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  • Humana Coverage Limitations: More of the Same

    Humana’s latest list of physical therapy services it won't cover may not have changed much, but that doesn't mean the limitations should continue, according to APTA. The association recently voiced its concerns over the ways the health insurer characterizes physical therapy, its imprecise terminology, and its continued noncoverage of aquatic physical therapy and group physical therapy.

    The APTA letter was sparked by the release of the latest updates to Humana's medical coverage policy, which has drawn attention in the physical therapy community because of a list of services it says it may not cover. That list includes aquatic therapy, group therapy sessions, sensory integration, community/work reintegration, and work hardening/conditioning.

    While disappointing for physical therapists (PTs) and their patients, the coverage limitations themselves aren't new, according to Alice Bell, PT, DPT, senior payment specialist at APTA. Bell was part of a payment and practice management staff team that reviewed the policy.

    "The latest update from Humana changed very little from the policy in place in 2017 and earlier," Bell said. "Noncoverage of aquatic therapy, group therapy, and work hardening dates back to at least 2014."

    Still, that doesn't mean the policy is acceptable, in APTA's view. Earlier this month, APTA sent a letter to Humana that specifically cites aquatic therapy and group therapy as services that should be covered.

    "Evidence demonstrates that for some patients the progression to land-based exercise and functional movement is effectively facilitated through the use of aquatic therapy," the letter states. When it comes to group therapy, APTA asserts that for certain conditions and patient populations, "the psychosocial benefits of peer support and group interaction can serve to enhance the therapeutic experience and impact," adding that it's distinct from group exercise in its integration into an overall skilled plan of care aimed at optimizing the effectiveness of therapy.

    The APTA letter also points out other areas in which Humana uses sloppy language or just plain gets it wrong. One example: Humana's description of exercise as a modality. "Modalities are passive interventions," the association reminds Humana. "Therapeutic exercise is an active aspect of therapy."

    APTA also describes Humana's statement that "[physical therapy] procedures in general include therapeutic exercises and joint mobilization" as an "extremely narrow" characterization of the profession.

    "Representing the interventions in such a limited way in the description of the practice fails to acknowledge the breadth and depth of the profession, the therapeutic benefit to the patient, and the services covered under the current policy," the letter states. "APTA would like to highlight that the core of skilled physical therapist practice lies in the evaluation, reevaluation, and implementation of therapeutic procedures."

    "Humana has taken some positive steps, particularly when it lifted prior authorization requirements for physical therapy earlier in the year," Bell said. "The latest coverage policy updates do not move any issues forward—or backward for that matter. That's why APTA will continue to advocate for changes that better serve patients."

    CMS to Study Administrative Burden of MIPS; PTs Can Participate

    The US Centers for Medicare and Medicaid Services (CMS) wants to engage in a study to gain a better understanding of the administrative burdens associated with its Merit-based Incentive Payment System (MIPS), and physical therapists (PTs) are invited to participate in the research even if they aren't currently involved in the program.

    According to an announcement from CMS, in addition to MIPS-eligible clinicians, the study is open to a limited number of clinicians who aren’t eligible for mandatory participation—such as PTs—even if they haven’t volunteered to participate. Currently, participation in MIPS is optional for PTs, though the system could be mandatory as early as 2019.

    During the April 2018–March 2019 study period, CMS will evaluate workflows and data collection methods and explore the challenges faced by clinicians in collecting and reporting data to MIPS. Applications for being included in the survey are being accepted through March 23, 2018. For more information, contact MIPS_Study@abtassoc.com.

    Want to learn more about MIPS, its relationship to the CMS Quality Payment Program, and the future of health care? Check out APTA's new value-based care podcast series.

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    #PTTransforms Blog: Keeping the Patient at the Center of Pain Management

    Although APTA’s recent “Beyond Opioids” panelists were diverse in experience and profession—including patient advocacy, health care provision, government, and business—several common themes arose around pain management. A new #PTTransforms blog post goes beyond the opioid statistics to highlight patient-centered strategies suggested by the guests.

    Several participants urged improved provider-patient communication, including patient advocate Joan Maxwell, who was prescribed opioids after each of 9 surgeries, without a single discussion about the risks and alternatives. In a Washington Post/Kaiser Family Foundation survey, only 65% of respondents said their doctor talked with them about the possibility of addiction when prescribing the drugs, and only 62% received education from their physician about other ways to manage pain.

    Read the full blog post here, and keep an eye out for upcoming posts on a variety of topics.

    APTA’s award-winning #ChoosePT awareness campaign focuses on physical therapy as a safe alternative to opioids for pain management. To learn more, visit the association’s consumer website, www.MoveForwardPT.com/ChoosePT/.

    CDC Issues 'Call to Action' to Address Treatment Gaps for Children Experiencing TBI

    The US Centers for Disease Control and Prevention (CDC) sees traumatic brain injury (TBI) in children as a public health problem with a ripple effect—not only are children receiving inconsistent care at the time of injury, but variation in rehabilitation and recovery approaches can lead to disability that lasts through adulthood.

    The CDC laid out its case in a recent report to Congress that identified what it believes are the most glaring gaps in current treatment for pediatric TBI. "The management of TBI in children is complex and depends upon multiple service delivery systems that frequently do not provide systematic or coordinated care to ensure optimal recovery," the report states. "Due to the lack of robust scientific evidence identifying optimal pathways to recovery, current management is too often based on clinical practice experience rather than research."

    The agency hopes to address this issue through a "first-ever evidence-based clinical guideline on the diagnosis and management of mild TBI among children and adolescents" now in development. The CDC believes those guidelines could help to address gaps in the management of TBI in children, but it says those guidelines alone won't be enough to fix the problems in the current state of treatment.

    The report, which the CDC describes as a "call to action," identifies 8 major areas in need of improvement:

    Access to comprehensive care at the time of injury. "There is substantial variation in care among the sites where children are seen for acute injury care," the report states. "Not only are there inconsistencies in TBI assessment but also in the comprehensiveness of discharge recommendations for all severity levels of TBI."

    Long-term management. The report asserts that "there are no formal systems to monitor the health of children with TBI over time" and that "frequently children who need pediatric rehabilitation services do not receive them."

    Family support and training. According to the CDC, parents of children who experience TBI often find themselves thrust into a situation in which they have to take on multiple roles, including being an advocate for their child in health care and school systems. "Few parents understand the potential for a TBI of any severity level to become a chronic condition," says the report.

    Return to school. "Many students who sustain a TBI will need post-injury support at school…However, children and their families often experience difficulties accessing these services," according to the report.

    Return to activity. The CDC acknowledges that return-to-play guidelines have been developed for sports, but it finds a lack of similar guidelines for physical activities outside of organized sports and not much in the way of guidelines for return to activities after moderate and severe TBI.

    Transition to adulthood for children with TBI. In what the CDC describes as "a particular area of concern," the report asserts that the use of health care services tends to decline as adolescents with TBI transition to adult care, with a resultant worsening of outcomes. Making matters worse, according to the report, is the tendency for public school systems to limit post-high school transition planning to only those students covered by the Individuals with Disabilities Education Act (IDEA), and the lack of any requirements for specialized education and transition services in private schools.

    Professional training. "Many medical, educational, and other professionals who provide care and support for children after TBI received limited training specific to TBI recognition or management," the report states. "Lack of adequately trained health care providers leads to inconsistent and variable clinical assessments, inconsistent diagnoses, variable guidance about expected recovery course, and variability in management decisions early and later after injury."

    Research. According to the CDC, "we currently know very little about long-term outcomes for children with TBI." The agency calls for high-quality studies to establish parameters for duration of rest and return to physical and cognitive activity, medication use, and the management of prolonged symptoms. "A wide range of medical, behavioral, physical, and other therapies are used in the management of [mild] TBI, but definitive, high-level evidence-based guidelines do not currently exist," the CDC writes.

    The CDC estimates that in 2013, there were roughly 640,000 TBI-related emergency department visits, 18,000 TBI-related hospitalizations, and 1,500 TBI-related deaths among children 14 and younger.

    Pediatricians' Group Releases 'Choosing Wisely' List of Orthopedic Treatments to Question

    The "Choosing Wisely" collection of treatments that providers and patients should question continues to expand—this time, into pediatric orthopedics, with the American Academy of Pediatrics (AAP) issuing a list that calls for dialing back the use of imaging, ultrasound, and orthotics.

    The AAP list, developed in partnership between the AAP Section on Orthopaedics and the Pediatric Orthopaedic Society of North America, makes the following 5 recommendations:

    • Do not order a screening hip ultrasound to rule out developmental hip dysplasia or developmental hip dislocation if the baby has no risk factors and has a clinically stable hip examination.
    • Do not order radiographs or advise bracing or surgery for a child less than 8 years of age with simple in-toeing gait.
    • Do not order custom orthotics or shoe inserts for a child with minimally symptomatic or asymptomatic flat feet.
    • Do not order advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory, and plain radiographic examinations have been completed.
    • Do not order follow-up X-rays for buckle (or torus) fractures if they are no longer painful or tender.

    Launched by the American Board of Internal Medicine Foundation in 2012, "Choosing Wisely" is a collection of ineffective and overused treatments and tests that has grown to 540 recommendations from more than 80 specialty society partners. In 2014, APTA became the first nonphysician organization to contribute to Choosing Wisely when it released its list of "5 Things Physical Therapists and Patients Should Question."

    APTA's Updated Defensible Documentation Resource Provides Insight, Practical Tips, and More

    Physical therapists (PTs) and physical therapist assistants (PTAs) know they can't take their eyes off the ball when it comes to properly documenting care. That's why APTA has revamped and updated its collection of online resources supporting defensible documentation.

    APTA's retooled webpage includes the latest on best practices in documentation, presented in an easy-to-navigate format. Extensive resources include an overview of the defensible documentation concept, elements of documentation within the patient/client management model, setting-specific considerations, risk management, and additional resources such as publications from the US Centers for Medicare and Medicaid Services (CMS) and relevant articles from PT in Motion magazine.

    Also included: tips on defensible documentation and a sample documentation checklist that outlines the process from initial examination and evaluation to completion of the episode of care.

    The webpage advises visitors that while the resources offered provide information "as comprehensive as APTA can reasonably make it," PTs and PTAs also need to check specific compliance requirements of payers, state laws, third-party administrators, and other organizations.

    Want more on defensible documentation? Check out "Defensible Documentation: Critical Documentation from the Payer Perspective," a recording of a January 16, 2018 webinar. Also, coming this summer: a 2-part webinar series on Medicare documentation, August 9 and August 23.

    2018 CSM Largest Ever; News and Videos Now Available

    APTA's biggest event of the year is now APTA's biggest event of all time: The 2018 Combined Sections Meeting (CSM) drew more than 17,000 people, including more than 14,000 registrants. This year marks the third year in a row that CSM achieved a record attendance number.

    This year's event, held in New Orleans February 21-24, was expanded to 3 venues and included an exhibit hall with more than 450 companies participating. In addition to hundreds of educational sessions covering a wide range of topics, the 2018 CSM also included poster presentations, preconference courses, and extensive opportunities for networking—all set in a city that lets the good time roll.

    Unable to attend and interested in getting a taste of what it's all about? Attending CSM and wondering what you missed? Check out the CSM daily news and a growing collection of video dispatches from the event.

    The 2019 CSM is scheduled for January 23-26 in Washington DC. Organizers are now accepting proposals for educational sessions and preconference courses as well as poster and platform presentations.

    Don't wait for next year to connect, learn, and get energized: plan on attending the 2018 APTA NEXT Conference and Exposition, set for June 27-30 in Orlando.

    Payers Looking for More Coding Detail

    Physical therapists (PTs), take note: the 59 modifier is a potential red flag for the US Centers for Medicare and Medicaid Services (CMS) and commercial payers.

    The 59 modifier is the code under the health care common procedural code system (HCPCS) used to represent a service that is separate and distinct from another service it's paired with. In an effort to tease out precisely why the service is distinct, CMS is requiring that in certain cases, providers use different modifiers instead of the 59 modifier. The modifiers—XE, XP, XS, and XU—are intended to bypass a National Correct Coding Initiative edit by denoting a distinct encounter, anatomical structure, practitioner, or unusual service.

    When the X modifiers were introduced in 2015, PTs weren't required to use them. But movement toward the use of these modifiers—and greater scrutiny of claims using the 59 modifier—is happening.

    CMS recently issued detailed guidance on the use of the 59 and X modifiers, complete with examples of what it considers appropriate and inappropriate applications. Providers should carefully review the CMS guidance document, as well as check their commercial payer payment policies regarding the use of the 59 modifier versus the X modifiers.

    APTA will continue to monitor this issue and share news of any changes.

    Spending on Health Care Projected to Increase 5.5% Annually Through 2026

    Health care spending is projected to rise by 5.3% in 2018 and continue at about that growth rate through 2026, according to estimates from the US Centers for Medicare and Medicaid Services (CMS). At the projected rates, spending on health care will represent nearly 20% of the US gross domestic product (GDP) by 2026, up from 17.9% today.

    According to the report from the CMS Office of the Actuary, the estimated increases are driven by 2 major factors: an aging US population that will increase Medicare spending, and an inflation rate on medical goods and services provided directly to patients that will outpace the overall economy's rate of inflation—2.2% compared with 1.1% annually.

    The average 5.5% annual growth in spending is higher than both the post-Great Recession rate of 3.8% from 2008 to 2013 and the 5% uptick related to the startup of the Affordable Care Act from 2014 to 2016—but it's still lower than the 7.3% annual increases experienced from 1990 to 2007, according to the report.

    Among other findings in the report:

    • Medicare spending will be the fastest-growing of all health insurance categories, increasing by 8% between 2019 and 2020, and 7.7% annually between 2021 and 2026. In contrast, private insurance is projected to grow at a slower 4.7% rate.
    • Part of the expected slower growth of private insurance can be attributed to an increased prevalence of high-deductible plans and the 2022 implementation of a tax on high-cost insurance plans, a tax that the CMS actuaries believe will spark employers to offer employee health insurance with reduced benefits and higher cost-sharing.
    • Prescription drugs will lead the way in increases to goods and services provided to patients, with a projected annual increase of 6.3% from 2017 to 2026.
    • The share of the population with health insurance will likely decline, from 91.1% in 2016 to 89.3%, the result of the elimination of the individual mandate for health insurance.
    • By 2026, government-sponsored efforts will represent 47% of all health care expenditures, up from today's 45% share. The portion of expenditures shouldered by private insurance is predicted to drop from 55% to 53% by 2026.

    The Post-Therapy Cap System: 5 Basics You Need to Know

    When Congress adopted a federal spending package that included the elimination of the hard cap on Medicare therapy services, it didn't just remove a rule—lawmakers also adopted a new system of payment thresholds and triggers, and a differential payment rate for physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), among other things.

    APTA supported an end to the hard cap, which is a significant win for the most vulnerable Medicare patients, but other parts of the system that replaced it are problematic.

    The elimination of the hard cap is retroactive to January 1, 2018, but not all details of the post-cap system have been worked out, and it's possible that some may change before their implementation dates. In the meantime, here are the basic elements of the new system.  

    1. It boils down to a threshold for using KX modifiers and a trigger for possible medical review.
    The basic idea is this: outpatient therapy under Medicare now has a $2,010 threshold; services delivered beyond that require a KX modifier indicating that the service meets the criteria for a payment exception. When therapy reaches $3,000, it's subject to possible targeted medical review—although CMS didn't receive any additional funding to conduct these reviews.

    2. Physical therapy and speech-language pathology still are lumped together in the thresholds.
    Just as in the previous payment system that included a hard cap and exceptions process, the new system doesn't separate physical therapy from speech-language pathology in establishing thresholds. Those $2,010 and $3,000 limits are for physical therapy and speech-language pathology therapy combined—another element opposed by APTA.

    3. The thresholds apply to all part B outpatient therapy services—including services provided by hospital outpatient departments.
    For the brief time beginning in January when the therapy cap was in place, hospital outpatient facilities were not subject to the cap. That changed with the adoption of the budget package, and now these departments or clinics are subject to the thresholds: $2,010 for use of the KX modifier and $3,000 for potential targeted medical review.

    4. The PTA payment differential will start in 2022—along with a special claims designation.
    In the post-cap payment system, outpatient therapy services performed by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) will be reimbursed at 85% of the Medicare physician fee schedule—a change opposed by APTA. However, that's not set to happen until 2022.

    For now, claims do not include a way to designate whether a service was delivered by a PTA, but that too will change by 2022, when CMS will develop a modifier to make that distinction. Between now and then, look for opportunities to comment on proposed rules around this process, along with guidance and more details as they develop.

    5. Home health also will be subject to the PTA payment differential, absent a plan of care.
    The 85% payment differential for services provided by a PTA or OTA will apply to home health care provided to Medicare part B beneficiaries—but only when a home health plan of care is not in effect. The budget deal that resulted in the end to the hard cap also established other new rules for home health.PT in Motion News recently reported on these additional changes.

    Now Available: Recording of 'Insider Intel' Session on Therapy Cap, Home Health, More

    The budget deal reached by Congress earlier this month included changes that affected not only the hard cap on therapy services under Medicare but also a host of other health care-related issues, including home health. Are you ready for what's coming?

    "Insider Intel" to the rescue.

    Now available: a recording of an APTA "Insider Intel" phone-in session devoted to the Medicare landscape since the budget deal. Hosted by staff from the APTA regulatory affairs unit, the 30-minute session covered where things stand and included a question-and-answer session.

    CMS Offers Settlement Option for Providers With Denial Appeals in Limbo

    The US Centers for Medicare and Medicaid Services (CMS) is offering some providers a chance to settle backlogged claims denial appeals at 62% of net allowed amounts, but there are limits and deadlines involved.

    Called the "Low Volume Appeals Initiative," the program is part of a CMS attempt to clear a glut of Medicare appeals piling up at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council levels.

    The program is limited to providers who have fewer than 500 appeals with no single appeal exceeding $9,000. Providers begin the process by submitting an "expression of interest" form to CMS. Providers with National Provider Identifiers (NPIs) ending in an even number have from between now and March 9 to turn in the form; the window for providers with NPIs ending in odd numbers will open on March 12 and close on April 11.

    To qualify for the settlement, the appeal must meet certain criteria:

    • The appeal was pending before the OMHA and/or council level of appeal as of November 3, 2017.
    • The appeal has a total billed amount of $9,000 or less.
    • The appeal was properly filed at the OMHA or council level as of November 3, 2017.
    • The claims included in the appeal were denied by a Medicare contractor and remain in a fully denied status in the Medicare system.
    • The claims included in the appeal were submitted for payment under Medicare Part A or Part B.
    • The claims included in the appeal were not part of an extrapolation.
    • The appeal is still at the OMHA or council level of review when an administrative agreement is fully executed.

    The final agreement would cover all claims that are approved for settlement. Once finalized by CMS and the provider, Medicare Administrative Contractors (MACs) will total the claim amounts and make a single total payment within 180 days of CMS' signature on the agreement.

    Questions about the initiative can be emailed to MedicareSettlementFAQs@cms.hhs.gov.

    Home Health Faces Challenges in Wake of Budget Deal

    A major advocacy issue for the physical therapy profession was resolved with the elimination of the hard cap on therapy services under Medicare, but other provisions in the massive budget bill that ended the hard cap have created different challenges. Case in point: in the home health arena, patients and providers are facing budget cuts and a reduction in payment units, with the possibility of even more dramatic—and potentially damaging—changes to come.

    The final budget package approved by Congress last week includes provisions reducing the home health care unit of payment to 30 days from its current 60-day unit. In addition, the home health market basket percentage—the amount of money CMS plans devote to goods and services in a particular area—will be 1.5%. Both changes are slated to start in 2020, and other potential harmful moves could be on the horizon. The changes, opposed by APTA, were included late in lawmakers' negotiations around the budget deal with no opportunity for input from stakeholders. The new provisions also eliminate therapy thresholds that affect episode payment calculations.

    The payment unit changes echo provisions included in CMS' failed attempt to adopt what it called the Home Health Grouping Model (HHGM), a sweeping overhaul of the home health payment system proposed the summer of 2017. APTA and other groups opposed nearly all of the proposals associated with HHGM, including the switch to the 30-day payment unit. In a letter to CMS, APTA described the 30-day unit as a change that would produce a "perverse financial incentive for providers to inappropriately decrease lengths of stay and/or avoid admitting patients who will require care beyond the 30-day episode." CMS dropped its efforts to adopt HHGM in the fall.

    Although the 30-day unit adopted in the budget deal is similar to what was proposed in HHGM, there's 1 major difference: the provision now in place is budget-neutral. The 30-day unit proposed by CMS through the HHGM would have resulted in significant reductions in reimbursement.

    But that doesn't mean the ideas behind HHGM are dead. In fact, says Kara Gainer, APTA's director of regulatory affairs, the budget deal also includes a provision directing the Department of Health and Human Services (HHS) to develop a new case-mix system that can be implemented by 2020. The concern of APTA and other home health supporters is that HHS will resurrect many of the changes proposed in the HHGM.

    "We expect that HHS will attempt to create a case-mix system similar in nature to the HHGM," Gainer said. "However, HHS has said that its revisions will be based on feedback from a technical expert panel." That panel met on February 1 and included a representative from APTA. Gainer is hoping that at least 1 more panel meeting will be held in 2018.

    So does Diana Kornetti, PT, MA, president of the APTA Home Health Section. Kornetti is also a credentialed home care coding specialist.

    "Right now, it appears that only 1 technical expert panel meeting is required by law during 2018, and that's already happened," Kornetti said. "This is the first thing that needs to change. There is no guarantee that the home health industry and its stakeholders will have any future opportunity to review and discuss the issues and concerns that will arise."

    According to Kornetti, should stakeholders get that opportunity, the case for the right kinds of changes to the home health payment will be much stronger if it's backed by documented outcomes for physical therapy.

    "Patient acuity is critical," Kornetti said. "Capturing correct and thorough data, using objective measures, will be increasingly important to establishing an accurate payment for physical therapist services. We must speak the language of outcomes moving forward as a profession—our services must show our impact on reduction of costs, while continuing to strive for increasing clinical quality."

    With the therapy cap issue settled, APTA will focus its advocacy efforts in different ways, Gainer explained. The threats to home health will be 1 of the association's targets.

    But as with any other attempt to get policymakers to listen, the effort will require participation from physical therapists and physical therapist assistants, Kornetti added.

    "A key principle in our code of ethics speaks to advocacy for those we serve," Kornetti said. "It has never been more important for the postacute physical therapist and physical therapist assistant to become informed and participate in this process. One rung of our ladder toward a fully autonomous profession is having representation at the table where decisions are being made."

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

    "The Good Stuff," is an occasional series that highlights recent, mostly local media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    “I went to Stanford, I was a professor at Cal Fresno. I had patients, friends, students I learned so much from. I’ve done this all because I’ve been pushed. I need to do as much as I can to prove I’m a good person. I still wasn’t whole." - Helen Grace James, PT, who won her federal lawsuit to receive an honorable discharge from the US Air Force after being expelled in 1955 for being a lesbian. (The Washington Post)

    For individuals who take a break from exercising, Ryan Balmes, PT, DPT, answers the question, "Where did all my muscles go?" (Esquire)

    Noah Greenspan, PT, DPT, provides a tip on how to keep the flu from turning into pneumonia. (Shape)

    Sharon Wentworth, PT, DPT, discusses the challenges of helping young female athletes avoid ACL tears. (USAToday app. website)

    Jessica Hill, PT, DPT, shares "4 tips that will help you start your day productively." (Gotham)

    Robert Gillanders PT, DPT, comments on 5 common running injuries and how to avoid them. (US News and World Report)

    The Illinois Physical Therapy Association has launched a copay advocacy effort. (WCIA13 News, Champaign, Illinois)

    Margaret Schenkman, PT, PhD, FAPTA, sees possibilities for vigorous exercise in the treatment of Parkinson disease. (The Denver Post)

    Marianne Ryan, PT, BS, outlines what women can expect of their bodies after giving birth. (NYMetroParents)

    Boss magazine lists physical therapy as 1 of the top 7 trending jobs of 2018. (Boss)

    Brett Walker, PT, physical therapist for the Chicago White Sox, paid a visit to his alma mater, University of Mary, in North Dakota. (Bismarck, North Dakota Tribune)

    Karena Wu, PT, DPT, suggests 4 exercises to combat text neck. (NBC News online)

    Heather Henry, PT, DPT, challenges the no pain/no gain theory. (US News and World Report)

    "Speech and physical therapy is poorly recognized for its benefits [to individuals with Parkinson disease]. Too often doctors just prescribe drugs." - Zoltan Mari, MD, on the possible treatment courses for singer Neil Diamond, who recently announced his retirement due to Parkinson disease. (next avenue)

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

    CMS Issues Coding, Other Details on Supervised Exercise Therapy for Peripheral Artery Disease

    US Centers for Medicare and Medicaid Services (CMS) has released details on how it will process claims made as a result of its decision to cover supervised exercise therapy (SET) in the treatment of peripheral artery disease (PAD).

    The expansion covers physician-referred SET for up to thirty-six 30- to 60-minute sessions over a 12-week period. The sessions must be conducted in a physician's office or outpatient facility, and must be delivered by "qualified auxiliary personnel" that includes physical therapists, nurses, and exercise physiologists. Supervision is to be conducted by a physician or "non–physician practitioner"—a physician assistant, or nurse practitioner/clinical nurse specialist.

    Although CMS announced the change in May 2017, it only recently released the nuts-and-bolts around provider coding and claims processing for Medicare Administrative Contractors (MACs). Details are available from 3 resources:

    To receive coverage for SET, Medicare beneficiaries with PAD must have a face-to-face visit with a physician and be referred for the program. The physician visit must also include education on cardiovascular disease and PAD risk reduction. Medicare Administrative Contractors can allow for more sessions or a second set of 36 sessions, but these additional sessions require another referral.

    New APTA Podcast Series Explores Big Picture and Details of Value-Based Care

    Everyone's talking about "value-based care," but what does the concept really mean, and how will it affect your practice? That's the subject of a new 21-part podcast series now available for download from APTA.

    The free series, delivered in easily digestible 5- to 7-minute presentations, moves from big-picture questions such as "What is value?" and "Why do we need quality measures?" to the nitty-gritty of the Merit-based Incentive Payment System (MIPS) and advanced Alternative Payment Models (APMs). Both MIPS and advanced APMs are pillars of the US Centers for Medicare and Medicaid Service's Quality Payment Program (QPP), a comprehensive shift away from the fee-for-service model of care.

    The series is part of APTA's efforts to educate physical therapists and physical therapist assistants on changes that currently are voluntary, but could be mandatory as early as 2019 and merit attention now. A link to the podcasts, as well as a wide range of other resources on value-based care, can be found on the association's Value-Based Care webpage.

    A Permanent Fix to the Therapy Cap: Improved Access for Medicare Patients Comes With Pending APTA-Opposed Cut to PTA Payment

    The looming threat of a hard cap on physical therapy services under Medicare has been eliminated.

    As part of a sprawling bipartisan budget deal passed today, Congress enacted a permanent solution to the problematic hard cap on outpatient physical therapy services under Medicare Part B, ending a 20-year cycle of patient uncertainty and wasteful short-term fixes.

    Ending the hard cap has been a high priority for APTA since its introduction in 1997 as part of the Balanced Budget Act. Legislators' backing for repeal reached a tipping point in 2017, when lawmakers developed a bipartisan, bicameral agreement to end the cap. Congress failed to enact that deal in 2017, but elements of the plan are included in the 2-year budget that was approved today.

    That's the good news. The bad news is that Congress chose to offset the cost of the permanent fix (estimated at $6.47 billion) with a last-minute addition of a payment differential for services provided by physical therapist assistants (PTAs) and certified occupational therapy assistants (COTAs) compared with payment for the same services provided by physical therapists (PTs) and occupational therapists (OTs), respectively. The payment differential, which was strongly opposed by APTA and other stakeholders, states that PTAs and OTAs will be paid at 85% of the Medicare physician fee schedule beginning in 2022.

    That pending payment differential under Medicare is somewhat comparable to that between physician assistants and physicians, but it was added to the budget bill late and without warning. It wasn’t part of the 2017 bipartisan agreement legislators reached, nor was it part of any discussions or negotiations on Capitol Hill since then.

    When the proposed differential was added to the budget deal late Monday night, the association quickly reached out to congressional offices with proposed amendments. None were accepted. Friday morning, Congress passed the massive budget legislation that includes increases for military and domestic spending, adding an estimated $320 billion to the federal budget deficit.

    “Stopping the hard cap is a victory for our patients, and for our dedicated advocates,” said APTA President Sharon L. Dunn, PT, PhD, board-certified orthopaedic clinical specialist. “For 2 decades we have held back the hard cap through repeated short-term fixes—17 in total—that were achieved each time only through significant lobbying efforts by APTA and other members of the Therapy Cap Coalition. In that time, the hard cap was a genuine and persistent threat to our most vulnerable patients, a threat we saw realized earlier this year when Congress failed to extend the therapy cap exceptions process. Today that threat has been eliminated.”

    Dunn said the January 1, 2022, implementation date for the opposed PTA payment cut provides time to explore solutions with the Centers for Medicare and Medicaid Services (CMS) as it develops proposed rules.

    “APTA will leverage its congressional champions, the APTA Public Policy and Advocacy Committee, and the PTA Caucus on strategies to address the CMS activities,” Dunn said. “Our collective efforts will drive the association’s work to ensure that guidance to implement the new policy is favorable to PTAs and the profession, while ensuring access is not limited for those in need of our services.”

    The legislation enacted today provides a fix for the therapy cap by permanently extending the current exceptions process, eliminating the need to address this issue from year to year. Among the provisions included in the new policy:

    • Claims that go above $2,010 (adjusted annually) still will require the use of the KX modifier for attestation that services are medically necessary.
    • The threshold for targeted medical review will be lowered from the current $3,700 to $3,000 through 2027; however, CMS will not receive any increased funding to pursue expanded medical review, and the overall number of targeted medical reviews is not expected to increase.
    • Claims that go above $3,000 will not automatically be subject to targeted medical review. Instead, only a percentage of providers who meet certain criteria will be targeted, such as those who have had a high claims denial percentage or have aberrant billing patterns compared with their peers.

    Over the coming days, APTA will provide additional details on the budget deal, including the impact on home health. For home health, the deal includes positives related to rural add-ons, a market basket update increase of 1.5% in 2020, and use of home health medical records for determining eligibility. However, it also requires a switch from a 60-day to a 30-day episode in 2020 and eliminates the use of therapy thresholds in case-mix adjustment factors.

    “While this package does not afford APTA with everything we would have liked, we should take a moment to celebrate closing the door on a 20-year advocacy effort that has challenged our ability to ensure timely and appropriate services to patients,” Dunn said. "Reaching this milestone affords APTA the opportunity to expand our advocacy agenda to implement more fully our vision to transform society by optimizing movement to improve the human experience.”

    Now's Your Chance to Step up to APTA Committee Service

    Have you ever wondered how the McMillan Lecturer is selected? Are you a strategic business thinker able to help move your association’s finances forward? Are you ready to serve your profession?

    The call for volunteers to serve on APTA committees is now open. Members interested in serving on the Ethics and Judicial, Finance and Audit, Leadership Development, and Public Policy and Advocacy committees, an Awards subcommittee, or the Reference Committee are encouraged to let APTA know of their willingness to participate. Application deadline is March 1.

    APTA heavily relies on its volunteers and needs the best skills, passion, and varied perspectives to build an energetic, inclusive, and innovative corps of volunteer leaders.

    Ready to take a lead in shaping the future of APTA? Apply through the Volunteer Interest Pool by updating your profile, then click "Apply for Current Vacancies" to answer questions specific to the committee. Don’t forget to click “Save Changes” to complete your application. Your profile and thoughtful responses to the application question will be read carefully and will help us select the most appropriate, diverse, and inclusive teams possible. For more information, contact Appointed Group Pool.

    PT, PTA Education Leadership Institute Accepting Applications for a Program That Inspires, Empowers, and Connects

    Being a director for a physical therapist (PT) or physical therapist assistant (PTA) education program can seem as lonely as it is overwhelming—but it doesn't have to be that way. Again in 2018, APTA is inviting a select group of emerging program directors to learn from mentors and each other in ways that will enhance their own work and strengthen the profession overall.

    The yearlong Education Leadership Institute (ELI) Fellowship program uses a blended learning approach (online and onsite components) to help PT and PTA educators in academic, residency, and fellowship settings to hone their skills in facilitating change, thinking strategically, and engaging in public discourse to advance the physical therapy profession. APTA is accepting applications to the program through March 1, 5:00 pm ET.

    ELI is a collaborative effort of the American Council of Academic Physical Therapy, Education Section, Physical Therapist Assistant Educators Special Interest Group, and APTA. It is accredited by the American Board of Physical Therapy Residency and Fellowship Education.

    Considering the fellowship experience? Check out the video testimonials of ELI graduates.

    From PT Pintcast: Now's the Time to Embrace Outcomes Registries

    Medical specialty societies and associations have a responsibility to help members define, measure, and report value—or someone else will do it for them. And registries such as APTA's Physical Therapy Outcomes Registry are important vehicles for staying ahead of the curve.

    This was 1 takeaway from a recent PT Pintcast podcast featuring Heather Smith, PT, MPH, APTA director of quality, and Nathan Glusenkamp, a registry expert who is director of registries at the American Academy of Orthopaedic Surgeons (AAOS).

    For Glusenkamp, associations are ideal for developing clinical registries because they bring "specialized experience" that can’t be matched. He is "a firm believer that if [medical specialty societies] are not engaged in defining value, reporting value, measuring value—that’s still going to happen, but it’s probably going to happen in a way [members] don’t like."

    Smith believes that association-run registries also serve another important function: helping providers get a handle on the seemingly inevitable move toward value-based health care.

    "I can’t stress enough, being prepared ahead of time and really getting involved as early as possible to start to think about the value that you bring," Smith says in the podcast. "Not just in the care that you deliver today, but think more broadly in new and different ways we may be able to bring value to the health care system. Being able to support payment for these services in new and emerging models is really exciting. So you’ve got to be involved to reap the benefits of the new frontier we’re moving into."

    Listen to the full podcast at www.ptpintcast.com. Learn more about the Physical Therapy Outcomes Registry at www.ptoutcomes.com.

    Making Transformation Possible: Panelists at APTA Event Explore Paths Toward Rethinking Pain Management

    Ending the opioid crisis—or even just making a dent in it—is going to require nothing less than transforming an entire culture's attitudes about pain and its management. But panelists at a recent APTA event believe there are models and concepts out there that provide hope for a future in which multidisciplinary nondrug approaches to pain replace an opioid prescription as the norm in health care.

    At its February 5 live event, "Beyond Opioids: Transforming Pain Management to Improve Health," APTA brought together 7 panelists with a range of perspectives, from a patient whose multiple surgeries were accompanied by opioid prescriptions, to a physical therapist (PT) who works in a program that educates and empowers patients to take more control of their pain, to a congressman who is fighting to raise public awareness of addiction as a disease. The entire conversation was broadcast live on Facebook, and a recorded version is available for viewing.

    Though each speaker brought something different to the table, a few common threads emerged when it came to what it will take to truly address the opioid epidemic, particularly as it relates to pain management. Panelists tended to emphasize the need for increased and more open communication, better identification of risk factors for opioid abuse, greater use of multidisciplinary approaches to pain management, and the need for more education delivered to patients, providers, employers, and entire communities.



    Panelist Joan Maxwell's story served as a touchpoint for the night, highlighting the patient experience and bringing current weaknesses in pain management into sharp relief. Maxwell's journey as a patient began with a double mastectomy, which led to a staph infection and subsequent surgeries—9 in all over fewer than 3 years. Along the way, Maxwell experienced a stroke. And at every juncture, she was prescribed opioids, with few conversations about what to expect in terms of pain and what other ways her pain might be managed.

    Luckily for Maxwell, who is now a patient and family advisor for John Muir Health and patient-member of Patient & Family Centered Care Partners Inc, she was able to avoid addiction. Her brother-in-law, however, was not as fortunate: over the course of what Maxwell described as "2 failed back surgeries," he became addicted to opioids. His wife administers his drugs and is careful to hide the medications from him.

    "He was just a regular person like all of us," Maxwell said, "but just 1 surgery, and he was addicted."

    Maxwell holds out hope that things can change for the better, beginning with more conversations between providers and patients about pain.

    Both Grant Baldwin, director of the division of unintentional injury prevention for the Centers for Disease Control and Prevention, and Rep Donald Norcross (D-NJ) echoed Maxwell's call for better communication, albeit in slightly different settings. Baldwin told the audience that more outreach is needed to spread the word about the CDC's guidelines for chronic pain management and its recommendations for nondrug approaches as a first-line treatment, while Norcross spoke about the need for better communication to lift the stigma around addiction and help communities and the federal government focus on a disease model.

    Norcross even offered advice about getting the message out.

    "Make an appointment when your congressman or congresswoman is in your district, and give the real story," Norcross said. "This is not some urban issue that happens in the dark of night. This can happen anywhere."

    As medical director of Swedish Pain Services and president of the American Academy of Pain Medicine, Steven Stanos, DO, brought firsthand knowledge of the latest approaches to pain management. Stanos outlined an intensive multidisiciplinary process at Swedish Pain Services that involves PTs, occupational therapists, pain medicine specialists, pain psychologists, and nurses in group and individual treatment settings. Although Stanos admitted that it's a system not available to everyone, and cost can be challenging for some patients, patients everywhere should be wary of treatment that relies on pain medications only.

    "I always think that [the presence of an opioid prescription] is a marker that [patients] didn't have comprehensive care," Stanos said. "A lot of [what needs to change] is about education and unlearning maladaptive ideas."

    Sarah Wenger, PT, DPT, is doing just that through a "Power Over Pain" program that emphasizes individualized approaches to management, with a focus on education and honest conversations with patients. Wenger is a board-certified clinical specialist in orthopaedic physical therapy and an associate clinical professor at Drexel University's College of Nursing and Health Professions.

    In many instances, Wenger explained, patients need to come to grips with the idea that they may always experience some degree of pain—"I don't think zero pain is particularly realistic for any of us," she added—but that they can be empowered when they understand how to manage pain in healthy ways. "The truth is, most people don't feel really great on opioids," Wenger said.

    Echoing previous panelists’ emphasis on communication were the final 2 speakers, Tiffany McCaslin and Bill Hanlon, PT, DPT, who also is a board-certified clinical specialist in orthopaedic physical therapy. McCaslin, a senior policy analyst for the National Business Group on Health, sees a need for employers to come to grips with the impact opioids and opioid-based pain treatment is having on employees and, in turn, on the overall operation of the business itself. The concept is at the heart of a new summit program being rolled out by her organization. "We're pressing on our members to take a look at this issue with eyes wide open" and to reduce the stigma around addiction, McCaslin said.

    As a PT working in addiction recovery at the St Joseph Institute in Port Matilda, Pennsylvania, Hanlon often finds himself helping patients who have suffered from a pain treatment system that relies too heavily on opioids. But that's not the entire patient population, he explained—many of the individuals he helps don't have underlying pain but experience it for the first time in the form of withdrawal symptoms.

    In either case, he said, communication and a multidisciplinary approach are key.

    "The way we approach addiction needs to be multidisciplinary, just as the approach to managing pain needs to be multidisciplinary," Hanlon said. "And as we get all the disciplines involved and understand the psychology of the person…we can help them more and more."

    But according to Hanlon, that multidisciplinary help must begin with helping a patient to understand what's possible—without an overreliance on opioids.

    "It's about communicating with people," Hanlon said. "It's talking with people and letting them experience the wellness."

    'Choose More Movement and Better Health': APTA Releases New #ChoosePT Video

    Anyone can experience pain—but nobody should feel trapped by opioids as the only way to manage it: that's the message at the heart of APTA's newest video public service announcement (PSA) in the #ChoosePT opioid awareness campaign.

    The new PSA, which debuted during a live panel discussion on pain management, features a teenaged boy, an adult woman, and an older man each experiencing pain, attempting to manage the pain through opioids alone, and ultimately making progress with physical therapy.

    "Pain is personal, but treating pain takes teamwork," the voiceover says. "When it comes to your health, you have a choice—choose more movement and better health. Choose physical therapy."

    The PSA is part of the association's national public awareness campaign, #ChoosePT, which has won multiple national awards, including best video for the first public service announcement.

    APTA's first #ChoosePT PSA reached more than 377 million Americans via television and radio in its first year of release, and APTA’s official consumer information website, MoveForwardPT.com, was visited by more than 3.2 million users in 2017.

    This video mentioned in this story is no longer available for viewing. You can follow APTA's ChoosePT videos on Youtube at https://www.youtube.com/user/MoveForwardPT.

    APTA Learning Center Offerings Will be Included in aPTitude CE Resource

    APTA's Learning Center courses will soon become a lot more accessible, thanks to a partnership with the Federation of State Boards of Physical Therapy (FSBPT) that will add the association's continuing education (CE) offerings to a widely used online system.

    In the coming months, APTA will add its complete catalog of Learning Center courses to aPTitude, FSBPT's online system that allows physical therapists (PTs) and physical therapist assistants (PTAs) to search for CE courses and track attendance. The resource is also available to state physical therapy licensing boards, which can use aPTitude for evaluation of CE compliance for purposes of licensure renewal.

    "APTA is excited to build on its established relationship with FSBPT by utilizing aPTitude," said APTA CEO Justin Moore, PT, DPT, in an association news release. "We look forward to mutually helping our members more easily navigate [CE] courses and activities."

    APTA already has loaded preconference and educational sessions for the 2018 Combined Sections Meeting into aPTitude. More courses and conference content will be added through the spring.

    The aPTitude arrangement was achieved by way of a formal partnership with FSBPT. Launched in 2017, the APTA partnership program is an initiative aimed at enhancing and developing mutually supportive and collaborative relationships with other organizations that have common interests and objectives.

    BuzzFeed Features Physical Therapy 'Success Stories'

    How about a little good news? Specifically, how about a little good news from patients who credit physical therapy and their physical therapists (PTs) for transforming their lives?

    Recently, BuzzFeed published "9 Physical Therapy Success Stories That'll Make You Choke Up A Bit," a collection of first-person accounts from patients who faced a range of issues including spine facture, labrum tears, recovery from a coma, and interstitial cystitis. The reason for the project, according to BuzzFeed, was to "inspire others who are currently recovering from pain, injuries, surgery, or other problems."

    A few choice quotes from contributors:

    "Thanks to physical therapy, I am now able to postpone [knee] surgery for at least 5 years without risking harm. Even though it may be hard, physical therapy is worth it in the end."

    "It was difficult and scary, but I can honestly say physical therapy saved my life."

    "My advice to all of you is to listen to your PT and trust them."

    "Once specific thing: PTs and [occupational therapists] need more recognition and props. They have to work really hard to get some of us back to some sort of norm."

    "I owe [my physical therapist] my mobility and my life without pain."

    With Deadline Looming, APTA Members, Patients, Multiple Organizations Press on for Therapy Cap Repeal

    Congress has until February 8 to act on funding the federal government, and between then and now, APTA, its members, patients, and other organizations are making sure that legislators and their staff receive an earful on the need to include a permanent repeal of the Medicare therapy cap as a part of any agreement.

    Here's a quick rundown of what the association and others have been doing to call attention to therapy cap repeal and other crucial health care issues left unresolved by Congress.

    APTA members make a difference
    The association's members continue to deliver the kind of grassroots advocacy that can grab the attention of legislators, with more than 15,000 member emails sent to Capitol Hill, along with nearly that many sent by nonmembers who support repeal of the cap. In addition, more than 20,000 emails have been sent by patients and non-member supporters through APTA's Patient Action Center, a resource that makes it easy to take action on the cap.

    At the same time, members and their patients enthusiastically responded to APTA's call for patient videos urging Congress to repeal the cap. Those videos are being featured on APTA's Facebook page, and will be used as APTA staff and volunteers continue the push for repeal up to the February 8 deadline for congressional action.

    Multiple organizations, 1 voice
    In addition to its work with the Therapy Cap Coalition, which includes the American Occupational Therapy Association (AOTA) and the American Speech-Language Hearing Association (ASHA), APTA has joined forces with other organizations by signing on to 2 letters to members of Congress.

    On February 1, APTA announced that it has joined more than 70 national provider organizations in urging Congress to reauthorize and fund multiple health care programs and policies, including action on the therapy cap. Participating organizations include the American Nurses Association, the American Psychological Association, the Child Welfare League of America, and the National Association of County and City Health Officials.

    “These programs and policies are core to this country’s health care and essential to ensuring that patients have access to the care they need,” said APTA CEO Justin Moore, PT, DPT, in an APTA news release. “We are better together, and APTA did not hesitate to sign on to this letter in hopes that Congress will hear us and take swift and decisive action not only to provide a permanent fix to the therapy cap, but to also address these other critical issues impacting our health care system.”

    The association also joined 50 other organizations, including the Alzheimer's Foundation, the Brain Injury Association, MedStar Health, and the National Rural Health Association, in a letter to Congress urging action on multiple Medicare fronts.

    "We write on behalf of some of the most vulnerable Medicare seniors, disabled, and critically ill patients across America who are now facing serious health consequences if Congress does not pass a Medicare package soon," the letter states. "Now that we are well into 2018, Congress' inaction on these important Medicare policies could mean real harm to the vulnerable patients we serve."

    AARP and the Therapy Cap Coalition meet the press
    AARP, a longtime supporter of therapy cap repeal, joined representatives from APTA, AOTA, and ASHA to take the repeal message directly to the press.

    During a February 1 press conference, AARP spokespersons made the case that time is quickly running out for beneficiaries—many of whom are elderly—who are subject to the $2,010 cap on what AARP Executive Vice President and Chief Advocacy and Engagement Officer Nancy LeaMond described as "vital services."

    "Two thousand dollars doesn't go very far for these treatments," LeaMond said. "And seniors need them after a stroke or a fall to talk, walk, or do other everyday tasks."

    Justin Elliott, APTA's vice president of government affairs, added that access to therapy also allows patients to pursue nondrug approaches to treatment.

    "The caps impact a wide spectrum of patients needing rehabilitation services, from patients who are recovering from a stroke or traumatic brain injury, to those who are suffering from chronic and often painful conditions and would prefer to choose therapy to address their pain instead of taking opioids to mask it," Elliott said. "Patients cannot hit the pause button on their rehabilitation as they wait for Congress to fix this problem."

    From PT in Motion: PTs Should Cultivate Their Knowledge of Medical Marijuana

    Despite a lingering social stigma attached to marijuana use, there is a growing interest in medical marijuana (MMJ) among patients, researchers, and health care providers, including some PTs and PTAs. Medical marijuana is a potential alternative to opiates, muscle relaxers, and anti-inflammatory drugs. But is it always safe?

    This month in PT in Motion magazine: "A Growing Interest in Medical Marijuana" explores the complicated legal landscape regarding MMJ and how a patient’s use of MMJ may influence physical therapy care.

    While state laws regarding marijuana use are inconsistent, there is a trend toward legalization and decriminalization. However, the United States Drug Enforcement Agency (DEA) is still trying to shut down domestic cultivation of marijuana. Mike Pascoe, PhD, a neurophysiologist and assistant professor in the physical therapy program at University of Colorado, says he meets many physical therapists (PTs), physical therapist assistants (PTAs), and students who are "uninformed about federal and state laws and the process for researching marijuana."

    Charles Ciccone, PT, PhD, FAPTA, told PT in Motion that "many patients are ahead of the curve" compared with clinicians. While no PT or PTA should ever advise use of any medication, Ciccone says clinicians should be able to educate patients on the "reported benefits of marijuana as regards chronic pain, spasticity, and chemotherapy-induced nausea and vomiting"—as well as potential adverse effects.

    Laura Borgelt, PharmD, a pharmacology professor at University of Colorado, educates PT students about how cannabis works in the human body, and how it can be helpful or harmful to certain body systems. Because it is often used to treat pain symptoms, she says, marijuana is "very relevant for a PT." She encourages PTs to be on the lookout for side effects such as cardiovascular issues while exercising, and changes in mood or memory.

    Vivian Eisenstadt, PT, MA, is among PTs who are "very much in favor of legalizing" marijuana. "Marijuana helps many people I treat," she says, comparing it to Vicodin or "any other medication a physician has prescribed for management of physical or mental pain." That said, she observes that sometimes marijuana use can affect a patient’s response time or focus. In such cases, she counsels the patient about "not taking the drug before sessions if it’s going to lower the quality" of the therapy session—just as she would for someone taking Vicodin or OxyContin. "As a PT," she explains, "it is my job to navigate the situation with compassion and professionalism."

    The variety of forms of marijuana consumption is a concern, as dosage is often inaccurately labeled, says Pascoe. Pharmaceutical-grade marijuana extracts and topical creams differ from commercial products such as baked goods or candy. In addition, the different cannabinoids found in marijuana have varying effects on the body.

    When researching medical marijuana’s effects, Ciccone urges PTs to consider the source of the information to be able to provide patients with balanced and valid information. Clinicians "should be vigilant for any problems that may arise if patients are using cannabinoids during physical rehabilitation."

    "A Growing Interest in Medical Marijuana" is featured in the February issue of PT in Motion magazine, and is open to all viewers—pass it along to nonmember colleagues to show them one of the benefits of belonging to APTA. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.