeals pending, the dollar amounts involved in those appeals, and the codes used in the initial claim, among other requirements.

    To help make things clearer, CMS offers a webpage on the SCF program and urges interested providers to join a conference call on May 22 at 1:30 pm ET. That call requires free advance registration, which closes at noon on May 22 or earlier if spaces fill up. Questions about the SCF can be emailed to OMHA.SCF@hhs.gov.

    This program is separate from the Low-Volume Appeals Initiative CMS announced in February of 2018.

    APTA Federal Advocacy Forum Brings the Profession's Energy to Capitol Hill

    Wonder if advocacy for physical therapy is still important now that a permanent fix has been applied to the Medicare therapy cap? Just ask the 270 physical therapists, physical therapist assistants, and students from 48 states who converged on Capitol Hill recently to educate legislators and staff about a range of important issues impacting the profession.

    The meetings took place April 29–May 1, as part of APTA's annual Federal Advocacy Forum in Washington, DC. Attendees discussed several issues, including:

    • The importance of integrating physical therapy into efforts to address opioid abuse
    • Passage of the CONNECT for Health Act (H.R. 2556/S. 1016), which would ease restrictions on the provision of telehealth under Medicare
    • Concerns about H.R. 4508 and its proposed changes to the Higher Education Act (PROSPER), which would affect student loan amounts, forgiveness, and repayment
    • The Sports Medicine Licensure Clarity Act (H.R. 302/S. 808), which would provide portability of malpractice insurance for PTs and PTAs who travel across state lines with professional and collegiate sports teams

    Members also were trained on best practices for advocating through a variety of channels, as well as the role data plays in advocacy. Amy Walter, national editor of the Cook Political Report and former political director of ABC News, was the keynote speaker.

    event also included APTA's annual recognition of outstanding federal advocacy efforts. This year, Linda John, PT, was awarded the Federal Government Affairs Leadership Award for her tireless efforts as an advocate, a Federal Affairs Liaison, a Key Contact, and a mentor. The association also recognized Sen Thom Tills (R–NC) with the APTA Public Service Award for his instrumental role in including physical therapist assistants within the TRICARE system as part of the National Defense Authorization Act in 2017.

    "The level of dedication and engagement at this year's forum was truly impressive," said Jennica Sims, APTA congressional affairs and grassroots specialist. "This kind of energy is crucial in advocacy and helps legislators understand the contribution of physical therapists to ensuring the health and well-being of children, working age adults, and older adults."

    Editor's note: The Federal Advocacy Forum serves as an advocacy recharging station for APTA members—and it's a lot of fun, too. Watch the video below, and check out this #PTTransforms blog post to find out what it's all about.


    APTA-Supported VA Change Will Expand Use of Telehealth for PT Services

    In a potentially game-changing win for physical therapists (PTs), physical therapist assistants (PTAs), and many other health care providers, the US Department of Veterans Affairs (VA) is following through on a proposal to dramatically expand the use of telehealth services across state lines for VA beneficiaries in all US jurisdictions The change, strongly supported by APTA, would also allow these services to be conducted in nonfederal sites, including the homes of VA patients.

    As noted in its final rule released on May 10, VA took this sweeping action because interstate barriers were limiting VA's ability to fulfill its federal mandate.

    "In an effort to furnish care to all beneficiaries and use its resources most efficiently, VA needs to operate its telehealth program with health care providers who will provide services via telehealth to beneficiaries in states in which they are not located, licensed, registered, certified or otherwise authorized by the state," VA writes in its rule. "Without this rulemaking, doing so may jeopardize these providers' credentials…because of conflicts between VA's need to provide telehealth across the VA system and some states' laws or requirements for licensure, registration, certification, that restrict the practice of telehealth."

    In addition to providing comments in strong support of this change when it was proposed in October 2017, APTA met with VA representatives to advocate for the expanded use of PT and PTA services provided via telehealth.

    "Our combined efforts with APTA have helped to create a change that will make a huge difference in the lives of VA patients," said Mark Havran, PT, DPT, president of the Federal Physical Therapy Section. "The patients who will benefit from this new rule are some of VA's most in-need, with many living far from provider facilities or experiencing mobility issues that make travel difficult. Now PTs and PTAs will be better able to provide the services those patients require."

    Some important things to understand about the new rule:

    The rule doesn't expand authority or scopes of practice.
    VA providers must continue to abide by federal law and the practice acts of the provider's state of licensure.

    The rule applies only to VA-employed providers—not to contracted providers such as providers in the Veterans Choice program.
    The limitation to VA-employed providers was necessary to create protections from any actions that might be taken by state professional licensing boards.

    Copays for telehealth services will go away.
    Congress authorized VA to waive copay requirements for telehealth services, which VA did.

    The rule doesn't go into effect immediately.
    The changes will go into effect 30 days after publication in the Federal Register, which hasn't happened yet. Don't expect that publication until sometime in December at the earliest.

    The rule won't solve all the issues with telehealth service delivery.
    VA acknowledges that the change addresses only 1 challenge to telehealth services, and has resolved to continue to work on technical elements that interfere with effective delivery, including patients' and providers' access to technology.

    Telehealth services currently are allowed in the VA system, but only if both the provider and patient live in the same state. Additionally, many VA medical centers restrict telehealth activities to federal property—for both the patient and the provider. The new rule would make it possible for the facilities to lift those restrictions.

    "This rule is a significant step forward in the recognition of therapy services provided through telehealth," said Justin Moore, PT, DPT, CEO of APTA. "APTA was happy to support this change, because we believe VA's vision and leadership in this important component of health care will help to shape the future of patient access."

    CMS Wants to Drop Functional Measure, 2 Quality Reporting Measures From IRF Requirements

    The US Centers for Medicare and Medicaid (CMS) is continuing its trend toward easing administrative burdens and eliminating what it believes may be duplicative quality-reporting activities—this time, by way of a proposed rule for inpatient rehabilitation facility (IRF) payment that would do away with a longstanding functional assessment and 2 outcome measures.

    The assessment slated for possible elimination is the Functional Independence Measure (FIM), part of the IRF Patient Assessment Instrument. According to a CMS fact sheet on the proposed rule, data collected through the FIM are being captured in other parts of the assessment instrument. The use of the FIM dates back to 1987; its use would end October 1, 2019.

    Also up for possible elimination: measures related to methicillin resistant staph aureus (MRSA) infection and the percent of patients assessed and given the seasonal flu vaccine. CMS describes both measures as ones in which costs of reporting outweigh the benefits. The reporting changes would be implemented October 1, 2018.

    Other changes in the proposed rule include:

    • A 0.9% payment increase for FY 2019—about the same percentage increase as in 2018
    • Elimination of reporting requirements related to the rehabilitation physician conducting team meetings remotely
    • Allowance for the postadmission physician evaluation to count as one of the required face-to-face physician visits
    • Removal of requirements for admission order documentation—but not the requirement for admission orders themselves

    Also included in the proposed rule is a general call for feedback on several topics, including ideas for achieving better electronic sharing of data between providers, the possibility of allowing the rehabilitation physician to determine whether a particular patient assessment could be conducted remotely, the training of nonphysician providers relevant to IRFs, and ways that nonphysician IRF provider roles could be expanded.

    APTA will submit comments on the proposed rule by the June 26 deadline.