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  • News From NEXT: Understanding Personality Types Can Enhance the PT-Patient Relationship

    Understanding one’s own personality, as well as the personalities of coworkers and patients, can make physical therapists (PTs) and physical therapist assistants (PTAs) more successful in both their workplace and home life, according to Jacky Arrow, PT, DPT. Arrow presented “He Said, She Said: How personality and communication can improve patient education” on June 14 at the 2019 NEXT Conference and Exposition.

    She pointed out that in communication between the PT and the patient, “It’s not their responsibility to come to us or to meet us half way. It’s our responsibility to meet them.”

    She first recommended that the attendees determine their own personality types. She mentioned several tests but focused on the Myers-Briggs Type Indicator, which places a person on 4 scales: extraversion vs introversion, sensing vs intuitive, thinking vs feeling, and judging vs perceiving.

    For example, Arrow explained, an introvert typically waits to be asked a question and then needs time to construct an answer. Extraverts, on the other hand, tend to be talkative and fast-paced. Regarding body language, extraverts tend to lean forward and talk with their hands, while introverts pause before answering and often sit back, sometimes with arms crossed. When treating patients who are introverts, she suggested, provide information in advance or tell them you plan on asking specific questions. Be prepared for follow-up questions either later in a session or at the next session. A strategy to working with extraverts includes active listening, thinking out loud, and planning talking points.

    Another example she provided related to judgers vs perceivers. Judgers respect rules and deadlines such as structured activity, she said, and they prefer a specific plan of care with milestones. Perceivers tend to be flexible with rules and deadlines and are open to adjustments in a plan of care. For those reasons, judgers do better with a written program calendar, while perceivers like to link progress to big-picture goals. To illustrate, she suggested that if the goal is to have a patient do an exercise for 30 seconds, tell a judger to exercise for 30 seconds. Tell a perceiver to sing the song “Twinkle Twinkle Little Star” to gauge the elapsed time.

    Understanding the personality types of colleagues also can be beneficial. “Knowing the other personality types fosters better working relationships. And it allows PTs and PTAs to practice their skills with those of other personality types,” Arrow said.

    News From NEXT: Attendees Rebuild Toy Cars to Aid Children’s Mobility

    PVC ratchet cutters, screwdrivers, and wire strippers may not be among the tools usually used by physical therapists (PTs) and physical therapist assistants. But at the APTA NEXT Conference and Exposition session "Go Baby Go: Mobility Research, Design, and Technology," those and other devices---such as electrical tape, collections of screws, a power drill, and myriad other items---were literally part of a clinician’s toolbox.

    Jason Craig, PT, DPhil, and Skye Donovan, PT, PhD, led the session, which addressed the importance of mobility for young children. The program---conducted on both June 13 and 14---primarily focused on actually converting 9 battery-powered children’s ride-on cars into effective, affordable mobility devices. Go Baby Go is a national program developed by Cole Galloway, PT, PhD.

    The cars that arrive from the toy manufacturer are designed to be operated with a foot pedal. But Craig explained, "Most kids can't operate a pedal, so we have a large button that can be positioned anywhere on the car." Usually the button is in the steering wheel---which was where conference participants placed them in the 9 onsite cars---but the location can change based on the child’s need. "We've placed it behind the head when the goal is to improve a child's posture," Craig said. "We placed one on the seat so the car would move only when the child stood up; it stopped as soon as he sat down."

    In addition to enhancing interventions, the modified toys serve another purpose. "This is about providing the children an experience they haven't had. By providing these cars, the children can explore the world," he said.

    It's also affordable. The cars as modified cost approximately $150 "versus thousands for a motorized wheelchair."

    Pointing to an array of unmodified, rideable cars on tables in the room, Craig then told the session attendees: "We need you to build these, because the kids are coming in later today for their cars." Each car was accompanied by an information sheet on the child---including his or her name, age, diagnosis, and interests.

    The session attendees worked in teams of 4 to 6 to modify the cars---disconnecting the pedal power control and connecting the large red plastic button the size of a small plate to the center of the steering wheel. The task was challenging not only because many PTs weren't familiar with the hardware tools and wiring schematics but also because of variations in both the cars and the needs of the children.

    About an hour into the session, the children and their parents began arriving, with the children telling the PT team working on "their" car what customizations and decals they wanted. Most of the cars were finished that day---a few needed additional work---and the session ended with the children test-driving their cars around the room and down the hotel's halls.

    'Allow Mistakes': Study of Infants With CP Emphasizes Importance of Balanced Approach to Movement Learning

    Infant prone mobility, considered strongly linked to later mobility gains and psychological development, can be difficult for children with cerebral palsy (CP), putting them at a disadvantage later in childhood. Now authors of a new study believe that pairing special assistive technology with a careful combination of movement learning strategies could facilitate important gains in this population. The study was published as part of a special issue of PTJ (Physical Therapy) focused on the intersection of pediatric physical therapy and development science.

    Researchers were particularly interested in impacts of 2 separate learning "mechanisms" that have been shown to have positive effects on skill learning in adults with neurological deficits: reinforcement learning (RL) and error-based learning (EBL). RL is aimed at optimizing the reception of rewards or penalties, focusing on the outcome; in contrast, EBL focuses on the errors made in movement.

    Both EBL and RL can be useful approaches, authors write, but they each have pros and cons: EBL promotes faster learning but is easier to forget; RL tends to be a longer process with more exploration (and variability) involved but is better retained. Authors of the study hypothesized that infants with CP would achieve better prone mobility gains through a combination of the 2 mechanisms than from RL alone.

    To test their hypothesis, researchers used the Self-Initiated Prone Progression Crawler (SIPPC), a device developed by study coauthor Thubi Kolobe, PT, PhD. The SIPPC resembles a skateboard outfitted with special motors and monitors. Infants are placed on them in a prone position that allows them to move their arms and legs. The SIPPC can then be programmed to sense and respond to movement the child initiates.

    Thanks to the addition of a specially wired onesie, the SIPPC's movement response was able to work as both an RL and EBL mechanism. Calibrated one way, the SIPPC reinforced RL by rewarding a movement that is consistent with achieving a goal—for instance, moving toward a toy. Set another way, the SIPCC could add an EBL element by picking up on movements that are not consistent with the goal achievement and move the infant in unintended directions.

    For the study, researchers divided 30 infants aged 4.5–6.5 months into 3 groups: infants with CP who received SIPPC sessions with the special suit that could combine RL and EBL, infants with CP who received only an RL experience through the SIPPC, and typically developing infants who received the RL experience only through the SIPPC. The sessions involved 3 5-minute trials that included caregiver-led movement of the SIPPC and of the infants' arms and legs as well as periods during which the infant was encouraged to move independently toward either a toy or the caregiver. Sessions were conducted twice a week for up to 12 weeks.

    Researchers found that after 12 weeks, infants in the combined RL and EBL group made improvements over the RL-only group in the areas of rotational amplitude—essentially, the amount of trial-and-error used—and the length of linear paths achieved. Wrist and foot path lengths remained about the same between the groups, but the combined group registered significantly higher scores than the RL-only group in the Movement Observation Coding Scheme (MOCS), a measure of goal-directed movement.

    "Overall the findings support the differential effect of RL and EBL in skill learning in infants with CP," authors write, adding that the greater use of trial-and-error methods among the combined group reflects the ways that infant learning of new motor skills may at times require RL but at the same time involve uncoordinated movements, a cognitively demanding process "that is likely to respond better to EBL." The ultimate result: greater travel distances and more goal-directed movement among the combined group.

    In a video interview at the 2019 APTA NEXT Conference and Exposition, Kolobe boiled down the essential findings of the study. [Scroll down for video]

    "Allow mistakes," Kolobe said, "because that's part of [infants'] repertoire of learning how to do something. Allow them to go after other options, because eventually they get the right one."

    Kolobe also believes the study scratches the surface of another important consideration—the complex nature of cognitive elements during movement learning.

    "A lot of cognition enters into [learning movement]," Kolobe said. "Infants do strategize. There's a lot of executive function required to move."

    Authors believe the executive function demands may be of special note among infants with CP. In their study population, they write, "adapted behaviors were not readily repeated at the next sessions"—a finding that partly may be attributable to the ease with which EBL can be forgotten and partly attributable to the type of brain insult associated with CP. The memory decay "highlights the need to carefully balance RL and EBL approaches," they add.

    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.

     

     

     

    UnitedHealthcare Announces New Pilot Program to Increase Access to Physical Therapy Services as Result of Collaboration With APTA

    This week, UnitedHealthcare (UHC) announced a pilot program in 5 states that will waive the cost of copays and deductibles for 3 physical therapy sessions for patients with low back pain (LBP) living in Connecticut, Florida, Georgia, North Carolina, and New York. The pilot, which could affect as many as 1 million enrollees, goes into effect July 1, 2019. Other states will join the program in 2020 and 2021.

    Specifically, the pilot will be available to UHC enrollees with new onset of LBP when receiving care from an outpatient in-network provider. This benefit change will not extend the enrollee’s physical therapy or chiropractic benefit maximum, and will apply only to services related to treating back pain. Enrollees must have physical therapy or chiropractic benefits remaining in order to use this benefit.

    UHC will send emails about the benefit change on a quarterly basis to enrollees in the 5 states as they gain access to the benefit. Information also will be included on myuhc.com in the enrollee’s benefit information under Rehabilitation Services - Outpatient Therapy and Chiropractic (Manipulative) Treatment.

    This pilot follows a multiyear collaboration between APTA, OptumLabs, and UHC that included publication of a study in the American Journal of Managed Care (subscription required). This study affirms that higher copays and payer restrictions on provider access may steer patients away from more conservative treatments for LBP, including physical therapy and chiropractic services. "Innovative modifications to insurance benefits," authors write, "offer an opportunity for increased alignment with clinical practice guidelines and greater value."

    "This type of collaboration between a professional association and a private insurer is key to advancing the essential role of the physical therapy profession in improving outcomes for patients," says Carmen Elliott, MS, APTA's vice president of payment and practice management. "APTA continues to advocate for benefit design that is validated by data and meets the needs of patients, providers, and payers.”

    The study's authors, which include APTA member Christine M. McDonough, PT, PhD, hypothesized that patients with LBP who had easier access to a wider array of providers and lower out-of-pocket costs would be more likely to first seek out conservative approaches such as physical therapist (PT) or chiropractic services.

    Researchers looked at 5 years of claims data from OptumLabs Data Warehouse for 117,448 adult patients to determine the relationship between health plan benefit design and patient choice of primary care physician (PCP) versus a physical therapist or chiropractor as the first-line provider for new-onset LBP.

    Patients were excluded if they were not enrolled 2 years before and after the onset of LBP with no prior diagnosis of LBP or back procedures, or if they had filled opioid prescriptions within a year of LBP onset. Included patients could not have had any neoplasm diagnosis in the previous year or recent LBP-related diagnoses, such as spinal fractures, that would require more intensive treatment.

    For the analysis, authors divided the patients into 2 groups: those who first sought treatment from either a PCP or a PT, and those who first sought treatment from either a PCP or chiropractor.

    Their findings include:

    Only 2.8% of the 82,052 patients in the PCP-versus-physical therapist group chose to see a PT first, while 31% of the 115,144 patients in the PCP-versus-chiropractor group chose to see a chiropractor first. The majority of patients had a point-of-service (POS) health plan, and approximately 30% had no copayment or deductible to meet.

    Fewer restrictions on provider access was associated with higher likelihood of seeking out physical therapy or chiropractic treatment. Compared with patients with a POS plan, patients enrolled in a preferred provider organization (PPO) plan—the least restrictive option—were 32% more likely to see a physical therapist first. Patients in exclusive provider organization (EPO) plans were 16% less likely than POS patients to see a physical therapist first. These findings were similar for choosing a chiropractor versus a PCP.

    Higher copayments decreased the likelihood of a patient seeing a physical therapist as first provider. Patients with a copayment over $30 were 29% less likely to see a physical therapist first than were patients with no copayment. This association was not evident for chiropractic.

    As deductibles increased, the odds of a patient seeing a PT first declined; this association was not consistent for chiropractic. Patients with a deductible between $1,001 and $1,500 were 19% less likely to see a PT first (as opposed to seeing a PCP) than were those who had no deductible, while patients in this level were more likely to see a chiropractor first. Patients with a deductible of $1,500 or more were 11% less likely to see a PT first and 7% less likely to see a chiropractor first.

    There were mixed results for consumer-driven health plans (CDHPs) such as health reimbursement accounts (HRAs) and health savings accounts (HSAs). Patients with HRAs were 16% less likely to see a PT first compared with patients without CDHPs, but they were slightly more likely to see a chiropractor first. Patients with HSAs were 25% more likely to see a PT first compared with patients without CDHPs. HSAs had no effect on the chiropractic group.

    "Our study has demonstrated that patients experiencing LBP are moderately responsive to network restrictions and cost sharing in their choice of entry-point provider," authors write. "Reductions in spending are not necessarily accompanied by improvement in value, particularly if patients bypass routine care that would prevent higher downstream costs."

    [Editor's note: McDonough is also the recipient of a 2015 Foundation for Physical Therapy Research Magistro Family Foundation Research Grant as well as a recipient of the 2009 New Investigator Fellowship Training Initiative in Health Services Research.]

    News From NEXT: 2018-2019 Marquette Challenge Raises Over $266,000 for the Foundation

    Students from across the country were recognized June 13 during the Foundation for Physical Therapy Research (Foundation) awards luncheon for their participation in the 31st annual Marquette Challenge—which for 2019-2020 will be called the VCU-Marquette Challenge. Virginia Commonwealth University (VCU) was recognized as the top fundraising school, raising $34,327. The challenge now takes on VCU’s name along with host Marquette University as part of the contest's tradition.

    Earning second place was the University of Pittsburgh ($22,648), and coming in third was the University of Delaware ($18,323). The Foundation also recognized Marquette University students for their financial commitment to the challenge in raising $25,000.

    The annual challenge is a grassroots fundraising effort coordinated and carried out by student physical therapists and physical therapist assistants across the country.

    This year, more than 150 schools nationwide participated in creative efforts to support the Foundation, raising a total of $266,019.

    Funds raised through the challenge go toward physical therapy research grants and scholarships and support the rigorous scientific review process that helps the Foundation identify the most promising new investigators. Since 2002, 27 research grants and scholarships have been awarded in the name of the challenge. Funds from the challenge also supported a recent high-priority research grant to look at physical therapist interventions for older adults who have multiple chronic conditions.

    To view the complete list of participating schools visit the Foundation's webpage.

    The Good Stuff: Members and the Profession in the Media, June 2019

    "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!

    Feeling the beat of pain management: Don Walsh, PT, DPT, MS, associate professor of physical therapy at North Georgia University, has teamed with professors from the school's music department to offer a drum circle as part of a pain management program—an idea funded in part by Move Together's Pro Bono Incubator. (Gainesville, Georgia, Times)

    Helping to shape health care policy: Alan Meade PT, ScDPT, MPH, has been appointed to the US Centers for Medicare and Medicaid Services Advisory Panel on Outreach and Education. (CMS announcement)

    Assistant coach/PT: Maral Javadifar, PT, DPT, talks about the path that led her to her position as an assistant coach for the Tampa Bay Buccaneers. (ESPN)

    Foam roller risks: Danielle Weis, PT, DPT, has a few words of warning for foam roller fanatics. (wellandgood.com)

    I like big putts and I cannot lie: Morgan Lemos, PT, DPT, describes how physical therapy can keep golfers on the course. (NBC2 News, Fort Meyers, Florida)

    Quotable: “Physical therapy and occupational therapy are important to him because he’s trying to gain the strength to stand from his chair for his badge pinning and salute for the national anthem." -Jessica Greenfield, whose 11-year-old son Miller aspires to become a police officer as he struggles with the challenges of a neurodegenerative disease. Miller was recently accepted as a cadet in the Sacramento, California, police department. (CBS13 News, Sacramento)

    Strength, courage, and inspiration in fighting cancer: Michelle Masterson, PT, PhD, delivered a moving speech at a cancer survivor celebration held by the Eleanor N. Dana Cancer Center at the University of Toledo Medical Center. (Toledo, Ohio, Blade)

    Bringing a PT perspective to CMS: Carmen Cooper-Orguz, PT, DPT, MBA, has been named to the US Centers for Medicare and Medicaid's annual advisory panel on hospital outpatient payment. (Federal Register)

    Sculpting a PT vision: Richard Smith PT, MS, has retired from his clinic position and is now making his mark as a sculptor. (Fairfield, Montana, Sun-Times)

    Getting in the swim of things: Laura Diamond, PT, MSPT, MS, leads a swim team of patients, family, and friends that competes in local fundraising events for cancer research. (Lincoln, Massachusetts Wicked Local)

    A PT's testimony on serving in the military as a transgender woman: Army Capt. Alivia Stehlik, PT, DPT, testified to congress about the contributions made to national defense by her and other transgender individuals in the military. (NBC News)

    When discomfort takes off: Blake Dircksen PT,DPT, offers tips on the best way to sit on a long flight. (lifehacker.com)

    Get some rest: Alika Antone, PT, DPT, discusses the importance of adequate sleep to good health. (South Sound Magazine)

    Don't stand for sitting: Kasey Kruse PT, DPT, outlines the risks of too much sitting, and what can be done to address them. (CBS News11/21, Dallas-Fort Worth, Texas)

    Quotable: "We physical therapists hope that people will begin to see physical therapy as a necessary and tremendously helpful part of maintaining a healthy lifestyle. Eventually, we hope people will come to physical therapy for an annual check up, so that we can spot dysfunction before it becomes painful and problematic." –Rena Eleazar, PT, DPT, on helping people to understand when they should see a PT. (Self)

    Helping heroes regain independence: Whitney Anderson, PT, DPT, shares her pride in being part of a rehab team that helped a wounded warrior gain independence through use of an exoskeleton. (KFOR News 4, Oklahoma City, Oklahoma)

    Easing plantar fasciitis pain: Chris Wilson, PT, outlines ways to manage plantar fasciitis at home. (Frontiersman)

    Got the (tummy) time? Tricia Catalino, PT, DSc, and Jill Heathcock, PT, MPT, PhD, discuss the importance of "tummy time" for infants. (New York Times)

    Worth the weight: Keaton Ray PT, DPT, ATC, provides pointers on how to start weight training the right way. (nextavenue.org)

    The Lakers' PT advantage: Judy Seto, PT, DPT, has been named director of sports performance for the Los Angeles Lakers. (lakersnation.com)

    The keys to more years in the driver's seat: Heidi Piccione PT, DPT, recommends movements that can build flexibility to help older adults keep driving. (Tampa Bay, Florida, Times)

    Journal-publishing how-tos: Christopher Kevin Wong PT, PhD, and Jean Fitzpatrick Timmerberg PT, MHS, PhD, share what they've learned about starting up an academic journal (they're cofounders of the Journal of Clinical Education in Physical Therapy). (Columbia University Medical Center newsletter)

    Let's dance: Michelle Reilly PT, DPT, explains how dancing can be an effective alternative to the gym when it comes to staying physically fit and active. (Omaha, Nebraska, World-Herald)

    Quotable: “There are times where somebody else has the knowledge that a physician doesn’t have to be the leader. A good example would be if physical therapy or some other modality is more important to the patient progressing. In those instances, the physician shouldn’t be necessarily calling the shots.” – Jason Higginson, MD, chief of pediatrics at eh Brody School of Medicine at East Carolina University, and co-author of JAMA module on working in interprofessional teams. (American Medical Association newsletter)

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

    News From NEXT: Oxford Debaters Argue: Is Social Media Hazardous?

    The verdict is in: social media is hazardous to the physical therapy profession. At least some of the time.

    That was the outcome of the 12th annual Oxford Debate, during APTA's NEXT Conference and Exposition in Chicago, which in traditional style-over-substance fashion included the pro team wearing hazmat suits while the con team adopted a Blues Brothers theme.

    "Our job isn't to say that social media is good or evil but that it's hazardous," Karen Litzy, PT, DPT, said in her opening remarks for the pro team. "People [complain], sell pseudoscience, and attack others. This is where social media becomes hazardous."

    Litzy was joined on the pro team by Jimmy McKay, PT, DPT (team captain), and Jarod Hall, PT, DPT. Taking the opposing position were Ben Fung, PT, DPT, MBA (team captain), Jodi Pfeiffer, PTA, and Rich Severin, PT, DPT. (Positions in the Oxford Debate are assigned, and may not reflect the personal opinions of the participants.)

    News From NEXT: Debaters Argue: Is Social Media Hazardous?

     

    Pfeiffer, dressed as Sister Mary Stigmata, led off for the con team, arguing, "Social media is vital. It's how we communicate with each other. Some people disseminate misinformation on social media. How do we correct it? On social media! We will use it to get rid of the misinformation."

    Hall responded, "One study said that, across social media, young professionals spend 116 minutes a day. Social media thrives on the misfortunes of others." Borrowing the concept of schadenfreude—defined as pleasures derived from the misfortunes of others—Hall referred to schandenFacebook. "It's where you relate the great things you said to Mrs Jones and ignore the stupid things you said to 50 others. Sometimes the grass looks greener (on the other side) because it's fake."

    Fung insisted that social media does more good than harm, asking, "Which is more hazardous to our profession: that questions are being asked or that we're not part of the conversations? One study found that only 1 in 10 people who need physical therapy will receive physical therapy. If you want to get the average person away from the screen, you have to be part of the conversation. The greater question is that when people ask questions, we're not there [on social media] in their time of need."

    Audience participation followed, with a near-even split of 7 for the pro position and 6 for the con. Among the comments:

    • Anything can be hazardous. If we're not using social media, we're missing an opportunity.
    • How many people at NEXT have met people on social media?
    • How many people have sat next to someone at NEXT who isn't paying attention because they're on social media?
    • Maybe we shouldn't be looking for evidence and research on social media.

    The attendees also made their views known by using clappers, running from one side of the room to the other as a debater made a persuasive point, and enthusiastically cheering.

    Severin summarized for the con team: "PTs are the movement experts. But people have an outdated image of physical therapy. #ChoosePT changed many views about physical therapy. The PT Day of Service, under the brand of physical therapy, has helped. Social media is key to that movement. Illinois and Texas recently adopted direct access legislation, and social media was vital in that effort. Social media has removed hazards to the profession. It's where we create communities. In addition, it's where patients and the next generation of PTs are going. We need to engage with our communities on social media."

    McKay summarized for the pro team: "My job isn't to show that social media is good or bad, just that it's hazardous. Social media leads you to do things you'd never do in person. … Social media is how the anti-vax science goes viral. This is how flat earth society thought goes around the world. Social media filters and distorts information. That's hazardous. But social media is not going away. So we must be safe when using it."

    After weighing the arguments and presentations, moderator Charles Ciccone, PT, PhD, FAPTA, found in favor of the pro team 29-23.

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    News From NEXT: For Optimal Outcomes, Look Beyond Compensation Patterns, Maley Lecturer Says

    "Any movement-related profession—personal trainers, athletic trainers, dance therapists, yoga instructors—who can observe impairments such as a weak muscle can try to fix it," said Beth Fisher, PT, PhD, FAPTA, in delivering the 24th John H. P. Maley Lecture on June 14 at Combined Sections Meeting. However, too often the "fix" involves the patient compensating with movement patterns that interfere with the ability of an affected limb to improve to its true potential. Fisher argued that with their level of education and skill, physical therapists (PTs) can and should identify and help the patient recover that capability.

    During her presentation "Beyond Limits: Unmasking Potential Through Movement Discovery,"

    Fisher said that in earlier clinician practice with patients with stroke and brain injury she continually hit ends points with her patients, but she realized "these were my endpoints and not the patient's, [because] at least 1 aspect of the movement abnormalities…were the results of compensation." Given the brain's ability to continuously alter its structure and function, and the body's ability to achieve movement goals in more than 1 way, people with an impairment tend to progress toward the movement pattern that is most efficient—achieves a goal using the least amount of energy and the fewest body parts. And while a compensatory solution may get the job done overall, this easy route that comes naturally may not lead to optimal improvement, thus denying the patient the best possible outcome. In fact, "the compensations [patients] choose may be the source of the problem—may actually predispose the problem to occur," Fisher said, by keeping the patient from exploring better ways to achieve their movement goals.

    She asked: Is this really the best we can do? "If we want to reach someone's full capacity, then we need to go beyond this limited choice that patients come up with on their own without a physical therapist," Fisher said. However, she argued, PTs have been academically trained to view movement from an impairment-driven perspective—the assumption that a patient's compensatory movement pattern results from an impairment that is masking his or her capability. And so both PT and patient expect that compensation will provide the best—or only—results.

    "If I have minimal expectations," Fisher asked, "how is that going to impact my patient's expectations? What is that going to do for recovery potential?" Instead, as professionals with the expertise to look beyond compensation approaches, PTs must encourage potentially riskier, more-difficult solutions. "With what we know about brain plasticity, it is our job to help patients realize that they have more options," she said.

    By modifying that implicit choice, the PT can help patients discover a capability they may not have even realized they have. "The most rewarding moments I have had in my career have come when I hear ‘I didn't know my leg (or arm) could do that,'" Fisher said.

    She noted that PTs can't ignore impairment, "but if we are only viewing the problem from that perspective then we and our patients will reach a plateau-minimizing capacity."

    Instead, every student and every therapist should include the perspective of looking at how a movement choice can mask capacity. "We need to start from the bottom up," Fisher said, "and teach students to observe movement and hypothesize how implicit choices—not just impairments—may be driving movement faults." Otherwise, "we have limited patients and their potential to discover other options for movement by a perspective that does not consider the choices they make."

    News From NEXT: McMillan Lecturer Outlines Keys to Excellence in the Physical Therapy Profession

    Tom McPoil, PT, PhD, FAPTA, said he intentionally structured the title of the 50th McMillan Lecture—"Is Excellence in the Cards?" as a question "to raise an element of doubt or uncertainty in our quest to achieve excellence." After all, he said during his delivery of the lecture on June 13 as part of the APTA NEXT Conference and Exposition in Chicago, he has several concerns regarding the profession's ability to achieve excellence.

    Before describing the reasons for his uncertainty, McPoil did recognize some of the profession's remarkable accomplishments since he began his career in 1973. "We no longer serve as a subservient technician in the health care system, our students now obtain an exceptional education and are granted a doctoral degree, we can practice in a variety of specialty areas in multiple practice environments, and we have achieved the ability to practice autonomously with patients having direct access to our services," he noted.

    But he said there still is room for improvement from both clinical and academic perspectives, and the remainder of his lecture outlined those perspectives. From the clinical standpoint, he described 3 areas.

    First, McPoil questioned continued acceptance of examination and management methods that may have been proven to have no evidence to support their use. As an example, he identified what is known as the podiatric model, which classifies foot types based on the concept of subtalar joint neutral position. McPoil said that subsequent studies—including those he and colleagues conducted—showed that "subtalar joint neutral position had no relevance to the typical pattern of rearfoot motion. In short, our results challenged the validity of the podiatric model." Yet, he continued, many physical therapist education programs and postprofessional continuing education courses still teach the model. McPoil expressed his hope that the profession will continue to stress the importance of using methods that have been validated with basic science and clinical evidence, especially at entry-level and in education programs, "as it is our new doctor of physical therapy graduates who must serve as our profession's change agents."

    Second, McPoil expressed concern over a lack of acknowledgment of historical research studies that provide evidence for a practice's continue use. He quoted a 2009 article by Mary Halefi ("Forget This Article: On Scholarly Oblivion, Institutional Amnesia, and Erasure of Research History," Studies in Art Education) that "recurring themes, issues, and concerns are part of any field" and failing to cite them along with more contemporary studies risks the loss of past scholarly endeavors upon which current research may be based. "Hopefully," McPoil said, "our professional journals will always perform their due diligence" to retain the contributions of past scholars and researchers in the profession.

    Inconsistence in the level of care was McPoil's third area of needed improvement. He noted some probable causes for inadequate care, such as limited patient time resulting from low payment rates, some highly specialized areas of practice that not all PTs are familiar with, and lack of clinical practice guidelines (CPGs) that address needed services. As for specialized areas of practice, he said that physical therapist-to-physical therapist referral was "rare," and the need for intraprofessional referral needs more emphasis during entry-level education. Concerning CPGs, McPoil argued that while important, they cannot always guide the clinician to an appropriate decision and "cannot replace the need for clinical reasoning and practice knowledge." He continued that such knowledge "can be achieved only through residency or fellowship training."

    To that end, McPoil said that it may no longer be feasible to train a generalist at the entry-level, and the profession must consider allowing specialization to begin before graduation. He identified challenges to developing residency and fellowship programs, such as student loan debt, salaries not commensurate with advanced clinical specialization, and a lack of federally funded support. He expressed his hope that the profession will prioritize development of these programs, as needed funding for them won't occur until they are the expected route following professional graduation. "Our pathway to excellence demands no less!" he said.

    McPoil followed up with his thoughts on achieving academic excellence, specifically the need for every faculty member to have "a personal agenda for scholarship that includes publication."

     

     

    News From NEXT: Building Wellness Programs in the Least Likely Places

    Sometimes, basic assumptions beg to be questioned. Just ask physical therapists (PTs) in the oncology rehabilitation department of Froedtert Hospital and Medical College of Wisconsin, who wondered why prevention and wellness couldn't be a part of the patient experience from the moment they entered the facility's doors.

    That questioning led to the development of an innovative group exercise program for patients checked in to the hospital for chemotherapy and other treatments primarily related to blood cancers—and so far, the program seems to be allowing many patients to leave as mobile, if not more so, than when they arrived. On June 13, the PTs shared their story of how they established and grew the program, known as the "Strength in Numbers" exercise class, as part of APTA's NEXT Conference and Exhibition in Chicago.

    The idea behind the program was based on a reality check of the typical path of an oncology patient visiting the hospital for treatment, explained Kelly Colgrove, PT. Unlike patients who arrive with other conditions such as congestive heart failure, "our patients walk in strong and independently." During the course of treatment, however, they often experience decreased muscle strength, challenging PTs to play catch-up before the patient is discharged.

    The Froedert PTs wanted to "Strength in Numbers" change that. As it now operates, the program—known as "SIN" to the amusement of patients—offers a 1-hour group circuit training class 2 times a week. Colgrove describe SIN as "a fun environment based on camaraderie and music, but all within the acute care setting."

    Patients are selected for the voluntary program based on their health at the time of check-in, Colgrove explained. Those whose condition is more fragile receive more typical 1-on-1 physical therapy. But the patients who qualify for SIN are assessed, given goals, and scheduled to participate in the group. Once the SIN group, patients still can choose to return to the more traditional therapy program.

    Besides the direct physical benefits to patients, the SIN program has helped to reinforce what the presenters call a "culture of mobility" at the hospital.

    The presenters led attendees through their process of developing and maintaining the program, encouraging audience members to think about similar possibilities in their own practice settings. They explained the importance of a solid basis in research, careful consideration of stakeholder concerns, evaluation of current and needed resources, and program metrics to evaluate outcomes, among other areas.

    Through their recaps, the presenters demonstrated how flexibility and creativity are key elements in all areas of development, implementation, and evaluation. "Being able to adapt and evolve is going to be key," explained Alyssa Kelsey, PT, DPT. For the SIN program, that means seeking ongoing input from patients and staff, as well as monthly check-in meetings to monitor operations and identify future goals.

    That flexibility should also include the capacity to question your own assumptions and evaluative measures, explained Colgrove. "Sometimes, the questions you think you want to answer at the beginning of the program may not be the questions you want to answer after a year," she said.

    One question has been consistent throughout the SIN program: Does it work? So far, the answer seems to be yes. Outcome measures for patients with a length of stay longer than 20 days and more than 50% participation in SIN found that 72% maintained or improved their 5-time sit-to-stand scores, 64% maintained or improved on Functional Gait Assessment, and 53% maintained or bettered their scores related to self-perceived deficits at discharge.

    And if patient enthusiasm for the program is any measure, the SIN program also seems to be doing well: according to the presenters, patients frequently have the same criticism of the offering—that the classes only occur 2 days a week.