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  • Physical Literacy Decline in Children Leads to Adverse Effects in Adults

    Physical literacy is as important as literacy in language, music, and mathematics. However, today’s children are becoming less physically literate, which could shorten their lifespan as much as 5 years less than their parents’. That was a point made in “Push Play: The Rise of Physical Therapy in the Physical Literacy Movement,” presented June 22 at NEXT 2017. The presenters were Christy Zwolski, PT, DPT, and Derek Roylance, PT, DPT, both with Cincinnati Children’s Hospital Medical Center.

    Zwolski said that physical literacy extends beyond sports: “Physical literacy is the ability, confidence, and desire to be physically active for life.”

    Although stating that “Humans are designed to move,” Zwolski noted that physical activity declined 32% from 1965 to 2009, and is projected to decline 46% from 1965 to 2030. The decline is occurring in all activity areas: occupational, domestic, transportation, and active leisure.

    The decline in activity also occurs as children age. At age 9, boys participate in approximately 190 minutes of moderate-to-vigorous physical activity (MVPA) a day. Girls engage in approximately 170 minutes of MVPA. By age 15, boys engage in less than 60 minutes, and girls are physically active for barely 30 minutes per day.

    Zwolski attributed part of the decline to a breakdown in the physical literacy cycle, in which desire and motivation lead to participation. Participation leads to ability, the “competence to move.” Ability, in turn, leads to confidence, which reinforces desire and motivation. She cited research suggesting that while confidence in performing activity is relatively high among 9-year-old boys and girls, by age 13 girls’ confidence has dropped sharply. Boys’ confidence remains fairly stable.

    Girls don’t perform as well as boys in many tests of motor competence, such as kick ball, 1-handed catch, and overhand throw, Zwolski said. (They do better than boys in skipping.) Further, girls’ performance lags further behind boys’ as girls age and begin to “disassociate physical activity with happiness.”

    Movement skills, she said, form the foundation for many lifelong activities. For example, when a child learns how to run, he or she can enjoy soccer, basketball, lacrosse, and tennis. Similarly, children who develop balancing skills can enjoy hiking, football, snowboarding, Zumba, and yoga. If basic skills aren’t developed in childhood, though, it becomes far more difficult to learn those other sports. He said physical literacy should be emphasized before sport-specific skills.

    Roylance presented a case series on promoting physical literacy in the community. Saying, “You don’t have to reinvent the wheel,” he explained that he consulted with a community relations specialist who already had identified programs involving youth physical activity. These ranged from a hospital lecture series on parenting skills to a baseball clinic sponsored by the Cincinnati Reds for children and their parents. Other programs included a health fair and a middle school field day.

    Oxford Debate: Specialist vs Generalist Education; Ciccone Declares Results to be the “Closest Ever”

    According to moderator Chuck Ciccone, PT, PhD, FAPTA, the 10th Oxford Debate, held June 23 at NEXT 2017, was the closest in its 10-year history.

    The motion being debated was: “Be it resolved that physical therapist and physical therapist assistant students will demonstrate expertise in a specific focused area of practice immediately upon graduation.”

    The pro team, arguing in favor of the resolution that graduating students should be able to demonstrate expertise in a specific area, consisted of Scott Euype, PT, DPT, MHS; Jody Frost, PT, DPT, PhD; and Frederick Gilbert, PT, DPT. Arguing against the resolution were Janet Bezner, PT, DPT, PhD; John DeWitt, PT, DPT, ATC; and Shawne Soper, PT, DPT, MBA.

    The pro team, dressed as personalities from the television show “The Voice,” led with Gilbert, who interspersed his arguments with a variety of hit songs. After a rousing version of “Ring of Fire,” he said, “We are not ready to treat what’s coming at us in the clinic. Generalists are generally good. But health care demands excellence. Are we prepared for the masses fed up with ‘sick care’?”

    Leading off for the con team was Dewitt, who said, “We are choosing a different path than we expected when we entered PT school. The missteps we take foster innovation and discovery, and that is good.” Citing the view of Gail Jensen, PT, PhD, FAPTA, that the hallmark of physical therapy is the ability to make judgments, often in uncertain conditions, DeWitt said, “Without that foundation, we cannot specialize. We need a robust set of tools to understand the needs of our patients.”

    Next up was Frost. Arguing in favor of specialization, she asked the audience: “Would you see a generalist for women’s health? Or for a spinal cord injury?” She spoke of the need for mentors, posing a question: “Clinicians: How many students chose their specialization after working with you? That’s good. We need specialists in practice. The generalists say they’re jacks of all trades, but there’s no way they could keep up with all the literature and research [required of specialists].” Continuing with the theme of “The Voice,” Frost concluded with a revised rendition of Lee Greenwood’s “God Bless the USA,” with lyrics reflecting the new title “God Bless the Specialist.”

    Soper, supporting the generalist position, responded: “Physical therapy is not about us. It’s about our patients and clients. So, where are they? All over the country. To care for the human experiences, we need physical therapists (PTs) where the need exists. But in rural areas, we have few PTs to cover huge areas. In those areas, it’s essential that patients have their needs met. Consider the patient poststroke or the child with special needs.” If a specialist isn’t where the patient is, “we’re not meeting the needs of society.” Education, Soper said, “needs to support a student’s exploration or else this is an opportunity missed.”

    Then came time for audience comments. Among them:

    “I’m a student and spending so much money. When I graduate, I want to be able to treat every patient who walks through the door.”

    A Florida-based PT said, “I get 7-10 requests a week for referrals. I’ve never been asked for ‘the best generalist.’ It’s always ‘the best neurologist’ or ‘the best orthopedist.’”

    An audience member commented, “We need to become movement specialists first. Then we can go from there.” Another audience member said, “I don’t know what all those letters after your name mean.” A PT based in Alaska said, “Where you care for patients across the state, you don’t know what’s needed until you’re there.”

    Then the program shifted back to the debaters. Wrapping up for the generalists was Janet Bezner, who said, “We have to meet the needs of all the people. Think of all the ICD-10 codes we address. We might see a child or an infant, a baseball player, a professional runner, a homemaker, a steelworker, or a painter. So we have to cast the net broadly to meet the needs of society. We’re not suggesting that there should never be specialists. But that should come after being a generalist.”

    Concluding for the pro team, arguing for specialization, was Euype. He said, “Being generally good is not good enough. We need to have a specialization. Do you want someone poststroke being treated by a generalist?” And, he added, “Students with specializations are more employable.”

    After scoring the debaters and tabulating the audience comments, Ciccone declared the generalist team the winner.

    From NEXT: PTs, PTAs, Must Take on the Challenges of Noncommunicable Disease

    Physical therapists (PTs) and physical therapist assistants (PTAs) are likely familiar with the health burden of noncommunicable diseases (NCDs), and many will even say that the physical therapy profession has a role in addressing that burden. But as 5 APTA Catherine Worthingham fellows would point out, saying that PTs and PTAs have a role is not the same as living out that role—and if the profession wants to achieve the latter, it has a lot of work to do.

    Marilyn Moffat, PT, DPT, PhD, DSc (hon), FAPTA, laid out the breadth of the NCD problem by way of a set of grim statistics, including a World Health Organization (WHO) estimate that 88% of US deaths are attributable to NCDs. Moffat said that although death rates associated with some of the 4 major types of NCDs—cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes—are trending down, the drops largely are related to drugs and surgical interventions and not in preventive lifestyle changes.

    Julie Fritz, PT, PhD, FAPTA, used Moffat's statistics as a springboard to talk about how NCDs affect different parts of society, pointing out that in certain locations, life expectancy is actually declining. "That's an inflection point that's worthy of note by all of us," Fritz said. "If you're poor, it really matters."

    The drivers, however, are less about socioeconomic factors and more about health behaviors, Fritz said. And while she believes changing those behaviors "is in our wheelhouse collectively as health care providers," in her opinion, PTs are "playing a very small role in being part of the solution to this situation."

    "We have to consider more upstream factors and think about care as a continuum," Fritz said. "The real goal is the well-being of the patient in a broader sense." But according to Fritz, PTs are doing little to approach the issue from this more proactive perspective; instead, "we just think more people ought to show up, and we're waiting for them," she said.

    The profession's slowness in making this shift isn't necessarily due to a lack of information or unclear policy directives, according to Lisa Saladin, PT, PhD, FAPTA. Saladin pointed to several resources, including the WHO global action plan on NCDs, that show not just the need for action but also the possibilities for the PT's role in reducing risk factors. But PTs can't go it alone, she added, saying that "we need to increase our level of partnerships."

    If any PTs or PTAs feel hesitant about taking on a more prominent role in the fight against NCDs, they shouldn't, according to Saladin. She cited 4 separate APTA positions, as well as the association's public policy priorities, as support for the physical therapy profession to step up to the plate. Without that action, she added, the policies don't amount to much. "We can talk the talk, and we can understand what our role should be," she said, but that doesn't necessarily mean the profession is acting on that understanding.

    So how does the profession shift to action? Gail Jensen, PT, PhD, FAPTA, said it begins with PTs and PTAs understanding that a "fundamental commitment to social justice" is "a part of who we are" as a profession. Jensen said that action won't happen until the profession fully embraces its ethical professional identity.

    Jensen said that the profession need look no further than its own code of ethics to understand its obligation to address NCDs—specifically, by way of Principle 8 of the code, which states that "Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally." That statement, linked to the core value of social responsibility, makes it clear that PTs and PTAs need to assume a role.

    But it's not simply about acting—it's about acting with a goal in mind, Jensen said, and that's an idea that brings its own challenges. "Do we really understand what it is to have a just health care system?" she asked.

    Karen Paschal, PT, DPT, MS, FAPTA, rounded out the presentations by focusing on how education "across our lifetimes as physical therapists" could spark a more active professional role in addressing NCDs. But bringing education up to speed first will require an examination of priorities, Paschal asserted. She challenged the audience by asking them, "How many of you have hired applicants who say 'I want to help prevent NCDs?'"

    Paschal said that change needs to take place in 3 major areas of educational focus. First, education around rehabilitation needs to provide more than an understanding of the role of NCDs—it needs to address what the PT and PTA can do. "Although we may give that [concept] language, we do not give that action in physical therapy," she said.

    Second, the profession needs to take an honest look at its education efforts around collaboration, including some of the underlying assumptions that color the profession's concept of what collaboration is. Paschal said that, too often, collaboration is understood as equivalent to an orchestral concerto, where "we dream of being the soloist accompanied by the orchestra." Taking up a real role in prevention of NCDs will require a much more humble attitude, she told the audience.

    Third, risk factors for NCDs need to be well-understood by PTs and PTAs, who in turn are ready to address those factors. "We need to change our orientation from rehabilitation and toward health prevention and promotion," Paschal said.

    In closing her portion of the discussion, Paschal may have summed up the crux of the entire presentation: "We need simply to think bigger."

    News From NEXT: Now Is the Time for PTs in Primary Care

    Physical therapists (PTs) "are in the perfect position to be involved in primary care," according to John Heick, PT, DPT, PhD, but to make the most of the opportunity, PTs need to understand the current primary care landscape and its potential for the future.

    That was the aim of "Primary Care Roles of Physical Therapists: A Perspective" presented on June 23 at the APTA NEXT Conference in Boston. Heick was joined by 6 other presenters—Steven Ambler, PT, DPT, MPH; Hadiya Green PT, DPT; Andwele Jolly, PT, DPT, MBA, MHA; Marie Johnson, PT, PhD; Ivan Matsui, PT; and Brian Young, PT, DSc—for a multifaceted look at primary care and the PT. The presenters were part of the team involved in creating a new APTA perspective paper on the topic. The session, with its attention to the here-and-now practicalities of the issue, provided important context for a later Rothstein Roundtable discussion focused on the future of PTs in primary care.

    Green began by providing background for the subject, pointing out that the idea that PTs could play a part in primary care is "not a new concept," but one that has received increased attention from APTA and its House of Delegates. In response, the association has begun to investigate and identify not just the roles of PTs in primary care teams, but which PT services may qualify as part of primary care delivery systems and the opportunities for integrating these ideas into practice, education, and research.

    Heick continued the context by describing primary care's history, which began with the need to treat the wounded overseas during World War I, and took formal shape when the US embraced the primary care model in the 1960s. The PT's role in primary care came later, when states began to create direct access provisions. According to Heick, the potential connection to primary care followed naturally, if for no other reason than that musculoskeletal conditions are the second most common reason for visits to the emergency department (ED) and account for 25%-28% of ED visits overall.

    PT education's part in primary care was covered by Johnson, who described how the curriculum evolved during the expansion of outpatient physical therapy in the 1970s and 1980s. That growth led to more focus on physical therapy as a doctoring profession, including the move toward the DPT and in the inclusion of not-always-explicit primary care concepts in educational guidance such as the Commission on Accreditation in Physical Therapy Education's evaluative criteria. There is more work to be done to increase primary care content, Johnson pointed out, including introducing opportunities for PT residencies in primary care.

    In some ways, the US military may provide insight into the future of primary care education in PT programs, explained Young, a Lieutenant Colonel in the US Air Force. Young presented an outline of the Army-Baylor DPT curriculum plan, which incorporates a significant amount of direct access concepts into its program. The result: PTs well-acquainted with an expanded role in primary care, with outcomes data finding no adverse effects among 472,000 direct access PT visits—which included PTs ordering imaging and prescribing medications.

    But gains aren't just being made in the military, explained Matsui, who serves on the faculty for Kaiser Permanente's Northern California Graduate Education program. Kaiser has been including PTs as primary care providers among its 21 hospitals across Northern California since the mid-1990s, when PTs were embedded in Kaiser-run clinics. Since that time, the program has shifted away from the embedding concept and toward a more consultative role for PTs, Matsui explained, where the PTs are asked to provide insight on the appropriateness of specialty referrals, special tests or imaging, injections, and work modification.

    Jolly focused on payment issues, noting that while the current Affordable Care Act (ACA) does not include PTs in the list of primary care providers, the value-based care programs arising from the ACA could change that. Expanded direct access to PTs would lead to lower utilization, fewer invasive interventions, shorter wait times, greater efficiencies, better patient education, and more appropriate diagnostic strategies—all of which would contribute to the "triple aim" of health care reform to lower costs, better the patient experience, and improve the health of populations, Jolly said. But, he added, there are a host of barriers to be addressed, including reimbursement issues, certification requirements, agreement on a diagnostic classification system, and malpractice and liability considerations.

    Ambler wrapped up the session by reminding the audience that the barriers are worth overcoming, because PT involvement in primary care represents a true benefit to society. He explained that expanded PT direct access in primary care settings would lead to greater coverage of underserved areas, a more diverse workforce, and an enrichment of the primary care body of knowledge, thanks to the unique perspective the PT brings to the table.

    APTA members can go online to read “A Perspective—Exploring the Roles of Physical Therapists on Primary Care Teams,” the association’s new perspective paper on primary care. (Log in to apta.org and look under Hot Topics Related to PT Scope of Practice on the Scope of Practice webpage.)

    Senate Recesses Without Health Care Vote: Keep These 3 Things in Mind

    The US Senate will be entering its July 4th weeklong recess without voting on a bill to repeal and replace major provisions of the Affordable Care Act (ACA). The bill as it now stands contains several elements that APTA finds troubling, including the elimination of requirements for coverage of "essential health benefits" (EHBs) including rehabilitation, and changes to Medicaid that would likely reduce patient access to care.

    With the next opportunity for a Senate vote at least a week away, here are few things to keep in mind during the recess:

    1. It's an evolving process.
    The bill originally presented in the Senate is already beginning to morph in an effort to garner support, and it likely will change even more before all is said and done. Will EHBs and better Medicaid coverage become part of the mix? Hard to say, so stay tuned.

    2. Recess is a great time to make a few calls.
    Concerned about what you're seeing in the Senate bill? Contact your legislators—or better yet, attend a town hall if your lawmaker holds one. APTA offers this handy app that makes it easy to take action.

    3. Your association is engaged.
    APTA does not oppose the idea of improving the ACA—something APTA has made clear in its statements on the Senate bill and on the American Health Care Act approved by the US House of Representatives—but the association does oppose any provisions that would create unneeded barriers to care for Americans. And APTA has been at work on Capitol Hill educating lawmakers on the importance of habilitation and rehabilitation.

    So, go ahead. Relax. Light a sparkler. Eat a burger. Watch a parade. But don't forget that there's work to be done.

    PTAs Included in TRICARE? House Committee Takes First Steps

    TRICARE, a major part of the US Department of Defense health care system, has long insisted that physical therapist assistants (PTAs) aren't payable under the program—and for just as long, APTA has advocated that there's no reasonable basis for the exclusion. Now it looks as if APTA's position may be gaining some ground.

    On June 28, the US House of Representatives' Committee on Armed Services approved changes to the 2018 National Defense Authorization Act (NDAA) that gives the US Secretary of Defense marching orders: conduct a review to figure out how to bring PTAs, occupational therapy assistants, and other support personnel in the TRICARE payment system. The changes, brought forward by Reps Ralph Abraham (R-LA) and Ruben Gallego (D-AZ), were incorporated as part of the committee's mark-up of the NDAA.

    The NDAA will move on to a vote by the entire House and, if approved, will be taken up by the Senate. Current language calls for the report from the Secretary of Defense to be completed by April 1, 2018.

    "The amendment in committee is only a first step but an important one," said Michael Hurlbut, APTA senior congressional affairs specialist. "It's a change that we hope will ultimately lead to coverage of PTAs under TRICARE."

    APTA will continue to monitor progress of the legislation and provide updates.

    On With the Shoe, Say APTA Volunteers in Boston

    When it comes to the transformational power of the physical therapy profession, sometimes you can measure success in feet—specifically, kids' feet.

    APTA members and staff, led by Brad Thuringer, PTA, recently made a very direct impact on some of Boston’s children in need by donating more than 700 pairs of shoes and several thousands of pairs of socks as part of the national "Shoes4Kids" campaign. Thuringer has led APTA's Shoes4Kids efforts for several years, making donations in the cities that host the APTA NEXT Conference and Exposition.

    This year, the city was Boston. This year was also a record-breaker for the level of APTA involvement, with donations being made onsite by attendees as well as at APTA headquarters in Alexandria, Virginia, where staff adopted Shoes4Kids as a part of its in-house "APTAServe" community service program.

    The donation event was held at Boston Catholic Charities. APTA volunteers, mostly students from the Simmons College physical therapy program, were on hand to help the children and their families find the right fit. Many of the children at the event had been wearing the same shoes for months, and had grown 1 or more shoe sizes over that time.

    "We are so grateful that … all the volunteers and donors chose to partner with Catholic Charities," said Holly Clark, director of stewardship and donor relations. "All of the APTA volunteers provided a special service to our families and treated everyone with dignity. Our families and children were absolutely delighted with the day. [The APTA volunteers] clearly communicated health and wellness benefits of what you were offering rather than needs of people. It makes a big difference."

    APTA will work with Shoes4Kids as part of the 2018 NEXT Conference in Orlando, with Orlando University of Central Florida hosting the program.

    2017 - 0630 - Shoes4Kids

    Oncology Section Introduces New Guideline on Diagnosis of Upper Quadrant Lymphedema in Patients With Cancer

    While early recognition of upper quadrant lymphedema secondary to cancer can play a crucial role in maintaining quality of life for patients, few clinical practice guidelines (CPGs) exist to help clinicians diagnose the condition. The APTA Oncology Section set out to change that with the publication of “Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association” in Physical Therapy (PTJ), APTA's science journal. An executive summary of the CPG will be published in Rehabilitation Oncology’s July issue.

    Authors Kimberly Levenhagen, PT, DPT; Claire Davies, PT, PhD; Marisa Perdomo, PT, DPT; Kathryn Ryans, PT, DPT; and Laura Gilchrist, PT, PhD, evaluated research on current diagnostic and assessment methods, including bioimpedence analysis, circumferential measurement, water displacement, perometry, and ultrasound imaging.

    In a podcast summarizing the work group’s recommendations, coauthor Claire Davies reminds clinicians, “We need to be aware that none of the diagnostic criteria are perfect in their diagnostic accuracy, especially [in] patients that fall just under or over a cut point. These [patients] have the potential to be misclassified. Also, the clinical presentation of lymphedema should influence the selection of diagnostic tool, as some measures … are more accurate in the early stage.”

    Physical therapists need to tailor the diagnostic approach to each patient. For example, Davies told PT in Motion News, “in some groups with early or subclinical lymphedema, volume measures may not be sensitive enough to diagnose and/or assess extracellular fluid. As tissue changes occur with later stage lymphedema, volume may be increased, yet measures of extracellular tissue fluid may not be as accurate due to fibrotic changes.”

    Authors of the CPG “encourage clinicians to cluster findings from their examination,” using the most appropriate tests recommended for each of the clinical presentations, to draw a conclusion on diagnosis.

    In her podcast, Davies ends “with a call for research.” Among their recommendations, authors of the CPG urge “further psychometric testing of the tools currently being used to assess and diagnose [secondary upper quadrant lymphedema].” They point out the need for research that examines diagnostic criteria at different stages of this condition. Further research should examine what “combination of history, symptoms, and other measurements” is “most accurate” for diagnosis, they state.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Coalitions Bring Rehab Message, Powerful Stories to Capitol Hill

    Talk about timing: less than a week after the US Senate unveiled a health care reform bill that threatens to weaken required essential health benefits (EHBs) that include habilitation and rehabilitation, and just days before the Senate's 4th of July recess, a trio of coalitions brought its powerful message to Capitol Hill: don't make changes that would limit access to these areas of care. APTA is a member of all 3 coalitions.

    The briefing, sponsored by the Habilitation Benefits Coalition, the Coalition to Preserve Rehabilitation, and the Independence Through Enhancement of Medicare and Medicaid Coalition, not only highlighted the value of rehabilitation and habilitation services and devices, it included compelling firsthand accounts of how access to these services and devices made all the difference in people’s lives.

    Sen Tammy Duckworth (D-IL) was on hand to tell the story of her care and rehabilitation after losing both legs while serving in the Army in Iraq. She described the "excellent" care at Walter Reed Medical Hospital, and how, through taxpayer support of Veterans Affairs, she was able to receive rehabilitation and needed prostheses. She said that in subsequent conversations with nonmilitary people, she often was told how they were saving up so that one day they would be able to afford the care and devices Duckworth received.

    "I realized how different the world was for people who have access to the care they need from those, who are the majority of Americans, who don't," Duckworth said. "And that's not right."

    Roseann Sdoia, a survivor of the 2014 Boston Marathon bombing, echoed Duckworth's opinion on the importance of accessible rehabilitation and devices. She described not only the costs associated with prostheses, but the considerable time that must be spent in physical therapy and occupational therapy to learn how to live with the devices. "I wouldn't be able to use those devices if I didn't have the rehab that taught me how to use them," she said.

    In addition to the briefing, coalition representatives, including APTA staff, visited 50 Senate offices.

    "The briefing was an effective way to highlight the importance of habilitation and rehabilitation in health care, particularly in light of the debate now taking place over health care reform," said Michael Matlack, APTA director of congressional affairs. "But we aren't stopping there. APTA will be working with these coalitions to continue to deliver that message while Congress is in recess and after it returns."

    2017 - 0629 - Rehab Hill Briefing

    CMS Backs Down on Change That Threatened Payment Levels for Complex Wheelchairs, Accessories

    With just days to go before the implementation of a change that would have opened the door for cuts to payment for complex rehabilitation technology (CRT), including specialized wheelchairs and components, the US Centers for Medicare and Medicaid Services (CMS) has taken steps to ensure that the reductions won't happen after all.

    The June 26 CMS decision manages to avert a planned July 1 change that would have affected payment for wheelchair accessories and back and seat cushions used with group 3 complex rehabilitative power wheelchairs. The looming cuts were related to a 2014 CMS decision to subject CRT to competitive bidding pricing, an approach associated with reduced payments from Medicare.

    After CMS made the 2014 decision, legislators enacted short-term fixes to delay the cuts. The change to competitive bidding was supposed to have been implemented on January 1, 2017; the 21st Century Cures Act signed into law in December 2016 moved startup back to July 1. In January, Congress asked that the Trump administration review the impending change before it took effect.

    The recent announcement from CMS puts the issue to rest. "CMS has reconsidered its policy on adjusting fee schedule amounts using information from the competitive bidding program for these items," CMS states in a guidance resource. "As a result, effective July 1, 2017, payment for these items will be based on the standard unadjusted fee schedule amounts."

    APTA has been a strong supporter of efforts to remove CRT wheelchairs and components from competitive bidding pricing, and is a member of the Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition. In a March letter to legislators, the ITEM coalition advocated for a permanent fix to the competitive bidding threat, writing that "regardless of injury, illness, disability, or chronic condition, all Medicare beneficiaries should be eligible for the same access to medically necessary mobility devices, services, and accessories."

    News at NEXT: Variation in Care Is the Profession's Greatest Challenge, Maley Lecturer Says

    Physical therapy cannot move forward as a profession until those who practice it resolve the issue of unwarranted variation in practice. Tara Jo Manal, PT, DPT, FAPTA, in her delivery of the 22nd John H. P. Maley Lecture, was unequivocal in sending this message to the profession. "The greatest challenge to the value of physical therapy is unwarranted variation—situations in which wide variation of care is not explained by the type or severity of the condition or by patient preferences," she said to a capacity audience on June 23 as part of APTA's NEXT Conference and Exposition.

    Physical therapy is not the only health care discipline with this problem; unwarranted variation is a challenge within all of health care in meeting the triple aim of improving societal health, enhancing the individual patient experience, and reducing costs. But even if physical therapy has not yet been in the "center of the crosshairs," Manal said, our profession increasingly has been identified as an area of interest as payment moves toward value-based systems in order to reduce waste in spending. The lack of standardization in physical therapist practice "puts all physical therapists at risk for reductions in covered rehabilitation services," she said.

    The profession's response must be to "invest inward to solidify our procedures, use what we already know to maximize our return on our clinical efforts, and solve this problem," Manal said. As a start, she suggested that the profession "stop looking to expand our scope and promote our ability to practice at the top of our license until we get our house in order, to ensure that all patients are cared for at the highest level in every physical therapy setting with every provider."

    Clinical practice today is "chaotic," Manal said. Some factors can't be modified, such as limitations set by payers and regulation. And it's hard to avoid "the chaos of the human factor," such as sick coworkers, appointment glitches, and equipment breakdowns. But what can be modified "is the disorganization and even confusion that occurs when we fail to standardize our physical therapy care," she said. When PTs take a "blank page" approach to every patient and treatment, clinical success is based on the premise that they "can remember all the information … for any given condition at any given moment" in applying treatment. "That is quite simply an unrealistic expectation."

    Creating and using evidence-based patterns of care will avoid the blank-page dilemma, Manal said, and how PTs and PTAs access needed knowledge to do so is key. Reading only primary literature isn't feasible—Manal cited a 2009 study concluding that for internists to stay current in their field they would need to read 34 articles daily, a "daunting" effort. Instead, she argued for reading synthesis documents such as clinical practice guidelines, which review, weigh, and grade available evidence.

    Among the reasons that clinical care patterns aren't more widely adopted, Manal said, are a lack of understanding of their added value to daily care and the belief of many clinicians that they already follow best practices.

    To the first reason, Manal countered that "standardized rules … add value by reducing clinical chaos and improving outcomes. [They] assess risk and suggest matched-treatment interventions to maximize the success of your physical therapy care." However, to make the most of standardized tests and measures, Manal said PTs must perform them at regular time intervals and as described in the literature, "not using our favorite modification." Further, tests with poor reliability and no validity need to be abandoned.

    This is not to say that evidenced-based care patterns are "cookie-cutter," Manal explained. "Some patients progress quickly and need no special efforts, while others require creativity and change—but guidelines ensure that milestones are met before progressions occur."

    To PTs who believe "I already do that," Manal argued that therapists who incorporate guidelines and use standardized patterns of care "unburden themselves from the fallacy of being all-knowing and, instead, benefit from the best we as a profession have to offer."

    Manal suggested that patient self-reporting and performance-based outcomes "can help tell you whether you are at or above the current best standard of care, or would benefit from adherence to standardized care patterns to decrease clinical chaos." She pointed to the APTA Physical Therapy Outcomes Registry as a tool to enable clinicians to compare themselves with colleagues. She noted, though, that, first, comparative data must exist, meaning "therapists must participate in collecting minimum data sets at specific time intervals" to make accurate comparisons.

     

     

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    News at NEXT: Sparking an 'Industrial Revolution' in Primary Care

    Sure, physical therapists (PTs) can explain the important role they could play in primary care. But is anyone listening? And what will it take to get physicians, facilities, and payers to take notice and act?

    From there, the questions get even more complex. Even if PTs manage to win over primary care stakeholders, is the current health care system prepared to make widespread PT involvement the rule and not the exception? And are PT education programs ready to provide the necessary training to support this new world of care?

    This seeming Gordian knot was the feature of this year's Rothstein Roundtable, part of APTA's NEXT Conference and Exposition. The title of the session—"Does Primary Care Need an Industrial Revolution?"—hinted at the panelists' consensus that some big changes need to happen, and it isn't going to be easy.

    Moderator Anthony Delitto, PT, PhD, began the discussion by noting a disconnect between patients' perceptions of primary and alternative care versus the realities of the health care environment. It's a disconnect that can leave PTs in a kind of limbo: when it comes to musculoskeletal pain and dysfunction, "the people who want alternative care … go to a chiropractor," he said, because they don't consider physical therapy an "alternative" treatment. And yet, PTs are not well-integrated into primary care settings, making it harder for the primary care patient to get the effective treatment they need quickly.

    "We need to figure out ways to better manage patients," Delitto said.

    The challenges to better patient management are fundamental, beginning with the primary care physicians themselves, according to Robert Saper, MD, who is working with Delitto on a PCORI-funded pragmatic trial examining whether or not prompt referral to psychologically informed physical therapy for patients with acute low back pain can reduce the risk of developing chronic back pain.

    "Primary care physicians do not know anything about physical therapy," Saper told the audience. " They don't know about the different [physical therapist] interventions. They don't understand your notes." The lack of understanding isn't necessarily surprising given the limited opportunities for physicians and PTs to interact, Saper said, adding that "the only reason I know [what PTs bring to the table in primary care settings] is because I crossed the bridge."

    Addressing that gap will require changes to physician education, and could be helped by simply getting PTs and primary care docs to physically work closer to each other. But as panelist Adam Goode, PT, DPT, PhD, pointed out, "co-location" alone isn't enough, because even when PTs and physicians share space, "we're still not seeing [a significant increase in] referrals."

    Panelists agreed that PTs need to become fully integrated into the primary care team. According to Saper, this means including PTs in rounds, case review meetings, and informal, regular conversations about care. "We have to get off our computers … and talk to each other."

    Saper and others provided examples of how this true integration has led to more effective primary care. All agreed that it takes more than an enlightened physician to make it happen, with panelist Jason Beneciuk, PT, DPT, PhD, MPH, noting that "executive support of systems like this is needed in order for [integration] to happen." Saper added that there were also logistical issues to be considered—things like scheduling, billing, and charting.

    Panelist Jay Irrgang, PT, PhD, scientific director of APTA's Physical Therapy Outcomes Registry, commented that "the physical therapist has got to be involved in triage of the patient." This could require a shared classification-based treatment system, he said, but the bottom line is "to realize what you can do quickly."

    "When a patient comes to a physician, they want something then," Irrgang said. "They want to fix the problem immediately." PTs may be the best option for doing just that, but referrals to physical therapist services often involve waits for the first appointment—and the first appointment usually is an evaluation, not a treatment session—representing a missed opportunity.

    Delitto proposed that the true proving grounds for more integrative systems could be in primary care facilities that operate on a "shoestring" budget, such as free clinics, which are more willing to take what bigger facilities would view as a risk. Panelists considered various possibilities, but seemed to agree that as long as volume-based payment systems rule the roost in health care, PT integration into primary care won't grow at the rate needed by patients.

    Beneciuk called the payment issue "the elephant in the room," saying that some providers might resist PTs in primary care, thinking "'you're not going to take that patient away from me.'"

    But making the case for an industrial revolution in primary care faces a catch-22: more outcomes data are needed to substantiate the effectiveness of an integrated PT role, but without wide integration of PTs, data can't be generated quickly enough.

    Delitto and Irrgang are Catherine Worthingham Fellows of APTA. Beneciuk is a Fellow of the American Academy of Orthopaedic Manual Physical Therapy, and Goode is a Fellow of the Center on Health Services Training and Research (CoHSTAR).

     

     

    News at NEXT: Foundation Receives Single $3 Million Donation, Largest Ever

    The Foundation for Physical Therapy (Foundation) recently received the largest single donation in its 38-year history—a $3 million gift that will be used to create an endowment for clinical research funding. The donation was announced at the Foundation's PT Party event held June 22 in conjunction with APTA's NEXT Conference and Exhibition.

    The remarkable donation comes from a family known for doing remarkable things for the Foundation—Stanley Paris, PT, PhD, and his wife Catherine Patla, PT, DHSc, MS. In past years, Paris has attempted to sail around the world and swim the English Channel, and he successfully bicycled across the United States, all in an effort to raise money for the organization, which is focused on strengthening physical therapy research.

    "This generous gift will transform the Foundation's ability to fund clinical research at a higher level, providing significant and ongoing support for research that forms the basis of physical therapist practice," said Foundation President, Edelle Field-Fote, PT, PhD, in a Foundation press release. "We are honored by the confidence that Dr Paris and Dr Patla have placed in us by recognizing and rewarding the exceptional work we do to support investigators in the field of physical therapy."

    "We support physical therapy research because it is critical to our profession's ongoing health." Patla said. "We want to sustain the Foundation's work for generations to come." In a video interview, Paris described the donation as a wise investment in physical therapy research. "We know that the money will be used carefully and spent effectively," Paris said.

    Paris and Field-Fote are Catherine Worthingham Fellows of the American Physical Therapy Association.

    2018 McMillan, Maley Lecturers Announced

    APTA honored recipients of its 2017 awards program on June 22, and set the stage for next year by announcing the 2018 Mary McMillan and John H. P. Maley lecturers.

    Laurita M. (Laurie) Hack, PT, DPT, PhD, MBA, FAPTA, has been named the 49th McMillan lecturer, and Robert J. Palisano, PT, ScD, FAPTA, was announced as the 23rd Maley lecturer. These popular, high-profile lectures will be delivered as part of the 2018 NEXT Conference and Exposition.

    In addition to the lecturer announcements, APTA officially honored members who have made outstanding contributions to the physical therapy profession. The honorees include newly named Catherine Worthingham Fellows as well as recipients of the Lucy Blair Service Award. APTA also announced award recipients for excellence in education, practice, service, publications, research, and academic achievement. View or download a full list of the 2017 recipients (.pdf) from APTA's website.

    Nominations for the 2018 Honors and Awards Program will open September 2017.

    Check out the history of APTA's honors and awards recipients.

    News at NEXT: 2016-2017 VCU-Marquette Challenge Raises Over $340,000 for the Foundation

    Students from across the country were recognized June 22 during the Foundation for Physical Therapy's (Foundation) first annual PT Party, formerly known as the Foundation's Annual Gala, for their participation in the 2016-2017 VCU-Marquette Challenge—which for 2017-2018 will be called the Mercer-Marquette Challenge. Mercer University pulled ahead of its competitors this year after a second place finish in last year's competition to win the title, literally, as the challenge now takes on Mercer's name along with Marquette University as part of the contest's tradition. Mercer raised $45,220.

    Earning second place was last year's winner Virginia Commonwealth University ($37,834), and coming in third was the University of Pittsburgh ($24,449). The Foundation also recognized Marquette University students for their financial commitment to the challenge in raising over $20,000.

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

    This year, 146 schools nationwide participated in creative efforts to support the Foundation, raising a total of $340,986. A record number of schools returned to participate this year, yielding a 70% retention rate. Since its inception, 269 schools have contributed to the challenge, raising over $3.7 million for physical therapy research.

    The Foundation annually awards a research grant and a Promotion of Doctoral Studies Scholarship (PODS) in the name of the challenge to deserving researchers. Since 2002, the challenge has specifically funded more than 23 research grants and scholarships and also partially funded the $300,000 Clagett Family Research Grant in 2010.

    To view the complete list of participating schools visit Foundation4PT.org.

    News at NEXT: Foundation Service Awardees Recognized at NEXT

    Friends and donors of the Foundation for Physical Therapy (Foundation) recognized the achievements of several people and groups at the Foundation's inaugural awards luncheon on June 22. The event honored annual service award recipients and celebrated the efforts of students in the 2016-2017 VCU-Marquette Challenge.

    "Foundation Service Awards are presented to individuals and groups who have demonstrated their commitment to supporting the Foundation and advancing our mission to fund physical therapy research," said Foundation Board of Trustees Vice President Michael J. Mueller, PT, PhD, FAPTA, at the luncheon. "We are certain that the future of the Foundation, and more important our profession, lay bright, so long as there remains support to fund evidence-based practice."

    The 2017 service awards were presented to 4 deserving contributors.

    The 2017 Robert C. Bartlett Trustee Recognition Service Award was presented to past trustee and current honorary trustee Barbara Connolly, PT, DPT, EdD, FAPTA. This award is presented to trustees whose personal service and commitment has helped develop and sustain activities that promote the funding of physical therapy research and education programs.

    Section President William H. Staples, PT, DPT, DHSc, accepted the 2017 Premier Partner in Research Award on behalf of the Academy of Geriatric Physical Therapy. Over the years, the Foundation has presented this award to a select few who have made generous and longstanding contributions, which are critical to the success of the Foundation and its mission.

    The 2017 Charles M. Magistro Distinguished Service Award was presented to Nancy E. Byl, PT, MPH, PhD, FAPTA. This award, named for the first president and chair of the Foundation, is presented annually to individuals for outstanding service and steadfast commitment toward promoting the Foundation's goals.

    The 2017 Spirit of Philanthropy Award was presented to Patricia A. Traynor, PT. Since 2005, this award has been presented annually to donors who exhibit enthusiastic support and dedication to the growth of the Foundation and its mission.

    Later that evening, the Foundation held the Boston PT Party, a nontraditional twist on the former annual gala. During the event, further tribute was paid to the Foundation's service award recipients, and the winners of this year's VCU-Marquette Challenge were announced. Mercer University took top honors and will succeed VCU in being co-eponym of the challenge with Marquette University for 2017-2018.

    Special thanks go to this year's event sponsors: HPSO/CNA, the Boston PT Party title sponsor for the 17th consecutive year; NuStep, producer sponsor; Tri W-G, dessert sponsor; and Performance Health, awards luncheon sponsor.

    News From NEXT: Physical Therapy and Movement Are Key to Slowing the Aging Process, Contends McMillan Lecturer

    Physical therapy may not be a souped-up DeLorean, a table-top machine, or a twistable pendant that takes its users backward in time, but unlike the fictional Doc Brown, Time Traveler, or Hermione Granger, physical therapists can use real-life tools to at least slow it down. Richard Shields, PT, PhD, FAPTA, in his delivery of the 48th Mary McMillan Lecture on June 22, said that as physical therapists (PTs) "we change time. We routinely turn over the hourglass" and through interventions "reset the aging clock of the human body."

    Discussing the future of the physical therapy profession at "micro" and "macro" levels, Shields said that for much of the profession's history PTs have remained in the center of this continuum. "But the frontiers of our profession lie at the extremes. Those are the places we must travel if we wish to truly transform society by optimizing movement," he said, alluding to APTA's vision for the profession—"Transforming society by optimizing movement to improve the human experience."

    On the micro level, Shields said that physical therapist interventions "are powerful regulators of genes that activate the energy systems" that can reduce the rate at which cells and tissues age. These movement-based interventions trigger cellular changes "in ways that the pharmaceutical industry"—if not Doc and Hermione—"can only dream about."

    Shields explained how, upon contraction, skeletal muscle is more than "a mere force vector." It also releases proteins known as myokines into the blood stream, where they regulate genes in cells throughout the body.

    Frequent movement, then, promotes the expression of healthy genes and represses the expression of genes that can damage tissues. And while the effect is to slow biological aging in cells and tissue, the benefits are not for only the already aged; they can be applied across the lifespan. Shields said that although PTs and PTAs "most often think about strength, endurance, coordination, and function; the cellular changes that we trigger are the most fundamental ways that we improve the health and well-being of humankind."

    Shields explained that it's possible to estimate how many healthy genes are being blocked as a function of a person's age, injury, immobility, or disease. "It is our role as physical therapists to prescribe interventions that unblock the genes that are health-promoting," Shields said.

    Further, he said, repeated movement creates a "molecular memory" that perpetuates the healthy genes' activity. Physical therapy, with its emphasis on continued movement and activity, is a catalyst for this molecular memory.

    Given current knowledge about the human genome, coupled with ever-improving methods of individual data collection, doses of movement can be customized for each patient, based on biological genetic regulators, environmental factors, and lifestyle influences that affect frequency, duration, and types of treatment prescribed. As a result, Shields predicted that "precision physical therapy will emerge side-by-side with precision medicine."

    Turning to the macro level of physical therapist practice—the impact on the human experience—Shields warned against treatments that are "more about the therapist or the technology owned by an institution than about the experience of the patient." He continued that using new attention-grabbing treatments that often involve technology may be at the cost of teaching the patient a needed skill for continued long-term mobility, "even something as simple as [manually] wheeling a chair" instead of using a motorized one.

    Using an airline flight for illustration, Shields explained how a patient's experience is affected by nuances of expectation. He asked: "How many of you wished you arrived in Boston 45 minutes early? How many expected to arrive on time? How many would have viewed the flight as a success if you arrived safely, even if delayed for a few hours? How many would have deemed the flight a failure if you had been carried off the plane because they needed your seat?"

    There is a difference, he said, between what you wish for, what you expect, and what you would view as either a successful or failed experience. He said patient satisfaction should be viewed and measured from all 3 tiers of expectation, with a standard tool (he suggested an "Experience Efficiency Index") with the goal of reducing the number of unmet patient expectations.

    "The idea of a central outcome measure about patient experience … is new but necessary, as growth can create silos that emphasize differences rather than commonalities," he said.

     

     

    Senate Health Care Reform Bill Contains Provisions Opposed by APTA

    Despite some changes designed to appeal to a wider range of US senators, the newly released Senate version of health care reform still contains provisions that concern APTA: namely, a loosening of required "essential health benefits" (EHBs) that include rehabilitation services, and changes to Medicaid that could reduce the range of available benefits. Changes are still possible, however, and APTA has plans to reemphasize its positions as the Senate considers the bill.

    The bill, technically a substitute for the American Health Care Act (AHCA) approved by the House of Representatives in May, is characterized as less extensive in its effort to repeal and replace the Affordable Care Act (ACA), but it contains several of the same features as the House legislation, including plans to cap and then reduce Medicaid appropriations, transition Medicaid to a block grant system, and change EHB requirements-features that APTA has publicly opposed.

    Like the AHCA, the Senate substitute bill weakens the power of federally mandated EHBs—which include physical therapy—by allowing states to apply for waivers to reduce the requirements or eliminate them entirely. The result, according to APTA, is a likely reduction in access to habilitative and rehabilitative services for millions of Americans that could have lasting societal effects. In a statement on the AHCA, APTA President Sharon Dunn, PT, PhD, wrote that the EHB change and other provisions set the stage for a health care system that would create "unneeded barriers to care and reduce the access to care for millions of Americans."

    The bill has yet to undergo review by the Congressional Budget Office (CBO) and could be altered based on the CBO analysis or compromise efforts within the Senate.

    Meanwhile, APTA is not sitting still. On June 27, association representatives will participate in a congressional briefing on Capitol Hill aimed at educating lawmakers and staff on the value of rehabilitation and habilitation services and devices in American's health care system. The event is sponsored by the Independence Through Enhancement of Medicare and Medicaid, the Habilitation Benefits Coalition, and the Coalition to Preserve Rehabilitation. APTA is a member of all 3 groups.

    APTA will continue to analyze and monitor the bill and report on potential effects.

    From the 2017 House of Delegates: Setting a Course for the Profession's Future

    As far as APTA's House of Delegates (House) is concerned, the future is now.

    During her address to the 2017 House that opened the 3-day meeting held June 19-21, APTA President Sharon Dunn, PT, PhD, challenged delegates to make "bold moves" that would define where physical therapy would go in its next 100 years. The House delivered, passing motions—several unanimously—that articulated the physical therapist’s (PT's) professional scope of practice and its place within the PT’s overall scope of practice, set in motion an investigation into the ways APTA might facilitate a physical therapy "innovation centers" program, and made commitments to increasing diversity and inclusiveness in the profession, among other policies. The common thread: nearly every approved motion had implications for the future of the profession.

    One notable moment in the meeting came when the House adopted a definition of the PT professional scope of practice, the culmination of a multiyear effort with the ambitious goal of capturing all that PTs do without resorting to a list of activities that risked missing something or quickly growing outdated. The definition, which passed by a unanimous vote of the more than 400 participating delegates, gets the job done in 2 paragraphs:

    "The professional scope of physical therapist practice is grounded in basic, behavioral, and clinical sciences. It is supported by education, based on a body of evidence, and linked to existing and emerging practice frameworks. The professional scope evolves in response to innovation, research, collaboration, and changes in societal needs.

    The professional scope consists of patient and client management, which includes diagnosis and prognosis, to optimize physical function, movement, performance, health and quality of life across the lifespan. Additionally, the professional scope includes contributions to public health services aimed at improving the human experience."

    The adoption of the definition completes the association's effort to recharacterize how the profession thinks about scope-of-practice issues under 3 domains: personal scope (what the PT is educated, trained, and personally competent to perform), jurisdictional scope (the activities associated with physical therapy in state practice acts), and the professional, a more global description of the practice of physical therapy.

    While the scope decision established a here-and-now waypoint to the future, other House actions set sights on how the profession could evolve. One example: a motion directing the APTA Board of Directors to explore models for "innovation centers" for PTs with creative ideas for bringing novel practice concepts to market. The models could include freestanding "incubators," industry partnerships, or partnerships within health systems, and the board is charged with investigating which, if any, alone or in combination, offer the most promise to help move practice forward.

    The House also looked to the future in terms of not just what PTs do but the makeup of PTs doing it. In another unanimous vote, delegates approved a charge to APTA to do whatever it takes to "implement best practice strategies to advance diversity and inclusion within the profession of physical therapy." It's an effort that delegates acknowledged will take more than the association alone, and could include work with education programs, employers, and even pre-DPT public and private academic institutions.

    Other actions taken by the 2017 House include:

    • Instructions to the APTA Board of Directors to develop a plan to help ameliorate the administrative burdens placed on PTs
    • A charge to the APTA Board of Directors to develop and adopt a new mission statement for APTA
    • Expansion of an existing policy to emphasize the PT’s role in disability evaluation and determination for purposes such as transportation, employment, and insurance
    • The establishment of a committee to review all House documents
    • A bylaws change that would permit chapters to assign full representation to representatives of physical therapist assistants (PTAs), PTA lifetime members, and retired PTA members
    • A bylaws change that would allow more chapter membership flexibility for APTA members who are uniformed personnel, or whose spouses or partners are in the uniformed services
    • Awarding honorary APTA membership to prominent researcher T. Richard Nichols, PhD.

    APTA members can view videos of all open sessions of the 2017 House of Delegates online. Final language for all actions taken by the House will be available by September after the minutes have been approved.

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    #ChoosePT Named 1 of the Country's Top Public Awareness Campaigns

    As APTA's #ChoosePT national opioid awareness campaign continues to gain momentum, it's also gaining recognition, most recently by earning a highly prestigious "Power of A" gold award from the American Society of Association Executives (ASAE).

    The Power of A awards "highlight the association community's valuable contributions to society on the local, national and global level," according to ASAE. "They honor the outstanding accomplishments of associations and industry professionals in the areas of strengthening lives, forging a more trained and highly competitive workforce, enhancing the economy, driving innovation and making a better world." The Power of A awards are among the highest honors given out by the society.

    According to APTA Chief Executive Officer Justin Moore, PT, DPT, the Power of A award is particularly special.

    "The Power of A awards recognize efforts to make the world a better place," Moore said. "This award is perfectly aligned with our profession's vision to transform society. We are proud that the #ChoosePT campaign is highlighting the ability of physical therapists to be positive change agents in this national drug crisis."

    This isn't the first honor the #ChoosePT campaign has received: in April, the #ChoosePT public service announcement was named Best Video of the Year by ASAE; and in early June, the Kentucky state senate issued a proclamation lauding the campaign and APTA's "phenomenal" members.

    ASAE includes more than 35,000 members representing nearly 7,500 organizations across the country. APTA will be formally recognized at the 18th Annual Summit Awards Dinner October 4 at the National Building Museum in Washington, DC.

    Want to support the #ChoosePT campaign? Access the campaign toolkit or contact APTA public relations staff to find out how you can get involved.

    CMS Proposes 2018 Quality Payment Program Rule: Here's What PTs Need to Know

    The US Centers for Medicare and Medicaid Services (CMS) may have slowed down the pace at which it is implementing the move toward quality-based payment, but that doesn't mean physical therapists (PTs) should be taking a business-as-usual attitude.

    With the release of its 2018 proposed rule for quality payment, CMS is taking some of the pressure off clinicians and groups with smaller practices or low numbers of Medicare patients to meet Merit-Based Incentive Payment System (MIPS) requirements. Still, the shift away from fee-for-service models continues, and even though PT participation in MIPS is still voluntary next year, it's almost a given that PTs will be mandatorily included as early as 2019.

    Details on the proposed rule are available from CMS, but here are a PT's 4 most important takeaways:

    1. Get involved in alternative payment models (APMs) now.
      Participating in an advanced APM could give you a 5% incentive payment with every year of successful participation. CMS offers a webpage specifically devoted to learning more about participating in APMs.
    2. APMs: They aren't just about Medicare.
      Don't limit your participation in APMs to only Medicare-based programs. According to CMS, beginning in 2019—the year PTs could be required to participate in MIPS—becoming a qualified provider through the "all payer combination option" will require the provider to participate in APMs with both CMS as well as an "other payer."
    3. Take MIPS for a test drive.
      PTs aren't formally included in MIPS, meaning reporting scores won't yet affect future payment adjustments. But you can report under MIPs voluntarily, which will help prepare you for future years when PTs are likely to be required to participate.
    4. Get with the technology.
      As health care moves to outcomes-based payment, it will be critical for PTs to have access to real-time clinical data to understand how they perform, identify areas to improve quality, and manage patient populations. Without data physical therapists will be unable to receive future incentive payments. APTA's Physical Therapy Outcomes Registry will have the ability to extract information from electronic health records, allowing your clinical data to be readily usable and actionable.

    From the APTA House of Delegates: Richard Nichols Named Honorary APTA Member

    T. Richard Nichols, PhD, became an honorary member of the American Physical Therapy Association (APTA) on June 21 by a unanimous vote of the APTA House of Delegates. Nichols is an internationally recognized scholar whose research has contributed to the advancement of scientific knowledge related to the control of movement. Per the proclamation proposing his honorary membership, Nichols has been "a stalwart advisor" to the association and to academic programs "that teach future physical therapists and advanced physical therapist clinicians."

    Look for more news from the just-concluded 2017 House of Delegates later this week, and view video-recorded sessions at www.apta.org/Livestream/.

    New at PTJ: Open-Access 'Best of the Best' Collection Focuses on LBP and Neck Pain

    As far as APTA's science journal Physical Therapy (PTJ) is concerned, "greatest hits" collections aren't just for musicians—and it's proving that point by issuing a special collection of PTJ articles on low back pain (LBP) and neck pain, all free to the public.

    Now available from PTJ: a new online-only "best of the best" issue that gathers PTJ articles from the past 2 years focused on conditions that loom large in both health care costs and clinician time. Articles reflect a range of themes and approaches, and include opinion pieces, cohort studies, and randomized controlled trials.

    Some of the hits include:

    Treatment-based classification systems for low back pain should include triage and consider psychosocial comorbidities. In this "Perspective" article, authors present a new and improved version of the treatment-based classification system included in the APTA clinical practice guidelines for LBP. Authors advocate for a 2-level triage process as well as the need to evaluate a patient’s psychosocial status.

    Taping isn’t shown to be effective for managing spinal pain . Based on the limited research available, authors find no real support for any type of taping for a variety of spinal pain diagnoses.

    Global postural re-education (GPR) can reduce pain and disability for neck pain .The randomized controlled trial found that GPR was more effective than manual therapy for patients with chronic, nonspecific neck pain.

    Cognitive functional therapy is a "promising" intervention for nonspecific chronic low back pain . In a cohort study, researchers found significant reductions in pain, functional disability, and a number of psychosocial outcomes.

    Trauma, osteoporosis, a back pain intensity score of ≥7, and thoracic pain are "red flags" for vertebral fracture in older adults . In patients over 75 years of age, trauma had the highest predictive value for a vertebral fracture diagnosis by their general practitioner.

    The Godelieve Denys-Struyf (GDS) method was better than standard interventions for low back pain . Researchers in Spain found that this motor control intervention improved disability scores more than a control group receiving transcutaneous electrical nerve stimulation, microwave treatment, and standardized exercises.

    Bill in House Aims to Hold Feds to Special Education Funding Obligations

    Think that the US government should live up to its promises when it comes to funding educational needs of students with disabilities? So does a bipartisan group of legislators who have introduced a bill that would obligate the government to pay what it promised to pay according to the Individuals with Disabilities Education Act (IDEA). APTA is among the many organizations supporting the legislation.

    Called the IDEA Full Funding Act (HR 2902), the bill seeks to ensure that the federal government pay 40% of the average per-pupil expenditure for special education, the percentage establish in the IDEA, signed into law in 1975. Federal contributions have consistently fallen short of the 40% mark, with the most recent federal funding only representing about 15.7% of expenditures.

    The legislation was introduced in the US House of Representatives by Reps Jared Huffman (D-CA), David McKinley (R-WV), Tim Walz (D-MN), Dave Reichert (R-WA), Kurt Schrader (D-OR), and John Katko (R-NY). Similar legislation will be introduced in the US Senate by Sen Van Hollen (D-MD).

    "The law guarantees every student the right to a free and appropriate public education, but Congress needs to provide the resources to make that guarantee meaningful." said Huffman in a press release. "That’s why I’m joining with my colleagues from across the aisle to introduce the IDEA Full Funding Act, because we know that providing our children with a first-class education should not be a partisan issue. The bottom line is this: no child should ever be denied a quality education, or be kept from reaching their full potential, because they have a disability."

    APTA is among the long list of organizations advocating for full funding of IDEA. That list includes the American Federation of Teachers, American Music Therapy Association, American Occupational Therapy Association, American Psychological Association, American Speech-Language-Hearing-Association, National Association of Social Workers, National Down Syndrome Congress, and National Education Association.

    APTA will monitor the bill's progress and report on developments as they happen.

    APTA 2017 House of Delegates Election Results Announced

    The following members were elected to APTA's Board of Directors and Nominating Committee on Monday, June 19, at the 2017 House of Delegates in Boston, Massachusetts.

    Jeanine Gunn, PT, DPT, was elected treasurer.

    Susan Griffin, PT, DPT, MS, was reelected speaker.

    Matthew Hyland, PT, PhD, MPA, and Sheila Nicholson, PT, DPT, JD, MBA, MA, were reelected directors, and Anthony DiFilippo, PT, DPT, MEd, and Cynthia Armstrong, PT, DPT, were elected director. Armstrong will serve the 1-year remainder of Gunn's unexpired term as director.

    Michael Eisenhart, PT, and Rupal Patel, PT, PhD, were elected to the Nominating Committee.

    These terms become effective at the close of the House of Delegates on Wednesday.

    'Bold Moves' Toward APTA Centennial Will Include New APTA Headquarters

    As APTA approaches its centennial in 2021, the association is charting a course for a series of bold moves, and at least 1 of those moves will be about as literal as it gets: relocation to a newly constructed headquarters designed to "support the profession's future."

    The plans were announced by APTA President Sharon Dunn, PT, PhD, during her address to the APTA House of Delegates, the association's primary policymaking body, which is meeting this week in Boston.

    Dunn's announcement about APTA's relocation came as she described bold moves the association's Board of Directors would like to make in the coming years.

    Dunn said that the workplace and workforce move is "fast becoming a reality," telling the House that "after 2 years of exhaustive investigation, the [APTA Board of Directors] is confident this move is in the association's best interest. It is both financially sound and advisable and it will be a significant investment in the future of our association, supporting the next generation of members and leaders."

    The new headquarters will be in Potomac Yard, a rapidly expanding residential, retail, and office area less than 2 miles from the current APTA offices near Old Town Alexandria, Virginia. The current APTA home was built in 1983, when the association was considerably smaller and workplace needs were different. Construction on the new offices is anticipated to be completed in 2021 in time for the celebration of APTA's centennial.

    Dunn described the entire set of bold moves as "ambitious" but within the association's grasp.

    "We are in a unique moment in our history to take on these challenges," Dunn said. "Clearly, we have a vision that supports this kind of thinking, and we have developed a culture of engagement and collaboration. We are better together—and together, it's time to act."

    APTA members can watch a recording of that address from APTA's livestream page: www.apta.org/Livestream.

    Study: Delaying ACL Surgery in Favor of Exercise Therapy May Produce Better Outcomes in Patients With 'Prognostic Factors'

    In brief:

    • Researchers analyzed Knee Injury and Osteoarthritis Scores (KOOS) of 118 young adults who experienced an ACL tear, comparing baseline with 5-year KOOS
    • Some participants received early ACL reconstruction surgery followed by exercise therapy; others received delayed surgery with a period of exercise therapy prior to the surgery; a third group received exercise therapy only
    • Researchers matched baseline and 5-year KOOS with "prognostic factors" associated with worse outcomes—cartilage and meniscus damage, osteochondral lesions, and knee extension deficits
    • Overall findings: early surgery was more often associated with worse outcomes, compared with delayed surgery or no surgery
    • In the early-surgery group, participants with meniscus damage at baseline reported worse KOOS at 5 years than did participants without meniscus damage at baseline; the delayed surgery group reported the opposite, with the meniscus-damage subgroup reporting KOOS gains over those without meniscus damage

    Researchers analyzing a study of patients with anterior cruciate ligament (ACL) tears have begun to connect the dots between early indicators of long-term outcomes and the kinds of treatments patients receive. They reached the conclusion that, for at least some, putting off ACL reconstruction surgery in favor of exercise therapy could be the way to go.

    In what authors call a "post-hoc exploratory, hypothesis-generating analysis of outcomes," researchers used data from the Knee Anterior Cruciate Ligament Nonsurgical versus Surgical Treatment (KANON) clinical trial conducted in Sweden to analyze how Knee Injury and Osteoarthritis Outcome Scores (KOOS) 5 years after injury compared with the presence of various baseline "prognostic factors" known to correlate to worse long-term outcomes. The trial focused on relatively active young adults (18-35 years) with no prior knee injuries who suffered an acute ACL rupture and began treatment within 4 weeks after injury.

    The researchers knew that the 4 prognostic factors—baseline cartilage and meniscus damage, osteochondral lesions, and knee extension deficits—increased the chances of worse outcomes at 5 years. What they wanted to find out was whether early ACL reconstruction surgery actually made those chances worse, compared with surgery delayed in favor of exercise therapy, or exercise therapy alone was responsible. Results were published in theBritish Journal of Sports Medicine (BJSM).

    A total of 118 participants were studied, with 59 receiving early (within 4-6 weeks) ACL surgery followed by exercise therapy, 30 receiving exercise therapy followed by surgery 2 to 56 months later, and 29 receiving exercise therapy only. All patients participated in the same "goal-oriented, physiotherapist supervised neuromuscular program at 9 outpatient clinics," according to authors. Functional measures were collected at baseline, 3 months, 6 months, 12 months, 24 months, and 5 years, with results adjusted for sex, age, body mass index, preinjury activity, education, and smoking.

    Among the findings:

    • For participants with baseline meniscus damage, early surgery followed by exercise therapy resulted in a KOOS that averaged 14 points worse than scores reported by participants with no baseline meniscus damage. But in what authors call a "surprising" result, when participants with baseline meniscus damage participated in exercise therapy and delayed surgery, their KOOS wound up being, on average, 14 points higher than those with no baseline meniscal injury.
    • Similar, albeit lower, effects were recorded for patients with baseline osteochondral lesions (average 5.4 points worse for the early-surgery group; average 6.2 points better for the delayed-surgery group in KOOS for pain). Participants in both categories (early vs delayed exercise) who reported baseline knee extension deficits reported small decreases for most KOOS categories.
    • Overall, participants whose ACL injury was managed with exercise therapy alone reported an estimated 10-point better KOOS at 5 years compared with the early surgery group.
    • Participants who received exercise therapy alone but later received " non-ACL surgery"—a knee surgery that was not ACL reconstructive—reported an estimated 14-point worse KOOS at 5 years compared with participants who received exercise therapy alone and no other surgeries.

    Authors of the study acknowledge that the findings related to meniscus damage were particularly unexpected, but not exactly beyond reason.

    "The mechanisms behind this surprising finding are not clear, but sustaining a second knee insult in the form of an early ACL reconstruction shortly after a previous knee trauma may increase the likelihood of experiencing persistent postoperative difficulties," authors write. They also speculate that the delayed-surgery group may have experienced more pain than their counterparts without meniscus injuries, and, as a result, "reconstructive surgery may have been more successful in relieving pain … compared with those electing to undergo surgery for a range of other reasons, including a desire to gain preinjury status, a pre-existing preference for surgery, and finding exercise therapy boring and time-consuming."

    Researchers also found that the baseline KOOS scores themselves functioned as prognostic factors for worse 5-year outcomes, with early-surgery participants who reported lower KOOS at baseline in turn reporting lower KOOS at 5-year follow-up compared with their delayed-surgery counterparts who also reported lower-baseline KOOS.

    "Low baseline KOOS scores also reflect more physical impairment and this may predispose an individual to worse postoperative outcomes," authors write. "Individuals who report worse KOOS scores prior to reconstruction may benefit from postponing surgery and commencing exercise therapy before considering surgical reconstruction."

    Authors acknowledge that the "exploratory nature" of their research included several limitations, including low sample size, lack of adjustment for multiple comparisons, and confidence intervals "suggesting uncertainty in some of the estimates." Still, they argue, this initial work is worth further exploration and, at the very least, could help to reinforce the concept that clinicians must approach treatment of ACL injuries at the individual patient level.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    CMS: Start Preparing for New Medicare Beneficiary ID Numbers

    Although the official rollout won't occur until 2018, it's not too soon for health care providers to prepare their practice management systems for a new Medicare beneficiary ID system that no longer uses Social Security numbers (SSNs).

    Details on the change are available in a guidance resource from the US Centers for Medicare and Medicaid Services (CMS). The shift will move the Medicare system away from Health Insurance Claim Numbers (HICNs) that contain the beneficiary's SSN, and toward a CMS-generated Medicare Beneficiary Identifier (MBI). The change, intended to thwart fraud, was required by provisions in the Affordable Care Act and the Small Business Jobs Act.

    According to CMS, new cards with MBIs will be mailed to beneficiaries beginning in April 2018, with official startup of the use of MBIs in claims beginning in October of the same year. Providers can start using the MBI as soon as their patients receive the new cards and should have systems in place to accept the new number by April 2018.

    The changeover includes a transition period from October 2018 through December 2019, during which time CMS will accept claims using either the HICN or MBI.

    JAMA Viewpoint: The 'False Dichotomy' of Hospital Falls Prevention vs Mobility Promotion

    Hospitals that keep patients immobile as a way of preventing falls are engaging in a "false dichotomy" that can be damaging in the long-term, argue authors of a "Viewpoint" article published recently in JAMA Internal Medicine (preview only available for free). In fact, they write, programs that promote mobility with supervision "may actually help to prevent injurious falls" more effectively than those that encourage patients to stay in bed.

    Current federal payment policies penalize hospitals for certain hospital-acquired conditions, including falls resulting in injuries. While well-intended, these policies have had "unintended consequences" for patient mobility, function, and quality of life, according to authors Matthew E. Growdon, MD, MPH; Ronald I. Shorr, MD, MS; and Sharon K. Inouye, MD, MPH. Patient immobility contributes greatly to "post-hospital syndrome," in which patients are at risk for functional decline, adverse events, and readmission to the hospital.

    Instead, the authors advocate for the Centers for Medicare and Medicaid Services (CMS) to "develop quality measures that promote mobility as part of routine clinical care"—including early mobilization protocols, documenting how often patients are out of bed, and use of patient accelerometers instead of bed or chair alarms to monitor patient movement.

    Despite widespread implementation of hospital falls-prevention efforts over the past 20 years, authors write, evidence shows the rate of "injurious falls" has not declined significantly in the United States. Research has found this to be true in Australia, as well.

    According to the authors, the problem with current falls prevention efforts lies in their "troubling assumption that keeping patients from moving can stop such falls." "Falls prevention teams could be transformed into mobility teams" to enhance patient outcomes, they write.

    Authors cite recent studies of combined assisted walking and mobility initiatives, such as the Hospital Elder Life Program (HELP), designed by coauthor Inouye, that may be more effective at preventing falls than current falls prevention programs that result in keeping patients immobile much of the time. Other promising programs included supervised walking combined with a balance assessment or a behavioral intervention to promote mobility after leaving the hospital.

    While noting that data collection will be the key to assessing effectiveness of such efforts, the authors argue that making changes now will "shine a bright light on the false dichotomy between fall prevention and the promotion of mobility."

    APTA offers a variety of resources on falls prevention, including a  practice guideline on the assessment and prevention of falls tests and measures related to falls , a Physical Therapy-published  clinical guidance statement from the Academy of Geriatric Physical Therapy , an  online community  for PTs and physical therapist assistants interested in falls prevention, and a  balance and falls webpage .

    The Good Stuff: Members and the Profession in Local News, June 2017

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

    Carole Lewis, PT, DPT, PhD, FAPTA, and 2016 McMillan lecturer, shares what it takes for PTs to embrace the "unprecedented opportunities presented by our aging population." (Atlas of Science)

    Julia Cook, PT, is assisting in the rehabilitation of a young patient who received a cutting-edge magnetic implant to treat scoliosis. (Augusta, Georgia, Chronicle)

    Murphy Halasz, PT, discusses how to counter the effects of sitting too much. (Prevention)

    Jason Harvey PT, MSPT; Julia Milner, PT; and Michael Nula, PT, hosted Rep Jim Langevin at their clinic.(Warwick, Rhode Island Beacon)

    Jan Dommerholt, PT, DPT, answers questions about the recent Tiger Woods arrest, the dangers of long-term opioid use for pain, and effectiveness of nondrug pain treatment options. (Washington, DC, ABC7 News: segment 1 and segment 2)

    Brian Mason, PT, DPT, explains his approach to rehabilitation of a 27-year-old patient who suffered a stroke at age 23. (Asbury Park, New Jersey, Press)

    Yasmin Broomand, PT, makes a difference in the life of a child with acute flaccid myelitis. (Jacksonville, Florida, Times-Union)

    Dustin Jesberger, PT, provides suggestions for training around a dislocated shoulder. (Men's Fitness)

    "Assuming you have been injured to the point of requiring it, your physical therapy exercises have brought you back to health and should not be discontinued after your first pain-free workout. Continue your exercises and eventually work them into your cross-training, since you have now discovered where your weakness is and need to make it a strength.” - advice for triathletes who have been injured. (USA Triathlon newsletter)

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

    KY Senate Recognizes #ChoosePT and 'Phenomenal' APTA Members

    APTA's #ChoosePT antiopioid campaign is reaching millions of Americans thanks to the work of both the national association and its individual chapters. Apparently, these efforts haven't escaped the notice of the Kentucky state senate, which issued a proclamation commending the campaign and thanking APTA's "phenomenal" members for their work.

    The proclamation, approved on June 1, recognizes APTA and #ChoosePT for educating the public on the "life changing effects of physical therapy as an alternative to painkillers." The motion was introduced by Sen Jimmy Higdon.

    "Inasmuch as the American Physical Therapy Association, with the dedication and hard work of its phenomenal membership, has earned a stellar reputation for its invaluable contributions to the healthcare industry and to the overall health and well-being of patients in America, said honoree is offered sincere commendation and gratitude for its continued service in this most worthwhile and consequential endeavor; and is extended best wishes for every future success as it continues to labor for the health of all Americans," the proclamation states.

    "I'm grateful that the Kentucky Senate has not only recognized the #ChoosePT campaign but also the incredible efforts of our membership," said APTA President Sharon Dunn, PT, PhD. "From the moment we began work on the campaign, the Kentucky Chapter has been an enthusiastic partner in extending the message to its state. The opioid epidemic continues to take lives and devastate families and communities on a daily basis. It's crucial that we unify in our effort to stop this public health crisis."

    The #ChoosePT campaign also has been recognized by the American Society of Association Executives, which named APTA's #ChoosePT public service announcement the winner of a Gold Circle Award for best video of the year.

    APTA Launches New Nutrition Webpage

    Yes, there's a role for the physical therapist (PT) in helping patients understand how nutrition affects function, but there are nuances to be considered and no shortage of factors that could affect just how to fulfill that role. Fortunately, there's now an APTA webpage that helps PTs navigate the issues.

    New to the APTA website: "Nutrition and Physical Therapy," a webpage with a collection of resources that delivers context for APTA's position that it's the role of PTs to "screen for and provide information on diet and nutritional issues to patients, clients, and the community"—within the bounds of the PT's scope of practice. That means, among other things, that PTs wishing to provide information on nutrition need to be certain that they're doing so in ways that are consistent with state licensing laws for both physical therapy and nutrition services, and assess whether this ability is within their personal scope of practice.

    The webpage provides factors to consider related to the PT's role in nutrition and diet, including additional certifications that may be required, use of the designation "nutritionist," and when to refer a patient or client to a specialist for nutritional education. Other resources on the page include links to dietary recommendations, a registered dietician nutritionist lookup, and information on how to pursue additional certifications.

    Study: Platelet-Rich Plasma for Tendinopathy? Researchers See Promise

    In brief:

    • Meta-analysis reviewed 18 studies (1066 participants) on the use of platelet-rich plasma (PRP) vs control (saline, anesthetic, corticosteroids, dry needling) in treatment of tendinopathy
    • Outcomes were measured by pain ratings at 12 weeks and, when possible, 6- and 12-month follow-up
    • Use of some form of PRP treatment showed better outcomes than controls, though the size of those outcomes varied depending on the kind of PRP used
    • All controls also demonstrated improved outcomes, with dry needling showing the highest standard mean difference of the 4 controls
    • Authors say more work needs to be done relative to effectiveness of specific PRP treatments on specific tendons

    Authors of a new meta-analysis from Australia say that a single injection of leukocyte-rich platelet-rich plasma (LR-PRP) can be effective in treating tendinopathy but that more work needs to be done to identify what other forms of PRP can and can't do, as well as how best to administer the treatments.

    Researchers analyzed data from 18 studies involving 1,066 adult participants with tendinopathy who received some form of PRP or another control treatment (saline, local anesthetic, cortiocosteroids, or dry needling). Studies that included patients undergoing surgery or treatment of nontendon soft tissue injuries were not included. The randomized controlled clinical trials that were assessed included trials of "any autologous blood product," with any dosage, volume, or number of injections accepted for review. The article appears in The American Journal of Sports Medicine (abstract only available for free).

    The review's conclusions were based on pain and function follow-up ratings at 12 weeks as well as 6 and 12 months. Authors found that nearly all PRP treatments produced some positive effects that exceeded controls. Effect ranged from a small standard mean difference (SMD) over control of 26.77 for autologous conditioned plasma (ACP) an overall larger difference in improvement—SMDs between 31.8 and 42.9, depending on the kit used—for LR-PRP.

    Researchers also found that all 4 treatments used as controls—saline, anesthetic, corticosteroids, and dry needling—produced some positive outcomes, with dry needling showing the highest SMD, at 25.22.

    While authors believe the results of the analysis point to the effectiveness of PRP injection, they acknowledge that a few details remain fuzzy: among them, whether some tendons are more responsive to PRP than others and the possibility that some forms of PRP are better suited to certain tendons. Earlier studies have indicated that such variability may exist, at least when it comes to the use of PRP and hamstring rehabilitation.

    The use of PRP continues to grow and is 1 component of regenerative medicine that physical therapists and physical therapist assistants can expect to see regularly in the future, according to a 2016 article in PT in Motion magazine.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Study: LBP Patients With Comorbidities at Higher Risk for 'Guideline Discordant' Care

    In brief:

    • Researchers analyzed commercial insurance claims for 513,980 adults with an initial report of back pain; matched claims history with presence of 0, 1, or 2 or more comorbidities
    • Compared with those reporting no comorbidities, patients with 1 comorbidity were 14% more likely to become a long-term user of back care (3-year period); patients with 2 or more comorbidities were 29% more likely to engage in long-term use
    • Patients with comorbidities also more likely to receive imaging, visit the ED
    • Individuals with comorbidities more likely to be prescribed opioids as an initial treatment and more likely to fill those prescriptions
    • Authors describe results as a "concerning" indication that more vulnerable patients may be at a greater risk of receiving lower-quality care

    Authors of a new study have found that for patients with low back pain (LBP), the presence of comorbidities such as diabetes, mental health issues, and hypertension raises the risk that they'll receive LBP care that uses more resources and veers off-course from LBP guidelines—including more prescriptions for opioids.

    The study, published in the Journal of Evaluation in Clinical Practice (abstract only available for free), analyzes commercial insurance claims data from 2007 to 2011 involving 513,980 adults with new visits for back pain. Researchers tracked LBP care-related claims for 3 years after the initial visit as well as procedure use and treatment patterns for the first 42 days after the visit, and matched these data with patients identified as having 0, 1, or 2 or more comorbidities based on ICD-9 codes. APTA member Sean Rundell, PT, DPT, PhD, was lead author of the study.

    The patient population studied had an average age of 45.2 years. Females made up 54% of the study group, and 44% of the population came from the southern United States. Most (80%) reported no comorbidities, with 16% (83,242) reporting 1, and 4% (21,304) reporting 2 or more. The most common comorbidities reported were endocrine, nutritional, and metabolic diseases and immunity disorders (36%), followed by diseases of the musculoskeletal system (29%), and diseases of the circulatory system (27%).

    Among the findings:

    • Compared with patients having no comorbidities, those with 1 comorbidity were 14% more likely to become a "long-term user" of back pain-related care. Patients with 2 or more comorbidities had a 29% greater likelihood of long-term use. The resource use pattern tended to include at least 1 episode of care every quarter for the 3-year study period.
    • Among the individual comorbidities studied, patients with comorbid musculoskeletal conditions were 53% more likely than those without to be high users of long-term back care resources. Individuals with mental health disorders, nervous system, and respiratory comorbidities each had more than a 30% increase in odds of long-term resource use.
    • Patients with comorbidities also were more likely than those with no comorbidities to use advanced imaging, visit the emergency department, and fill at least 1 prescription for opioids.
    • Overall, 22% of the study population filled at least 1 opioid prescription, but that average was higher among patients with comorbidities: among patients with mental health comorbidities, 27% of patients with anxiety disorders and 45% of patients with substance use diagnoses filled at least 1 opioid prescription. The same pattern was observed for patients with chronic pulmonary disease (35% prescription fill rate) and asthma (26% rate).
    • When it came to opioid prescriptions as an initial treatment, patients with depressive disorders, substance abuse disorders, and anxiety disorders were more likely to receive a prescription, as were patients with chronic respiratory conditions and asthma.

    Authors note that "guidelines discordant" care is sometimes acceptable for LBP patients with comorbidities. Still, they assert, the opioid prescription and fill numbers are "disconcerting," particularly given that some the highest fill rates were associated with patients whose use of opioids could pose a danger: individuals with substance abuse diagnoses, patients with mental health disorders that may require psychotropic medications, and patients with respiratory conditions.

    "Despite long-standing guidelines, current management of back pain continues to lack concordance with recommended practices," authors write. "[The current study's] findings are concerning because it indicates that more vulnerable patients, ie, those with a higher comorbidity burden, may be receiving lower-quality care that has a higher risk for adverse events."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Unintended Origins, New Directions, Dark Reality: Latest News on the Opioid Epidemic

    Although awareness of the severity of the nation's opioid crisis is growing and the number of practice guidelines recommending nondrug approaches to pain treatment is increasing, the problem itself continues to take its toll on Americans across the country. That toll is well-documented by the media, with an increasing amount of attention also being paid to how the country found itself in this situation and what we do to make our way out of it.

    Here's a brief roundup of recent reports.

    Despite guidelines, Americans are still receiving lots of opioids for low back pain.
    A National Public Radio – Truven survey reveals that more than half of respondents experienced low back pain in the last year; among those who sought help from a physician, a surprisingly high number received prescriptions for painkillers. "We have a serious problem with our health care delivery system where physicians are highly incentivized to prescribe pills and perform procedures because that's what pays," Stanford University psychiatrist Anna Lembke tells NPR. "They're also motivated to please patients but don't have much time to manage complex medical conditions."

    Did this 1980 letter help to spark the opioid epidemic?
    The New York Times reports on "how a one-paragraph letter with no supporting information helped seed a nationwide epidemic of misuse of drugs like Vicodin and OxyContin by convincing doctors that opioids were safer than we now know them to be." The letter, which appeared in a 1980 issue of the New England Journal of Medicine, has been cited more than 600 times as evidence that addiction was a rare occurrence; the letter's author, Hershel Jick, MD, tells the Associated Press that "I'm essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did."

    Fentanyl use is spreading at a harrowing rate.
    According to the US Drug Enforcement Administration (DEA), the amount of DEA seizures of drugs that include fentanyl more than doubled from 2015 to 2016. "Drug use today has become a game of Russian roulette. There's no such thing as a safe batch; this is the opioid crisis at its worst," DEA spokesman Rusty Payne tells CNN.

    Ohio is suing 5 drug companies for their role in the opioid crisis.
    Ohio Attorney General Mike DeWine announced that the state has sued 5 drug companies, alleging misconduct by intentionally lying about the dangers of painkillers and making false claims about the benefits of the drugs. In 2016, overdose deaths rose to more than 4,000—a 36% increase from 2015. "This lawsuit is about justice, it's about fairness, it's about what is right," DeWine said. "These drug companies knew that what they were doing was wrong and they did it anyway."

    One businessman is shining a light on evidence as the path out of the opioid epidemic.
    From Forbes magazine: Former hotel entrepreneur Gary Mendell founded Shatterproof to battle the opioid crisis, and has formed a task force that, instead of being led by high-profile business or health care industry leaders, puts "science front and center" by turning over leadership to experts in the science behind pain and addiction. The task force aims to "find evidence-based ways for employers and state governments … to incentivize healthcare providers to use more evidenced-based quality measures and approaches to treat patients with pain or addiction," according to the article.

    APTA's #ChoosePT campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Housed at MoveForwardPT.com/ChoosePT, #ChoosePT includes a video public service announcement, as well as other targeted advertising and media outreach.

    From PT in Motion: PTs Keeping Rowers Afloat

    When it comes to the physical therapist's (PT's) role in keeping rowers healthy, it's all about form following function. And vice versa.

    The June issue of PT in Motion magazine includes "Fluid Motions," an article that takes a close look at rowing (aka crew): the special demands it puts on the human body, the injuries that can result, and the interventions PTs use to get these high-intensity athletes back on the water. The PTs interviewed for the story treat rowers at different levels, from amateur to professional, and from local rowing clubs to university teams.

    While injuries can vary, the most common problems involve the back and knees, according to the article. No matter the injury site, however, the PT is faced with a twofold task: help the athlete recover, and find out what's causing things to go wrong. Sometimes, it's a matter of improving form to better accommodate the repetitive forces rowers must face. Other times, the rower's form may be fine, but weaknesses or positioning in other parts of the body can lead to injury.

    The article also examines the special needs of women rowers, the challenges for the PT treating the adolescent athlete, and the importance of good coaching that emphasizes the role of proper biomechanics.

    Because rowers will—hopefully—spend more time with their coaches than with a PT, the importance of careful coaching can't be overemphasized, according to Doug Adams, PT, DPT, who was interviewed for the story. Fortunately for the local youth rowing clubs Adams works with, the coaches understand the big picture.

    "[The coaches] are learning to focus on some of the intangibles, and maybe not spending as much time in the boats," Adams says. "They're working on some skills that will keep these athletes healthy."

    "Fluid Motions" is featured in the June issue of PT in Motion and is open to all viewers—pass it along to nonmember colleagues to show them 1 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.