Public and private payers are widely
using performance measures to assess the use of low-value interventions, such as
imaging for patients with uncomplicated low back pain, and using the results
for public reporting and pay-for-performance, say authors of a position paper
written on behalf of the American College of
Physicians Performance Measurement Committee
and published October 30 in Annuals of
The paper gives an overview of
performance measures that target low-value services in order to help physicians
understand the strengths and limitations of these measures, provides specific
examples of measures that assess the use of low-value services, and discusses
how these measures can be used in clinical practice and policy.
The discussion includes 2
categories of low-value interventions:
(1) those for which the harms probably exceed the benefits (eg, performing
colorectal cancer screening for patients older than age 85 years) and (2) those
that may provide benefits but for which a quantitative assessment of their
benefits and costs by a multistakeholder group (patients, clinicians, and
policymakers) suggests that the tradeoff between health benefits and
expenditures is undesirable (eg, screening for cervical cancer in low-risk
women aged 65 years or older and in women who have had a total hysterectomy for
performance measures should be based on rigorous study designs (for example,
randomized controlled trials) that assessed the benefits, risks, and costs of
interventions," say the authors. However, to develop performance measures
for low-value services, they suggest that researchers "will probably need
to use data from different types of research design and methods, including
subgroup analyses from clinical trials, cohort studies, cost–benefit analyses,
and cost-effectiveness analyses."
"Just as with
other performance measures, those for low-value services can be used in a
variety of ways to improve quality and health care value," they add.
Read more about the American College of Physicians' (ACP) high-value care initiative that aims to help physicians and patients understand the
benefits, harms, and costs of interventions, and determine whether services
provide good value. Go to the February 2011 issue
of Annuals of Internal Medicine for
free full text of ACP's clinical guideline for diagnostic imaging for patients
with low back pain. The guideline calls for diagnostic imaging only if patients
have severe progressive neurologic deficits or signs or symptoms that suggest a
serious or specific underlying condition.
The Osteoarthritis Action Alliance (OAAA) recently posted a recording of its October 17 "lunch and
learn" event titled Energy Balance and the Obesity Epidemic. This
30-minute presentation by weight control and obesity expert Steven Blair, PED,
FACSM, offers some possible explanations about the causes of the US obesity
epidemic. Blair discusses some of his research on this issue, including his
energy balance study, which revealed critical information about the relationship
between diet, weight, and energy expenditure.
is a member of OAAA.
New research from the Netherlands shows that older patients with
chronic obstructive pulmonary disease (COPD) are at increased risk for carotid
artery plaque formation and for the presence of vulnerable plaques with a lipid
core, according to
the American Thoracic Society.
cross-sectional study, part of the Rotterdam Study, an ongoing population-based
cohort study examining the occurrence of and risk factors for chronic diseases
in subjects aged 55 years and older, involved 253 patients with COPD and 920
patients without the condition. COPD was confirmed by spirometry.
Participations with carotid wall thickening (intima-media thickness ≥ 2.5 mm)
on ultrasonography underwent high-resolution MRI to characterize carotid
with COPD had a twofold increased risk of carotid wall thickening on
ultrasonography compared with controls. This risk increased significantly with
the severity of airflow limitation. On MRI, vulnerable lipid core plaques were
significantly more frequent in participants with COPD compared with those
should be aware that COPD patients are at increased risk for asymptomatic
carotid atherosclerosis and that COPD might lead to vulnerable plaques by
inducing or aggravating the presence of plaques with a lipid core," said researcher Bruno H.C. Stricker, MD, PhD.
underlying risk factors for stroke in COPD patients can help identify those at
high risk and lead to the development of more personalized preventive treatment
strategies targeting this devastating complication," he added.
findings were published online ahead of print publication in the American
Thoracic Society's American Journal of
Respiratory and Critical Care Medicine.
of Haitian Rehabilitation (FONHARE) is a grassroots Haitian organization
providing rehabilitation services to the citizens of Ouanaminthe. It is the
only organization providing rehab services in the northeast of Haiti to 13
cities with almost 500,000 citizens. Ivens Louius, the founder and
director, is a physical therapist and an occupational therapist. FONHARE currently
is providing services in a medical clinic owned and run by Louius's brother, who is a physician. A foundation has
been laid for a large onsite rehabilitation clinic adjacent to the medical
clinic. There is a genuine need for volunteers to be part of establishing
rehabilitation and physical therapy as a specialized service in a country
that had virtually none before the 2010 earthquake. For more information about
volunteer opportunities, as well as opportunities to provide financial support,
visit FONHARE at www.fonhare.org.
Self-reported function, hip range of motion (HROM), and patient-perceived improvement
occurred after an 8-week program of exercise therapy (ET) for patients with hip
osteoarthritis (OA), say authors of an article
published in Archives of Physical
Medicine and Rehabilitation. Manual therapy (MT) as an adjunct provided no
further benefit, except for achieving higher patient satisfaction, they add.
For this investigation, 131 patients with hip OA recruited from general
practitioners, rheumatologists, orthopedic surgeons, and other hospital
consultants in Dublin, Ireland, were randomized to 1 of 3 groups: ET (n=45),
ET+MT (n=43), and wait-list control (n=43).
Participants in both ET and ET+MT groups received up to 8 treatments over 8
weeks. Control group participants were rerandomized into either the ET or ET+MT
group after the 9 week follow-up. Their data were pooled with original
treatment group data—ET (n=66) and ET+MT (n=65).
The primary outcome was the WOMAC physical function (PF) subscale. Secondary
outcomes included physical performance, pain, HROM, anxiety/depression, quality
of life, medication usage, patient-perceived change, and patient satisfaction.
There was no significant difference in WOMAC PF between ET (n=66) and ET+MT (n=65)
groups at 9 weeks (mean difference 0.09) or at 18 weeks (mean difference 0.42),
or other outcomes, except "patient satisfaction with outcome," which was higher
in the ET+MT group. Improvements in WOMAC, HROM, and patient-perceived change
occurred in both treatment groups compared with the control group.
therapists (PTs) should consider a number of details before contracting with
payers, whether private or public. View
APTA's new Managed Care Contracting Toolkit
today to learn valuable information about joining a managed care plan, and
securing and tracking contracts. A chapter on "doing the math"
can help you decide which fee schedules, patient populations, and
payment methodologies are best suited to your practice. The toolkit also breaks down the pros and cons of common
methodologies that third-party payers use to pay for physical therapy services
and offers information on negotiating contracts.
APTA's Payment and Practice Management Department created the member-only toolkit to help PTs make informed decisions about joining a provider network.
analysis of clinical practice guidelines archived on the National Guideline
Clearinghouse (NGC) website as of June 2011 demonstrated poor compliance with
Institute of Medicine (IOM) standards, with little if any improvement over the
past 2 decades, say authors of an article published this month in Archives
For the study, 2 reviewers independently screened 130 guidelines selected at
random from NGC's website for compliance with 18 of 25 IOM standards.
The overall median number of IOM
standards satisfied (out of 18) was 8 (44.4%). Fewer than half of
the guidelines surveyed met more than 50% of IOM standards. Barely a third of
the guidelines produced by subspecialty societies satisfied more than 50% of
the IOM standards surveyed.
Information on conflicts of interest was given in fewer than half of the
guidelines surveyed. Non-English literature, unpublished data, and/or abstracts
were rarely considered in developing guidelines. Differences of opinion among
committee members generally were not aired in guidelines. Benefits of
recommendations were enumerated more often than potential harms. Guidelines
published from 2006 through 2011 varied little with regard to average number of
IOM standards satisfied.
everywhere is developing guidelines and there is no real quality control,"
lead author Philip A. Mackowiak, MD, told Reuters
"There is no good oversight of who actually develops the guidelines or
what criteria need to be met in order for them to be published."
IOM's standards were not published until 2011. Mackowiak acknowledges that
the experts who developed the guidelines reviewed by his team would not have
been able to use IOM's standards. However,
he added that similar standards have been published before and that they were
basic enough that they should have been followed, says Reuters.
photos and brief descriptions of your events to firstname.lastname@example.org and we will consider them for
our NPTM Celebrations webpage.
a deserving APTA member who is 50 years or older, committed to being active and
fit, and encourages others to be the same. Go to www.apta.org/FitAfter50/ to learn more about the campaign
and to nominate yourself or another deserving 50+ year old.
"APTA applauds the proposed legal settlement of the nationwide class action lawsuit directed toward ensuring Medicare coverage of reasonable and necessary therapy and nursing services for people with chronic and degenerative health conditions," says APTA President Paul A. Rockar Jr, PT, DPT, MS, in a statement issued today regarding the lawsuit Glenda Jimmo, et. al vs. Kathleen Sebelius. Plaintiffs in the lawsuit alleged that the US Department of Health and Human Services, Medicare contractors, and administrative review boards were arbitrarily limiting coverage for patients who did not show long-term improvement in their conditions, even though official Centers for Medicare and Medicaid Services rules state these services should be covered.
Under this proposed agreement, Medicare would pay for skilled therapy and nursing services if they are needed to maintain the patient's current condition or prevent or slow further deterioration.
The New York Times
highlighted how the policy change will result in significant cost savings in the long term by allowing patients to receive physical therapy and other services in community-based settings and avoiding expensive care in hospitals and nursing homes.
APTA will continue its efforts to ensure access to appropriate physical therapy services. The association also will work with the Centers for Medicare and Medicaid Services and its contractors to ensure accurate and fair incorporation of revisions to the current Medicare manuals and regulations that reflect this significant change. In addition, the association will continue to analyze the proposed settlement for potential impact on Medicare policies regarding the reporting of functional limitations on the claim for outpatient therapy and the requirement to complete a functional reassessment at defined intervals under the Home Health Part A benefit.
APTA plans to actively educate members to ensure proper understanding and application of the newly revised Medicare regulations.
66% of online American adults use social networking sites, according to a 2012 Pew Internet Project study, many users remain skeptical
about using social media for professional purposes. To demonstrate some of the
potential benefits of social media, APTA hosted an online roundtable discussion Monday with 5 physical
therapists and 1 student of physical therapy, all of whom actively use Twitter
and other social media tools to network about physical therapy issues.
53-minute discussion, conducted using Google+ Hangouts and archived via
YouTube, covers the weekly #SolvePT tweetchat, ways that social media are
effective in advocacy efforts, benefits of social media for physical therapy
educators and students, and the challenges of discussing critical issues in a
social media environment, among other topics.
in the panel were Allan Besselink, PT,
Dip MDT, Christopher Bise, PT, DPT,
MS, OCS, physical therapist student Matt
DeBole, Selena Horner, PT, MS, GCS,
Eric Robertson, PT, DPT, OCS, and
Ann Wendel, PT, ATC, CMTPT.
roundtable is available on the Social Media Tips & Best Practices
webpage of APTA.org, which includes links to APTA's policy on social media, a new video tutorial for Twitter,
and other resources.
National Physical Therapy Month ends, take the time to acknowledge your
colleagues or students with an APTA 2013 Honor or Award nomination. By
nominating the person or people you feel are most deserving of an honor or
award, you can help APTA celebrate their many contributions to the physical
Your participation in the nominating process is
extremely important. It's quick, easy—and in keeping with APTA's green
initiative, all APTA national Honors and Awards applications are available for
Go to APTAs Honors and Awards page and submit your nominations
online. All submissions must be received by December 1.
E-mail questions to email@example.com or call
800/999-2782, ext 3233, for more information.
running out to nominate yourself or an APTA-member colleague to national office.
The online Nomination Form (NC 1) is
available on APTA's website under "Leadership and Governance" and
then "Elections and Nominations." The APTA Nominating Committee is
seeking recommendations for the 2013 Slate of Candidates for the following
positions: secretary, vice speaker, 3 directors, and 2 Nominating Committee
value of gathering information on body mass on patients or clients is the focus
of a new podcast in the recently launched series titled Extracting Hidden Gems
from Simple Clinical Measures: The Why, How, and Then What?
Excess body mass or obesity has been identified as a critical health
issue in the United States and around the world. Learn what data physical therapists should gather
and what to do with it, and find additional resources on body mass index, in
this prerecorded podcast that discusses the anthropometric characteristic of
Extracting Hidden Gems from Simple Clinical Measures series can be found on
APTA's recently enhanced vital signs and other patient screenings webpage. This quality-focused web
resource provides information on why and when vital signs and other patient
information should be gathered.
research shows that age, race, employment status, living situation, and education
and income levels are just some of the factors that may play a role in hospital
readmissions. However, the Centers for Medicare and Medicaid Services (CMS) is
not taking these causes into account in its readmissions reduction program,
which started penalizing hospitals October 1 for excessive readmissions, says
an article by Reuters News.
In the study,
published in Journal of General Internal
Medicine, researchers analyzed data from 20 studies on pneumonia and 52 on
For pneumonia patients, among the factors linked to the risk of being
readmitted to the hospital were being older and not white. Having a low level
of education, low income, and being unemployed also were tied to a higher risk
of going back into the hospital.
For heart failure patients, the risk of being readmitted to a hospital was associated
with being elderly, African American, or Hispanic.
The researchers cannot say for certain that the risk factors identified are
what cause a patient to be readmitted to the hospital. But they note in their
report that this kind of information could be used by physicians, case
managers, and discharge planners "to flag patients at high risk of
readmission because of certain nonmedical vulnerabilities," says Reuters.
Visit APTA's hospital readmissions webpage for information
about how physical therapists can help reduce readmissions by providing recommendations for the most appropriate level of care to the health
care team prior to and during care transitions.
Board of Director member Dianne Jewell,
PT, DPT, PhD, CCS, recently was appointed to the National Quality Forum's
(NQF) Ad-hoc Planned Readmissions Committee. NQF readmissions panels have primarily
been staffed with physicians, which makes Jewell's appointment particularly significant
for the physical therapy profession.
hoc review may be conducted on an endorsed measure at any time if 1 or more of
the following criteria are met:
reviews can be requested at any time by any party, as long as there is adequate
evidence to justify the review.
conduct an ad hoc review requested by the Centers for Medicare and Medicaid
Services for the endorsed measures: 1551, hospital-level 30-day all-cause
risk-standardized readmission rate following elective primary total hip
arthroplasty and total knee arthroplasty; 0330, hospital 30-day all-cause
risk-standardized readmission rate following heart failure hospitalization for
patients 18 and older; and 0505, hospital 30-day all-cause risk-standardized
readmission rate following acute myocardial infarction hospitalization.
review is being completed due to material changes to a currently endorsed
measure (eg, expansion of a measure to a different population or setting). This
is intended as a focused review of the planned readmission algorithms that have
been incorporated into each of the condition/procedure specific readmission
Centers for Disease Control and Prevention (CDC) has updated its clinician guidance webpage to reflect the most current
information based on the investigating into the multistate fungal meningitis
outbreak among patients who received contaminated steroid injections.
contains updates to FAQs, case definitions, and information on diagnostic
testing. Three interim treatment guidance documents also have been updated.
CDC urges clinicians to contact patients who
have received medicines associated with 3 lots of preservative-free
methylprednisolone acetate from the New England Compounding Center that were recalled on September 26. The potentially contaminated injections
were given starting May 21.
behavior is important for patient or client success in all practice settings.
Physical therapists and physical therapist assistants have long been asking
patients and clients to change some of their behaviors, either for the short
term or for the long term and for reasons that will improve their functional
status or quality of life or prevent decline. A new podcast introduces a series on health behavior change,
providing an overview of key theories and models and their value to PTs and
A second podcast focuses exclusively on the
Transtheoretical Model of Behavior Change, an important and complex model that
involves emotions, cognitions, and behavior. This model, relying on
self-report, has been applied to a wide variety of problem behaviors including
smoking cessation, condom use for HIV protection, the use of sunscreens to
prevent skin cancer, and stress management. The podcast provides an example of
how the model can be applied to a patient with a shoulder strain due to an
of a study that investigated the
comparative effectiveness of early use of thrust manipulation (TM) and
nonthrust manipulation (NTM) in patients with mechanical low back pain (LBP)
suggest that there is no difference between early use of TM or NTM, and, secondarily,
that personal equipoise affects study outcome. Intra-group changes were
significant for both groups, say authors and APTA members Chad Cook, PT, PhD, MBA, FAAOMPT, Kenneth Learman, PT, PhD, OCS, COMT, Christopher Showalter, PT, OCS, FAAOMPT, Vincent Kabbaz, PT, and Bryan
O'Halloran, PT, OCS, SCS.
trial, patients aged 18 and older with mechanically reproducible LBP were
randomized into 2 treatment groups. The main outcome measures were the Oswestry
Disability Index (ODI) and a Numeric Pain Rating Scale, with secondary measures
of rate of recovery, total visits and days in care, and the work subscale of
the Fears Avoidance Beliefs Questionnaire work subscale.
of 149 subjects completed the trial and received care over an average of 35
days. There were no significant differences between TM and NTM at the second
visit follow-up or at discharge with any of the outcomes categories. Personal
equipoise was significantly associated with ODI and pain.
deadline to submit nominations to participate in APTA's Innovation Summit
2013: Collaborative Care Models is October 22.
Summit will bring together innovators and thought leaders from physical
therapy, health policy, payment, and other health professions to explore the
role of physical therapists in new models of health care delivery and payment.
Participation in the Summit will be available to all members through live web
streaming. Attendance onsite will be limited to speakers, panelists, and
invited attendees, including the member innovators selected through this
sections, chapters, and the Student Assembly are each invited to nominate a
member who is involved in an innovative model of care to attend the March 7-8,
2013, onsite meeting in Alexandria, Virginia. A panel of member experts will
select 20 member innovators to share their innovative practice models as a part
of the Summit. Those selected will receive free registration and a stipend
for travel and lodging expenses. Chapters and sections whose nominees are
selected will receive special recognition during the Summit.
Members involved in innovative
models of care or payment may want to contact their chapter or section directly
to ask to be nominated to attend the Summit.
and nomination materials are available at this link.
Components may direct questions about the nomination process to firstname.lastname@example.org.
your last chance to weigh in on the topics to be covered in the final House
proposal town hall scheduled for Tuesday, October 23, 9:00 pm-10:30 pm, ET.
What would you like to discuss? What topic have we missed? Let us know. Suggest
ideas via the Additional
blog posted to www.apta.org/governancereview. Contact Amber
Neil if you are
interested in attending. Can't join a town hall? Have your voice heard via the
comment blogs on the following topics: House
activity, and Resolutions
With Older Adults: An Evidence-Based Review of What Really Works," the
latest report from The Gerontological Society of America,
provides 40 pages of recommended guidelines for health care providers
interacting with the fastest-growing age segment of America's population.
The report provides 29 specific recommendations in 4 categories: general tips
for improving interactions with older adults, general tips for improving
face-to-face communication with older adults, tips for optimizing interactions
between health care professionals and older patients, and tips for
communicating with older adults with dementia.
the specific steps outlined in the report, providers are encouraged to avoid
speech that might be seen as patronizing to an older person, verify listener
comprehension during a conversation, and pay close attention to sentence
structure when conveying critical information.
The recommendations were contributed by experts
in the fields of gerontology and communications. Each is accompanied by a brief
explanation of the rationale, tips for implementing the recommendation in busy
health care settings, and selected references for further reading. The
objective is to encourage behaviors that consider the unique abilities and
challenges of older adult patients and produce positive, effective interactions
among everyone involved.
Encourage your Spanish-speaking patients to visit Ejercicioy estado físico, a comprehensive web resource from MedlinePlus that
offers tips on becoming and staying active based on the Department of Health
and Human Services' 2008 Physical Activity Guidelines for Americans, the latest news on the benefits of
physical activity, and information on exercise-specific topics—such as strength
training, aerobics, and interval training. Users can find links to a heart rate
calculator, food tracker, and calories-burned calculator. Tutorials and videos,
information tailored to women, and patient handouts also are available.
The role of
family caregivers has dramatically expanded to include performing
medical/nursing tasks once only provided in hospitals, says a new report by the AARP Public Policy Institute and the United Hospital Fund.
The report is based on a nationally representative population-based online
survey of 1,677 family caregivers to determine what medical/nursing tasks they
(46%) of caregivers performed medical/nursing tasks for family members with
multiple chronic physical and cognitive conditions. Three out of 4 (78%) family
caregivers who provided medical/nursing tasks were managing medications,
including administering intravenous fluids and injections. Caregivers
reported finding wound care very challenging; more than a third (38%) wanted
The report reveals the complexity and difficulty of
specific tasks, the lack of support and training family caregivers receive, and
the effect on their quality of life. It makes 10 recommendations, including:
profession or health care provider is solely responsible for ensuring that
family caregivers who
take on these daunting responsibilities are trained and supported," the
authors write. "This effort requires the coordinated efforts of all
sectors—hospitals, home care agencies, community agencies, nursing homes,
hospices, and physician and other clinician practices—and a level of teamwork
that challenges attitudes and behaviors so firmly entrenched in the current system."
The Centers for Medicare and Medicaid Services (CMS) will hold
a special open door forum (ODF) on October 22, 2:00
pm-3:30 pm ET, to allow providers to ask
questions about the manual medical review of therapy services that exceed
During this special ODF
(conference call only), CMS will discuss therapy documentation requirements and
answer any questions providers may have. CMS requests that providers who order
or provide therapy services nationally participate in the call. The therapy cap
applies to all Part B outpatient therapy settings and providers in:
Participants may submit
questions prior to the special ODF to email@example.com.
participate, call 866/ 501-5502 and enter conference ID 44803009.
newest publication, Adult Fitness Examination: A Physical Therapy Approach,
brings together a series of tests and measures that enables physical therapists
to build lifelong health and wellness plans with their asymptomatic adult
by APTA member Dan Millrood, PT, MEd,
and Charlotte Chua, PT, DPT, this groundbreaking assessment tool contains the
ready-to-use instructions and resources PTs need to identify, quantify, and qualify
key components of physical health and wellness.
educators, it's a textbook that addresses educational objectives related toprevention,
health promotion, fitness, and wellness.
Adult Fitness Examination includes:
Adult Fitness Examination (AFE-001, $34.99 for APTA members) from APTA's online bookstore.
foot ulceration (DFU) is associated with a nearly 2-fold increased risk for
all-cause mortality above that of diabetes alone, says a Medscape Medical News article based on a meta-analysis published in Diabetologia.
authors included 8 studies in their analysis. The studies were published
between 1996 and 2011 and reported on a total 17,830 patients with 81,116
patient-years of follow-up. Patients with both type 1 and type 2 diabetes were
included in all but 1 study, in which all patients had type 2 diabetes.
3,095 patients with DFU had a significantly longer duration of diabetes (12.72
years) compared with the 14,735 patients without DFU (7.19 years). The
prevalence of coronary artery disease was significantly higher among patients with
DFU (31.4% vs 14.7%), as was that of both hypertension (57.6% vs 35.7%) and
hypercholesterolemia (47.6% vs 11.1%).
follow-up, there were a total 3,619 deaths from any cause. The population with
DFU had a 1.89 pooled relative risk for all-cause mortality compared with the
patients with diabetes without DFU. Unadjusted rates of all-cause mortality
were 99.9 per 1,000 person-years for the population with DFU vs 41.6/1,000 in
the group with diabetes only.
analysis of 3,138 patients in 4 studies for whom information on cardiovascular
mortality was available showed that rates of fatal myocardial infarction and
fatal stroke also were higher among patients with DFU. However, the overall
proportion of deaths resulting from cardiovascular causes was almost the same
in the DFU and non-DFU groups—43.6% of the 117 DFU patients and 44.2% of the
952 diabetes-only patients.
higher mortality rate in patients with DFU may also "relate to their more
advanced stage of diabetes, with greater overall disease burden and
noncardiovascular complications of foot ulceration such as sepsis," Medscape says.
acknowledgement of legislation effective
October 1, the Right to Choose a Physical Therapist,
Blue Cross Blue Shield (BCBS) of North Carolina has revised its corporate medical
policy to include electrodiagnostic studies that are
provided by a licensed physical therapist who currently is listed on APTA's website
as a board-certified clinical electrophysiologic specialist per the American
Board of Physical Therapy Specialties.
North Carolina Chapter worked diligently for 3 years with state legislators and
BCBS of North Carolina, citing physical therapists' education and clinical
preparation to provide these services. After being assured that qualified PTs
provide evidence-based, outcome-based, and cost-effective health care that encourages
collaboration of the health care team, BCBS adopted the policy reflecting the
ability of PTs certified in clinical electrophysiology to independently perform
on the effects of pay-for-performance have found mixed results and raise a
number of questions that require more research and experimentation, says a new Health Affairs issue brief.
The brief summarizes the results of 9
studies that looked at public and private pay-for-performance initiatives. Two
studies focus on the Centers for Medicare and Medicaid Services' Premier
Hospital Quality Incentive Demonstration project. The first study found that
hospitals in the demonstration initially showed promising improvements in
quality compared with a control group. However, the effects were short lived. After
the fifth year of the demonstration, there were no significant differences in
performance scores between participating hospitals and a comparison group of
hospitals not in the project. In the second study, which analyzed 30-day
mortality rates for patients with acute myocardial infarction, congestive heart
failure, pneumonia, or coronary artery bypass graft surgery between 2004 and
2009, the results showed no difference in mortality rates between hospitals in
the Premier demonstration and a control group of nonparticipating hospitals.
greater success is the Medicare Physician Group Practice Demonstration, a pilot
project that ran from 2005 to 2010, awarding bonuses to physicians in 10 large
physician group practices if they achieved lower cost growth than local
controls and met quality targets. Researchers at Dartmouth College and the
National Bureau for Economic Research found an improvement in quality but
modest reduction in the growth of spending for most Medicare beneficiaries.
Cost reductions were greatest for the 15% percent of patients with dual eligibibility,
typically low-income people who qualify for both Medicaid and Medicare and who
often have complex, chronic conditions.
brief also examines studies on Medicare's Hospital Value-based Purchasing
Program, Medicaid-focused health plans in California, and safety net providers.
In a Health Affairs blog post, 3 policy experts discuss how
monetary rewards can undermine provider motivation and worsen performance, suggesting
that pay-for-performance initiatives might backfire.
campaign recently launched by the Joint Commission provides information to
patients about how and when to get palliative care, and offers examples of questions
that palliative care providers may ask them and questions that they can ask
providers. The educational campaign is part of the Joint
Commission's Speak Up program that urges people to take an active role in their
health care. Speak Up brochures are available in English and
more about the role of physical therapists in palliative care at APTA's Hospice
and Palliative Care webpage.
healthy eating reduce body fat and preserve muscle in adults better than diet
alone, according to a study funded and conducted by the National Institute of
Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National
Institutes of Health (NIH).
NIDDK senior investigator Kevin Hall, PhD, analyzed
the individual effects of daily strenuous exercise and a restricted diet by examining data from 11
participants from the reality television program "The Biggest Loser."
Researchers measured body fat, total energy expenditure, and resting metabolic
rate 3 times: at the start of the program, at week 6, and at week 30, which was
at least 17 weeks after participants returned home. Participation in the
program led to an average weight loss of 128 pounds, with about 82% of that
coming from body fat, and the rest from lean tissue.
Hall used a mathematical computer model of human
metabolism to calculate the diet and exercise changes underlying the observed
body weight loss. Because the TV program was not designed to directly address
how the exercise and diet interventions each contributed to the weight loss,
the computer model simulated the results of diet alone and exercise alone to estimate
their relative contributions.
At the competition's end, diet alone was calculated to
be responsible for more weight loss than exercise, with 65% of the weight loss
consisting of body fat and 35% consisting of lean mass such as muscle. In
contrast, the model calculated that exercise alone resulted in participants
losing only fat, and no muscle. The simulation of exercise alone also estimated
a small increase in lean mass despite overall weight loss.
The simulations also suggest that the participants
could sustain their weight loss and avoid weight regain by adopting more
moderate lifestyle changes, such as 20 minutes of daily vigorous exercise and a
20% calorie restriction, than those demonstrated on the television program.
most important thing for ACL surgery patients is to start physical therapy
early and rigorously," says Rick W. Wright, MD, in a Medical News Today article about his systematic review published in Journal
of Bone and Joint Surgery. "It can be difficult at first, but it's
worth it in terms of returning to sports and other activities."
Wright and his colleagues in the Department of Orthopedic
Surgery at Washington University School of Medicine identified 85 articles on treatment following reconstructive ACL surgery from
2006 to 2010 through multiple search engines. Twenty-nine Level-I or II studies
met inclusion criteria and were evaluated with use of the CONSORT (Consolidated
Standards of Reporting Trials) criteria. The authors included studies on postoperative
bracing, accelerated strengthening, home-based rehabilitation, proprioception
and neuromuscular training, and 6 miscellaneous topics investigated in single
authors also found that bracing following ACL reconstruction is not beneficial,
but home-based rehabilitation can be successful. Neuromuscular interventions,
while not harmful to patients, are not likely to yield large improvements in
outcomes and should not be performed to the exclusion of strengthening and
range-of-motion exercises. Vibration training may lead to faster and more
complete proprioceptive recovery, but further evidence is needed.
strengthening was more effective
than concentric strengthening in reducing pain and improving function in
patients with Achilles tendinopathy, say authors of an article
published online in American Journal of
Physical Medicine & Rehabilitation.
men with Achilles tendinopathy were assigned to either the experimental group (n
= 16) that performed eccentric strengthening or the control group (n = 16) that
performed concentric strengthening for 8 weeks (50 minutes per day, 3 times per
week). A visual analog scale, isokinetic muscle testing equipment, the
side-step test, and the Sargent jump test were used to assess pain, muscle
strength, endurance, and functional fitness factors before and after the
In comparison with the control group, the experimental group showed
significant improvement in pain, ankle dorsiflexion endurance, total balance
index, and agility after the intervention. However, there was no significant
difference in dexterity between the 2 groups.
In a new podcast titled "Using Evidence in a
Private Outpatient Setting," Jason
Grandeo, PT, DPT, OCS, shares the 3 main strategies that he and his
colleagues at Body Dynamics Inc in Falls Church, Virginia, use to incorporate evidence
in practice: monthly journal clubs, grand rounds focused on the hands-on
examination and treatment aspect of physical therapy, and Physicians'
Information and Education Resource (PIER) summaries. PIER summaries are
completed when a physician or other health care provider comes to the facility
to discuss an area in which he or she specializes.
also offers tips for physical therapists who have not yet incorporated evidence
in their practice. "Make a pitch for using 1 of the strategies we use,
such as a journal club, or doing it as a group. If there is no interest, you
may need to ask yourself if you are working at the best
place to support your career growth."
recording is part of the Research to Practice podcast series, which provides
practical information on implementing the use of research as part of
evidence-based practice in the physical therapy clinic.
involved in an innovative model of care delivery such as an accountable care
organization or pay for performance? If
so, contact your chapter or section and ask your leadership to nominate you to
attend APTA's Innovation Summit: 2013:
Collaborative Care Models.
will bring together innovators and thought leaders from physical therapy,
health policy, payment, and other health professions to explore the role of
physical therapists in new models of health care delivery and payment.
Participation in the summit will be available to all members through live web
streaming. Attendance onsite will be limited to speakers, panelists, and
invited attendees, including the member innovators selected through this
sections, chapters, and the Student Assembly are each invited to nominate a
member who is involved in an innovative model of care to attend and participate
in the Summit, to be held March 7-8, 2013, in the Washington, DC area. A panel
of member experts will select 20 member innovators to share their innovative
practice models as a part of the Summit. Those selected will receive free
registration and a stipend for travel and lodging expenses. Chapters and
sections whose nominees are selected will receive special recognition during
deadline for nominations is Monday, October 22. More information about the
Summit is available at www.apta.org/innovationsummit. Components can direct questions
about the nomination process to firstname.lastname@example.org.
study of the Greater Cincinnati/Northern Kentucky region, researchers found
that the rate of strokes among adults younger than 55 years of age increased
from 12.9% in 1993/1994 to 18.6% in 2005.
incidence rates in people aged 20 to 54 were significantly increased in both
black and white patients in 2005 compared with earlier periods. The
investigators also found that the mean age at stroke significantly decreased
from 71.2 years in 1993/1994 to 69.2 years in 2005.
explanations for the increase could be that physicians are detecting strokes in
young people more often, both as a result of better imaging technology and more
vigilant screenings, says a Reuters Health article.
really don't think that's the major reason," lead researcher Brett Kissela
told Reuters. "We're definitely
seeing a higher incidence of risk factors for stroke now."
developing obesity, diabetes, and high blood pressure at a younger age, they
also are increasing their risk of stroke at a younger age.
is of great public health significance because strokes in younger patients
carry the potential for greater lifetime burden of disability and because some
potential contributors identified for this trend are modifiable," the
The study is published in Neurology.
Don't forget to weigh in on the
topics to be covered in the next House proposal town halls scheduled for
Thursday, October 18, and Tuesday, October 23; 1 session will be offered on
each of those evenings at 9:00 pm-10:30 pm, ET. What would you like to discuss?
What topic have we missed? Let us know. Suggest ideas via the Additional Thoughts comment
blog posted to www.apta.org/governancereview. Contact Amber
Neil if you are
interested in attending. Can't join a town hall? Have your voice heard via the
comment blogs on the following topics: House
activity, and Resolutions
than 13,000 Medicare beneficiaries were affected by 14 breaches of protected
health information between September 23, 2009, and December 31, 2011,
requiring notification under the American
Recovery and Reinvestment Act, according to a new report by the Department of Health and Human Services' Office of Inspector General (OIG).
For the most part the breaches
involved beneficiaries' names, Medicare identification numbers, dates of birth,
diagnoses, and services received. One breach affected 13,412 beneficiaries. This
breach involved a Medicare Summary Notice printing error by a Centers for
Medicare and Medicaid Services' (CMS) contractor, which caused the notices to
be sent to incorrect addresses. Ten breaches resulted from other mismailings or
from loss of documents during transit. In another 2 breaches, beneficiary
information was posted online. In the remaining breach, a CMS contractor
employee was arrested for stealing beneficiary information.
Although CMS notified all
beneficiaries affected by the 14 breaches, it failed to meet the Recovery Act’s
standard for timeliness for 7 of them. Notification letters for 6 of the
breaches did not explain how the contractors were investigating the breach,
mitigating losses, or protecting against further breaches. Moreover,
notification letters for half the breaches, including the largest breach, were
missing either the date the breach occurred or the date it was discovered.
Notification letters for 3 breaches did not include the types of unsecured
protected health information involved, contact procedures for individuals who
want to learn more, or steps individuals can take to protect themselves from
"CMS has made progress in
responding to medical identity theft by developing a compromised number
database for contractors," says the report. "However, the database's
usefulness could be improved."
Based on its findings, OIG recommends that CMS ensure
that breach notifications meet Recovery Act requirements, improve the
compromised number database, provide guidance to contractors about using
database information and implementing edits, develop a method for ensuring that
beneficiaries who are victims of medical identity theft retain access to needed
services, and develop a method for reissuing identification numbers to
beneficiaries affected by medical identity theft.
realize the promise of whole genome sequencing, scientists and clinicians must
have access to data from large numbers of people who are willing to share their
private information, say authors of a report issued yesterday by the
Presidential Commission for the Study of Bioethical Issues. "This in turn
requires public trust that any whole genome sequence data shared by individuals
with clinicians and researchers will be adequately protected," they write.
The commission's investigation
found that current governance and oversight of genetic and genomic data varies
in its protection of individuals from the risks associated with sharing their
whole genome sequence data and information. In particular, a great degree of
variation exists in what protections states afford to their citizens regarding
the collection and use of genetic data.
improve current practices and help ensure privacy and security as the field of genomics advances,
the commission offers 12 recommendations, including proposals that clinicians and researchers use
robust and understandable informed consent procedures and engage in productive
exchanges of those collections of genomic information that are based on such
consent procedures. The commission recommends that the federal government
facilitate broad public access to the important clinical advances that result
from whole genome sequencing. The commission also urges federal and state
governments to ensure a consistent floor of individual privacy protections
covering whole genome sequence data across state lines, regardless of how the
data were obtained.
Education Leadership Institute (ELI) Fellowship, a shared collaborative with
the Academic Council, Education Section, Physical Therapist Assistant Educators
Special Interest Group, and APTA, now is accepting applications for 2013 with a
submission deadline of January 4, 2013. This yearlong invitational blended
learning (online and onsite components) fellowship program includes mentorship
and is designed to provide emerging and novice (0-7 years) physical therapist
and physical therapist assistant education program directors with leadership
skills to facilitate change, think strategically, and engage in public discourse
to advance the physical therapy profession. Successful graduates from this
program are recognized as Fellows of the Education Leadership Institute. To
learn more about the ELI Fellowship, click here. To access the application,
of all types can engage in a systematic approach to better identify and prevent
medical errors and adverse events that occur commonly among patients with limited English proficiency
(LEP). Research available from the Agency for Healthcare Research and Quality
makes these 5 key recommendations to improve detection of medical
errors across diverse LEP populations and prevent high-risk scenarios from
becoming safety events:
hospitals with resource or other limitations that preclude a full rollout of
these strategies at once, the authors suggest beginning incrementally by
choosing any strategies that can be readily implemented and, at a minimum,
focus on addressing the root causes that lead to high-risk scenarios for
medical errors among patients with LEP.
study, Bringing It to Life, highlights a breakdown in communication involving
hospital staff and a 45-year-old Spanish-speaking man with type 2 diabetes who
goes to the emergency department accompanied by his wife.
Robert Wood Johnson Foundation (RWJF) is hosting a video contest for health care providers to
showcase their innovative, patient-centered approaches that improve the way
care teams communicate with their patients, especially when a patient is
transitioning from the hospital to home care. If you've pioneered a collaborative
way to improve patients' care and their health outcomes, read the judging criteria and submission guidelines and
submit your video by November 17.
will receive special recognition from RWJF, a professionally produced video
segment on their innovation, and the opportunity to discuss their methods with
patients and health care providers in local and national media.
workouts may trump land-based exercise for people with chronic obstructive
pulmonary disease (COPD), says an article by Reuters Health based on a study published in European Respiratory Journal.
their investigation, Australian researchers randomly assigned 53 participants
to workouts in a hydrotherapy pool, gym-based training, or standard medical
care without exercise. The exercise programs include 3 weekly 1-hour sessions
over 2 months. Forty-five patients completed the study.
they worked out on land or in water, patients were able walk faster after the
training than when they just got usual care. But patients who exercised in the
pool reported less fatigue and developed more physical endurance than those who
trained in the gym.
endurance shuttle walk test, patients who'd exercised in water outpaced the gym
trainers by 228 meters (748 feet).
in the water-based exercise training group reported an improvement in many
functional aspects of their daily life such as improved stamina and ability to
complete tasks such as walking long distances when shopping," said lead
author Renae McNamara, PT.
had been some concerns that people with COPD might not tolerate the pressure
from the water on the chest. The researchers saw no drop-outs due to worsening
COPD in patients training in the pool, although they did see some in the gym
group. The authors reported that most of the participants in the study did not
have severe disease, says Reuters.
On Wednesday, New York Gov Andrew Cuomo vetoed legislation that would have weakened existing state restrictions on physicians' ability to refer patients to facilities in which they have a financial interest. Assembly Bill 3551-A would have added some of the same exemptions found in the federal Stark law, such as the in-office ancillary exceptions for certain designated health services.
The New York Chapter has been actively opposing the bill, which was approved by the state legislature earlier this year and sent to the governor in September. The Alliance for Integrity in Medicare—a coalition of provider organizations, including APTA, committed to ending the practice of inappropriate physician self-referral—sent a letter to Cuomo in July asking him to veto the bill.
APTA wants to know how you are planning to celebrate National Physical Therapy
Month. E-mail your plans to email@example.com.
of a meta-analysis published in the Journal of Rehabilitation Medicine report
that their findings indicate small, but significant, effects of physical
therapy on balance in people with multiple sclerosis who have a mild to
moderate level of disability.
A systematic literature search was conducted in Medline, Cinahl, Embase, and
PEDro, both electronically and manually up to March 2011. The authors selected
randomized controlled trials of physical therapy interventions in people with
multiple sclerosis, with an outcome measure linked to the International
Classification of Functioning, Disability and Health category "changing
and maintaining body position." The quality of studies was determined by
the van Tulder criteria. Meta-analyses were performed in subgroups according to
Of the 233 full-text papers screened, 11 studies were included in a qualitative
analysis and 7 in a meta-analysis. The methodological quality of the studies
ranged from poor to moderate. Low evidence was found for the efficacy of
specific balance exercises, physical therapy based on an individualized
problem-solving approach, and resistance and aerobic exercises on improving
balance among ambulatory people with multiple sclerosis.
Fit After 50 campaign is officially under way. Launched in conjunction with
National Physical Therapy Month, Fit After 50 is designed to reach Baby Boomers
with the message that physical therapists play a vital role in helping people
aged 50 and older remain active, fit, and mobile as they age.
out 50 Days, 50 Ways, a daily series of 50 tips for Baby Boomers from APTA
members about how to prevent injury and maintain mobility by staying active and
fit. Find the tips on www.moveforwardpt.com/FitAfter50, Twitter @MoveForwardPT, and Facebook.com/MoveForwardPT. Encourage your friends,
family, colleagues, and community members who are 50 and older to visit the
site and share the tips with their social networks.
check out the APTA Fit After 50 Member Challenge, an opportunity to nominate a
deserving APTA member, including yourself, who is 50 years old or older and committed
to being active and fit, and encourages others to be the same. Go to www.apta.org/FitAfter50/ to learn more about the campaign
and submit your nomination.
you are currently helping people aged 50 and older to remain active and fit as
they age, let us know by contacting firstname.lastname@example.org.
Thanks to the many members who have joined the virtual town halls
to discuss the House governance proposals! The discussions have been rich and
the input very informative. Based on attendee feedback, 2 additional town halls
have been scheduled for Thursday, October 18, and Tuesday, October 23; 1
session will be offered on each of those evenings at 9:00 pm-10:30 pm, ET. The
topics will be chosen by you. What
would you like to discuss? What topic have we missed? Let us know. Suggest
ideas via the Additional Thoughts comment blog posted
to www.apta.org/governancereview. Contact Amber
if you are interested in attending. Can't join a town hall? Have your voice
heard via the comment blogs on the following topics: House constituency, House activity, and Resolutions Committee.
A study by
The George Washington University School of Public Health and Health Services
suggests that the higher the work-family conflict the greater the risk that
health care workers will suffer from neck and other types of musculoskeletal
To examine if an association exists between work-family
conflict and musculoskeletal pain among hospital patient care workers,
researchers conducted a survey among 2,000 hospital workers who
provided direct patient care in 2 large Boston hospitals. Nearly 80% of the
workers took the survey. The research team included 1,199 patient care workers
in the current analysis. The team assessed work-family conflict with 5
questions. Researchers asked workers if they agreed with statements such as "The
amount of time my job takes up makes it difficult to fulfill family or personal
responsibilities" and "My job produces strain that makes it difficult
to fulfill my family or personal responsibilities."
In addition, the team used a questionnaire to assess how much the participants
in the study experienced musculoskeletal pain during the previous 3 months. It
also recorded factors that might affect the outcome of the study, such as the
amount of on-the-job lifting or pulling.
The researchers discovered that nurses and other employees who reported high
conflict between their job duties and obligations at home had about a 2 times
greater chance of suffering from neck or shoulder pain in the last 3 months.
Workers with the highest work-life imbalance had nearly a 3 times greater risk
of reporting arm pain during that period.
The researchers found that workers who reported a lot of conflict had more than
a 2 times greater chance of experiencing any kind of musculoskeletal pain. At
the same time, the research found no lasting link between this kind of ongoing
conflict and lower back pain, which might be caused when hospital workers lift
heavy patients on a regular basis.
Lead author Seung-Sup Kim says
that the work-home conflict might exacerbate shortages of
key health professionals caused when burned-out nurses or other health
professionals retire early or leave the field because of the stress. In
addition, Kim says, workers distracted by issues at home or by ongoing muscular
pain might be more likely to call in sick or if they do show up for work might
provide less than attentive care.
On Monday, the therapy cap with an exceptions process went into effect for outpatient hospitals. In addition, the manual medical review exceptions process for claims exceeding $3,700 became effective for phase I providers. Originally, the Centers for Medicare and Medicaid Services (CMS) had announced that providers would know the dollar amount that their patients accrued toward the
therapy cap on October 1. Due to some systems challenges, this information was not available. CMS announced this week that the information will be available October 8 through eligibility inquiries. Physical therapists (PTs) should check with their Medicare Administrative Contractors to determine the best way to obtain the dollar amounts accrued. When the data is available on October 8, PTs can then determine whether there is a need to seek an exception to the therapy cap.
To help PTs with the implementation of the cap and the manual medical review exceptions process, APTA has created a Medicare Therapy Cap Resources webpage. This webpage compiles relevant information available from
APTA and CMS in 1 place.
In this month's Heard on the Hill podcast, Mike Matlack, APTA director of grassroots and political affairs, breaks down the races for the United States Senate and House of Representatives and discusses the toss-up states in the Senate and competitive seats in the House. He also explains how the Electoral College looks as the candidates head into the debates.
Source: National Journal
Researchers at the European Association for the Study of Diabetes 2012 Meeting reported this week that higher levels of leisure-time physical activity cut the risk of cardiovascular and all-cause mortality in people with type 2 diabetes, says an article by Heartwire. People with diabetes who did little or no exercise at baseline and then substantially increased their leisure-time physical-activity
levels over approximately 5 years cut their risk of death by almost two-thirds.
The researchers used data on leisure-time physical activity, recorded yearly, from more than 15,000 men and women with type 2 diabetes included in the Swedish National Diabetes Register. Participants were grouped as either "low physical activity" (no regular exercise or exercise once per week) or "regular exercise" (between 3 times per week and daily exercise). If patients died during the course of the study, their last recorded physical-activity level was used for the analysis.
Over a 5-year period, regular exercisers were significantly less likely to have a cardiovascular event or to die either from cardiovascular disease or any other cause.
The investigators also looked at patients who reported doing little or no physical activity at baseline but who increased their regular exercise to at least 3 times per week by the end of the study period (a mean of 4.8 years). Cardiovascular deaths among these patients dropped by 67% compared with patients who did not improve their exercise habits. Rates of all-cause mortality were reduced by almost the same degree.
Session moderator Nick Wareham, MD, stressed that the data "… should encourage us to focus on encouraging physical activity as part and parcel of medical care."
Researchers at King's College London have identified a gene linked to age-related degeneration of the intervertebral discs, a common cause of lower back pain.
Back pain costs the United Kingdom an estimated £7billion ($11 billion in US dollars) a year due to sick leave and treatment costs. Lumbar disc degeneration (LDD) is inherited in 65%-80% of people with the condition, suggesting that genes play a key role. Until now, the genetic cause of lower back pain associated with LDD was unknown, says King's.
For this study, scientists compared MRI images of the spine in 4,600 individuals with genome-wide association data, which mapped the genes of all the volunteers. They identified that the gene PARK2 was implicated in people with degenerate discs and could affect the speed at which they deteriorate.
The researchers say the results show that the gene may be switched off in people with LDD. Although it is still unclear how this might happen, it is thought that environmental factors, such as lifestyle and diet, could trigger this switch by making changes known as epigenetic modifications to the gene.
was published online September 19 in Annals of Rheumatic Diseases.
The Marquette Challenge is an annual student-led grassroots fundraising effort that supports physical therapy research. Over the past 24 years, students participating in the Marquette Challenge have raised more than $2.3 million in support of the Foundation and its mission.
To learn how your school can help advance
physical therapy research and gain national recognition check out the interactive Challenge kit.
population level, diabetes is a stronger risk factor for new heart failure (HF)
than 4 other modifiable risk factors, namely smoking, dyslipidemia, obesity,
and hypertension, suggests the latest analysis from the Atherosclerosis Risk in Communities (ARIC) study cohort.
a longitudinal study of more than 15,000 African American and Caucasian men and
women in 4 communities across the United States, who were recruited during the
1980s when they were aged 45 to 64. The current analysis included 14,709 of the
participants followed an average of 17.6 years.
to the authors, the lifetime risk of incident heart failure was about 1 in 3
for its African American participants and reached 1 in 4 in Caucasians. In both
groups, that risk was higher than the lifetime risk of new coronary heart
disease or stroke in the same population.
addition, they found that a percentage drop in diabetes prevalence would avert
more cases of new HF than the same percentage decrease of any of the 4 other
studied modifiable risk factors. Specifically, a 5% proportional reduction in
the prevalence of diabetes in ARIC African American participants would result
in approximately 53 fewer HF cases per 100,000 person-years and 33 fewer HF
hospitalizations per 100,000 person-years for Caucasians.
Free full-text of the article is available in Journal of the American College of
for the 2012 APTA State Policy and Payment Forum now is open. This year's event
will take place December 1-3 at the Hilton Alexandria Old Town in Alexandria, Virginia. The
State Policy and Payment Forum is designed to increase your involvement in and
knowledge of state legislative and payment issues that have an impact on the
practice of physical therapy and improve your advocacy efforts at the state
level. You will hear from influential public policymakers and other physical
therapy advocates, collaborate with colleagues in developing your chapter or
section's advocacy efforts, and network with other professionals from across
this year will include presentations on physical therapy copay legislation,
term protection for physical therapy, emerging scope of practice issues, silent
preferred provider organizations (PPOs), health information technology (HIT),
Medicaid, state health exchanges, and much more. Some programming highlights
for this year's forum include:
event is open to APTA members only. Registration is $140 for PTs and
physical therapist assistants (PTAs) and $90 for students. Virginia
Chapter members get a special discounted rate of $100 for PTs and PTAs, and $50
for students. Registration closes November 9. Registration will not be
available onsite, so be sure to register by the deadline. Additional
information is available at www.apta.org/stateforum.
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