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  • New Phys Ed Studies Say There's More Work to Do

    Despite concerns that US education policy over the past 2 decades may be squeezing out opportunities for physical activity in school, it turns out that average student attendance in physical education (PE) classes hasn't dropped since the mid-1990s—but then again, it hasn't increased either and remains below recommended levels. Those were among the conclusions in a pair of recently completed studies that also found public schools not fully embracing policies that could improve their PE programs.

    The 2 studies were conducted by the National Physical Activity Plan Alliance (NPAPA) at the request of the President's Council on Fitness, Sport, and Nutrition. APTA is an organizational partner of the NPAPA. [Editor's note: Want to learn more about the National Physical Activity Plan and the work of the NPAPA? Check out this video, and read the entire National Physical Activity Plan, a roadmap for community-level change.]

    To reach their conclusions, researchers looked at nationally representative survey responses. The attendance study focused on self-reported data from students, while the research on policy implementation was based on information primarily gathered from PE instructors. The study on PE attendance is an update on previous NPAPA research, while the policy study is a first-ever investigation into the degree to which schools have adopted best-practice recommendations from SHAPE America's Essential Components of Physical Education. The attendance study was published in Research Quarterly for Exercise and Sport (abstract only available for free); the PE policy study was published in the Journal of School Health (abstract only available for free).

    PE Attendance
    Researchers found that the percentage of students attending 1 or more PE classes per week continues to hover at around 50%--more or less the same rate reported since tracking began in 1991. The latest data, from 2015, puts the average number of days a high schooler attends PE classes at 4.11 per week; however, nearly half (48.4%) of students reported attending no PE classes on average. Only 29.8% of students reported attending the recommended 5 days of PE per week.

    While authors of the study say that their findings challenged a recent Institute of Medicine report that claimed "political and economic pressures" on school systems were reducing PE curricula, they also acknowledged that, though relatively stable, the attendance numbers aren't good enough.

    "The prevalence of PE attendance among US high school students is still well below the recommended national guidance of daily PE attendance and is far from reaching the [Healthy People 2020] national health objectives," authors write.

    PE Policies
    For the policy study, researchers analyzed the degree to which schools have adopted the 7 policy recommendations contained in the SHAPE resource: providing daily PE; prohibiting waivers, substitutions, and exemptions; limiting class size; not assigning or withholding PE as punishment; ensuring full inclusion of all students in PE; and having state-regulated teachers endorsed to teach PE.

    The results were mixed at best.

    The good news: about 75% of schools said they didn't allow substitution of other activities (such as sports teams or marching band) for PE, and nearly the same rate required certified or licensed PE teachers. More than half didn't allow PE to be assigned or withheld as punishment, and just over 40% enforced maximum student-to-teacher ratios in PE classes.

    The less-good news: Only a quarter of schools prohibited exemptions from PE, and just 4% of schools provided daily PE for the recommended amount of time. A mere 0.2% of schools reported implementing all 7 policy recommendations, and about half (49.3%) were implementing only 2-3 policies. The findings also uncovered regional variations.

    "The findings of this study suggest that many elementary, middle, and high schools across the United States are not implementing essential policies to ensure effective [PE] programs," authors write. They identified the provision of daily PE, class size limits, and prohibiting exemptions from PE as the policies most in need of wider adoption.

    APTA Senior Practice Specialist Hadiya Green Guerrero, PT, DPT, says that the studies shine a spotlight on the gap between widely accepted standards and day-to-day reality in schools.

    "This study is a reminder of the overall lack of progress in improving the well-being of our children by incorporating more movement in schools," Green Guerrero said. "There are progressive policies out there, but these reports show that what's needed is more advocacy in our own communities for their adoption. We can develop any number of great ideas, but without implementation we'll continue to see an increasingly unhealthy population of children of all backgrounds."

    APTA has long supported the promotion of physical activity and the value of physical fitness. In addition to representation on the NPAPA and other organizations, the association offers several resources on obesity, including a prevention and wellness webpage that links to podcasts on the harmful effects of inactivity. Interested members also are encouraged to join the APTA Council on Prevention, Health Promotion, and Wellness to engage with a community of shared interest. APTA is also a board member of the National Coalition for Promoting Physical Activity.

    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.

    PTJ: Falls Are 'Critical Health Hazard' for Individuals With Upper Limb Loss

    Arm motion is critical to helping compensate for losing one's balance and avoiding a fall. For individuals with upper limb loss (ULL), the lower extremities take on the burden of reacting to avoid a fall, and the lack of upper arm movement may put them at greater risk for falls than older individuals, say authors of a new study in PTJ (Physical Therapy). This "critical health hazard," they write, requires falls screening and "targeted physical therapy to enhance postural control and minimize fall risk."

    Via an anonymous online survey, researchers asked 109 individuals with an average age of 43 with ULL about their body and health characteristics, upper and lower limb loss characteristics, physical activity level, fall history in the previous year and circumstances, and upper limb prosthesis use. Participants also completed the the Activities-specific Balance Confidence (ABC) Scale. 

    Authors found:

    Falls are prevalent in this population, surpassing fall rates for older individuals and stroke survivors. Including individuals with ULL and those with upper and lower limb loss, 45.7% fell at least once in the past 12 months, while 28.6% reported 2 or more falls. Those numbers were slightly lower for respondents with only ULL, with 40.7% reporting 1 fall and 22.0% reporting 2 or more falls. The percentage of respondents experiencing a single fall is higher than for older individuals (33%) and community dwelling stroke survivors (~40%).

    Of all those who reported falls, 31.7% were injured in the most recent fall and 14.6% required medical attention.

    Most falls were due to slips, trips, and loss of balance. Of the reported falls, 30% occurred while walking outdoors, and 30% occurred while walking up or down stairs. Only 11% of falls occurred during physical exercise or playing sports. Most fell because they lost their balance (27%), tripped (25%), or slipped (18%).

    Balance confidence and self-perception play a role. Respondents were significantly more likely to fall if they had lower balance confidence and low perceived physical capabilities. They also were 6 times more likely to fall if they reported using an upper limb prosthesis.

    These results, especially the high rate of injuries, have "considerable clinical importance because it suggests the presence of a critical health hazard for individuals with ULL," authors write. "Balance confidence, use of upper limb prostheses, and perceived physical capabilities could be useful screening metrics."

    While further research is necessary on which interventions are best to address these fall risks, authors suggest that balance-targeted therapies, as well as interventions developed for older adults to better recover from trips, could also help individuals with ULL "refine their motor response to perturbations and enhance overall stability."

    "Monitoring these patients during rehabilitation would help create awareness of this health concern, and identify individuals at risk of falling in the community who could benefit from intervention," they write.

    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.

    Foundation Announces 2019 Grant Opportunities

    The Foundation for Physical Therapy Research (Foundation) now is accepting applications for a host of 2019 Research Grants—including a new mechanism, made possible through a bequest from a lifetime APTA member, that will award up to $360,000 for a 3-year research project.

    The new Goergeny High Impact/High Priority Research Grant is the result of a $1.58 million bequest from the estate of Magdalen and Emil Goergeny. Originally from Hungary, the Goergenys immigrated to the United States in 1960, where Magdalen received physical therapist training and established a practice. The Goergenys' bequest, received after their deaths in 2013, is among the largest personal donations ever received by the Foundation.

    Application deadline for all grants is early August 2019, with 2 grants requiring letters of intent due May 31. Grant opportunities include:

    • Goergeny Research Grant (High Impact/High Priority): Up to $360,000 (2-year total of $240,000 with third year competitive renewal) for research focused on the role of physical therapy in the prevention of secondary health conditions, impairments of body structures and functions, activity limitations, and/or participation restrictions. Interested applicants must submit a letter of intent by May 31, 2019, at noon ET.
    • Magistro Family Foundation Research Grant: $100,000 for a research project investigating physical therapist interventions. Investigators at any level are welcome to apply regardless of funding history. A letter of intent is required; applicants will be invited to submit full applications based on content. Letter of intent is due May 31, 2019, at noon ET. This grant is made possible by the Magistro Family Endowment Fund.
    • Foundation Marquette Challenge Research Grant: $40,000 for an investigator-initiated research project by an emerging investigator. This grant is named in honor of the annual student fundraising effort, the Marquette Challenge.
    • Health Services Research Pipeline Grant: $40,000 awarded to support research that examines how patients obtain physical therapy-related health care, how much that care costs, and outcomes, with an emphasis on the most-effective ways to organize, manage, finance, and deliver high-quality physical therapy-related care while potentially reducing medical errors and improving safety for patients. Investigators at any level are welcome to apply regardless of funding history. This grant is made possible by APTA.
    • Pediatric Research Grant: $40,000 to an emerging investigator for research consistent with the current Academy of Pediatric Physical Therapy Research Agenda. This grant is made possible by the Academy of Pediatric Physical Therapy.
    • Women's Health Research Grant: $40,000 to an emerging investigator for research in abdominal and pelvic health physical therapy that aligns with the mission and vision of the APTA Section on Women’s Health. This grant is made possible by the APTA Section on Women's Health.

    Questions? Email the Foundation, or call 800/875-1378.

    Note: Before starting your funding application, be sure to carefully read all eligibility guidelines, instructions, and information on funding mechanism deadlines. Also, it's a good idea to start the submission process early to allow for potential questions to be answered.

    New Pilot Study Opportunities Available From CoHSTAR

    The Center on Health Services Training and Research (CoHSTAR) has opened a call for the development of multiple pilot studies that would help set the stage for larger efforts to advance a wide range of health services research. APTA was a major financial contributor to the development of CoHSTAR, having donated $1 million toward the center's startup in 2015.

    The selected pilot studies would address research questions in CoHSTAR's 4 areas of specialization—analysis of large data sets, rehabilitation outcome measurement, cost-effectiveness, and implementation of science and quality improvement research—and the CoHSTAR Pilot Study Program webpage lists examples of specific types of studies that would qualify for funding. Each pilot study will receive $25,000 in funding for direct costs.

    Priorities for funding will be given to applications that align with 1 of the 4 areas of CoHSTAR specialization, have a strong likelihood of leading to broader research with major external funding, and have good potential to result in future research with high societal or policy impact for physical therapy. Principal investigators must include at least 1 physical therapist (PT) who is a US citizen or a certified permanent resident of the United States.

    Letters of intent are due to CoHSTAR by June 1, 2019. Based on those letters, in early July CoHSTAR will invite applicants to submit a full application by August 26. Award winners will be notified on October 15. For more information, visit the CoHSTAR Pilot Study Program webpage.

    CoHSTAR was established with a Foundation for Physical Therapy Research grant of $2.5 million. In addition to APTA’s $1 million donation, funding for CoHSTAR also came from APTA components, individual PTs, foundations, and corporate supporters.

    JAMA Oncology: Telerehab Makes a Difference in Patients With Advanced-Stage Cancer

    "Collaborative telerehabilitation" isn't a regular part of care for patients with advanced-stage cancer, but maybe it should be, say authors of a study recently published in JAMA Oncology (abstract only available for free). They found that the approach, which combines remotely delivered rehabilitation instruction with outpatient physical therapy and regular communication, can reduce pain, improve function, shorten hospital says, and decrease the use of postacute care facilities.

    The findings are based on results from the Collaborative Care to Preserve Performance in Cancer (COPE) program, a randomized clinical trial designed to address what the JAMA authors describe as a "knowledge gap" in the application of collaborative care models (CCMs) focused on patient function. The COPE trial includes patients with stage III or IV solid or hematologic cancer with a life expectancy of more than 6 months, and who reported moderate functional impairment (a score of 53-60 on the Activity Measure for Postacute Care assessment, or AM-PAC).

    The 516 participants in the study were divided into 3 groups studied over 6 months: a control group that was encouraged to self-report on pain and function via telephone or web-based surveys (every other week for the first month and monthly thereafter), an "arm 2" group that received a collaborative telerehabilitation program led by 2 physical therapist (PT) fitness care managers (FCMs) with 15 years or more of specialization in cancer rehab, and an "arm 3" group that added pharmacological pain management to the collaborative telerehab model, overseen by a nurse pain care manager (PCM).

    The collaborative telerehabilitation model put patients in touch with FCMs who provided instruction on "an incremental pedometer-based walking program" as well as the Rapid Easy Strength Training (REST) resistance training program, individualized based on patients' physical impairments. Participants also reported to the FCMs on pain and function, where FCMs "encouraged the use of compensatory strategies and initiated rehabilitative analgesic modalities when indicated," authors write.

    The participants in the telerehab model also were referred to local outpatient PTs "to further adapt their conditioning and analgesic regimens," with the outpatient PTs and FCMs working together to advance step and REST goals. Participants in arm 2 reported on progress, pain, and function weekly for the first month of the study and were then allowed to drop back to every other week or even once a month. FCMs received an alert if participants reported loss of function or increased pain, or if they failed to achieve the recommended 4 REST sessions per week.

    The arm 3 participants received the same rehabilitation approach but at the direction of a PCM, with the only real difference being that during the monitoring phase participants could request a call from the PCM, who could recommend the prescription of pharmacological treatments to address pain and function.

    Among the findings:

    • Physical function, as measured by the AM-PAC, improved for the arm 2 and 3 groups versus control by about 1.3 points—a difference that exceeded the minimum clinically important difference (MCID) threshold of 1 point.
    • Both the arm 2 and arm 3 groups reported clinically significant, albeit similar, reductions in pain compared with control as measured by the Brief Pain Inventory—pain interference dropped by 0.4 for arms 2 and 3, while pain intensity dropped by 0.4 for arm 2 and 0.5 for arm 3.
    • When it came to quality-of-life measures, a slightly different picture emerged: arm 2 telerehab-only participants reported significant improvement over control via the 5-item EQ-5D-3L assessment, but arm 3 participants (telerehab plus pain management) did not.
    • Hospitalization days were on average 57% higher for the control group (7.4 days) than for arm 2 participants (4.2 days), and 18% higher than for arm 3 participants (7.2 days). Authors note that the differences had to do with shorter, not fewer, hospitalizations in arms 2 and 3.
    • Among patients who were hospitalized, arms 2 and 3 were 4.3 times more likely to be discharged home than was the control group.

    "Although modest, the COPE interventions' effect sizes of 0.23 for mobility and -0.24 for pain are nonetheless notable given the remote, low-touch delivery; the known positive effect of the control condition; and the trial's vulnerable, high-needs participants," authors write. "Furthermore, our findings agree with reports suggesting that surprisingly modest functional losses and gains among individuals with borderline dependency…can profoundly affect their requirement for inpatient care."

    The researchers were surprised by the data that showed the addition of pharmacological pain management to be less effective than telerehab alone when it came to improving function and about equally effective in decreasing pain. They believe more study is needed but speculate that the greater reliance on nonpharmacological approaches in both arms, as well as a "more seamless integration of pain- and function-directed treatments in arm 2, may have contributed to the outcomes.

    Authors also note that in addition to reduced pain and improved function, results of the COPE trial shed more light on possible avenues for reining in the costs of care for individuals with late-stage cancer.

    "Our findings of reduced hospital use among participants in the telerehabilitation arms add to growing evidence that proactively addressing functional impairment among vulnerable patients reduces hospital utilization," authors write "Reducing the requirement for institutional care among patients with late-stage cancer has the potential for high financial return given that hospitalizations account for a large proportion of health care spending in this population, drive regional variation in costs of care, and are not associated with survival or [quality of life]."

    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.

    It's Never Too Late: Study Finds Beginning PA Later in Life Reduces Mortality Risk Nearly as Much as Remaining Active From Adolescence

    You've probably experienced it before: your 40-something patient thinks that after 4 decades of relative physical inactivity, there's no point in starting now.

    Tell your patient to think again. A recent study that tracked leisure time physical activity (LTPA) levels of more than 300,000 adults for as long as 46 years concludes that middle-aged adults who take up LTPA for the first time reduce risk of all-cause mortality by nearly as much as adults who've remained active since adolescence. And that risk reduction extends to deaths related to cardiovascular disease (CVD) and cancer.

    The study analyzed data from an AARP-sponsored diet and health survey conducted from 1995 to 1996 in relation to mortality information from the National Death Index. The survey, administered to participants aged 50–71, asked respondents to identify levels of regular moderate-to-vigorous LTPA at various points in their lives—at age 15-18, 19-29, 35-39, and during the previous 10 years. A little more than 20 years later (2017-2018), researchers paired respondents with mortality reports to gauge the effects of LTPA on risk of death. Results were published in JAMA Network Open.

    Authors of the study had a sensible-sounding hypothesis—that participants who reported more LTPA in adolescence, and then maintained higher levels of LTPA throughout adulthood, would be found to have lower risk of all-cause, CVD, and cancer-related mortality. They were right—but there was more to the story.

    As they predicted, researchers found that compared with a control group that reported low levels of LTPA during their lifetimes (fewer than 60 minutes per week), participants maintaining moderate to high amounts of LTPA (2-8 hours per week) from age 15 to 40 or older lowered their risk of death, reducing all-cause mortality risk by 29% to 36%, and dropping CVD and cancer-related death risk by an average of 38% and 18%, respectively.

    To the researchers' surprise, however, adults who reported low levels of LTPA in adolescence but increased those levels after age 30 generated comparable reductions in risk of death compared with control—a drop of 35% for all-cause mortality, and reductions in CVD and cancer-related mortality of 43% and 16%, respectively.

    "We anticipated that participants who maintained the highest levels of activity throughout adulthood would be at lowest risk and were thus surprised to find that increasing activity early or late in adulthood was associated with comparable benefits," authors write. "These benefits held similarly for men and women…and were independent of changes in BMI over time."

    Researchers also found that respondents who reported high levels of LTPA in early adulthood but lower levels at 40 or older "appeared to have little all-cause or CVD-related mortality protection in midlife."

    Authors say their study supports earlier research into the benefits of PA in midlife, but they believe theirs is the first to look at LTPA over a longer period of time and to track increased or decreased levels of LTPA at multiple points. The results echo those of another recent study linking higher rates of PA midlife to lowered risk of Alzheimer's disease and other dementia in later years.

    [Editor's note: Visit APTA's prevention and wellness webpage for resources on how physical therapists and physical therapist assistants can help individuals become more physically active, and share the latest PA information from APTA's consumer-focused MoveForwardPT.com with your patients, clients, and others interested in the benefits of exercise and movement. Want to connect with others interested in physical therapy's role in improving health? Join APTA's Council on Prevention, Health Promotion, and Wellness. The association is also an organizational partner in the National Physical Activity Plan Alliance, and has a seat on its board of directors.]

    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.

    Too Much Focus on Productivity Increases Risk of Unethical Behavior, Say Researchers

    Employers that overemphasize productivity goals over evidence-based practice (EBP) may inadvertently set the stage for unethical behaviors by physical therapists (PTs) and physical therapist assistants (PTAs), say authors of an unedited new study published ahead of print in Archives of Rehabilitation Research and Clinical Translation. Organizational culture, say authors, is "the most easily changeable" factor in promoting ethical behavior.

    In an email survey, researchers asked licensed PTs and PTAs in the state of Texas about their practice settings, their employers' use of productivity goals, and observed unethical behaviors, such as inappropriately discharging patients or falsifying or changing documentation.

    The majority of the 3,446 respondents were women (70.5%) and had been practicing an average of 15 years. One-third of respondents were PTAs. The most-represented practice settings were skilled nursing facilities (SNFs) (23.1%) and private outpatient clinics (17.7%).

    Their findings include:

    The majority of employers set formal productivity goals. Of the respondents, 73.9% said their employers set productivity goals for them. Of that group, 85.1% indicated that the goal was based on billable units per hour. However, 54.5% said they had no input into the goal-setting process.

    The use of productivity goals varied by setting. SNF clinicians were most likely (97.1%) to report having productivity goals, while school system PTs and PTAs were least likely (13.2%). [Editor's note: an accompanying table in the unedited article includes different percentages.]

    As the rate of expected productivity increased, so did the rate of observed unethical behaviors. Of all respondents, 53.3% indicated their productivity goals were difficult or very difficult to meet, and 60.2% felt they were high or much too high. Most clinicians said that productivity goals influenced their clinical decision making.

    SNFs had the highest prevalence of observed unethical behavior as well as the highest frequency of each behavior. PTs and PTAs in SNFs were 4 times more likely as those in other settings to report having observed unethical behavior.

    Overall, unethical behavior is not widespread. While a majority of respondents had observed unethical behavior, 68.6% reported observing it "rarely" or "never."

    However, workplace cultures emphasizing ethics are not common, either. Only 38.9% of respondents said their organization's culture emphasized ethical practice, far below the business average of 66%.

    Focusing on ethics and evidence-based practice may discourage unethical behaviors. The degrees to which an organization emphasizes ethical and evidence-based practice were negatively associated with observed unethical behavior. Employees whose organizations emphasized productivity over EBP and ethical practice were, respectively, 6 times and 3.39 times more likely to have observed unethical behaviors.

    One of the contributing factors to unethical care is a payment environment that results in patients and clinicians being "disconnected from negative consequences" over overutilization, say authors. They write, "Historically, utilization of rehabilitation has been highly influenced by financial incentives, with significant variances in factors unrelated to caseload such as geographic location and payer source."

    Authors explain that business pressures toward overutilization often are accompanied by a gradual shift in the attitudes of clinicians, who "justify overutilization of rehabilitation services by portraying it as meeting their patients' desires or sustaining their own livelihood." This "moral re-construal" in turn paves the way for unethical behavior, with clinicians and patients seldom experiencing the results of overutilization, given the typical health care system with its long gaps between service delivery and payment.

    Given the ways business decisions can set the stage for unethical behavior, change must take place at the organizational level, which also happens to be "the most easily changeable component," researchers write. Among their recommendations: Survey employees about the ethical climate and organizational behavior; avoid the use of productivity standards based on billable units; and involve clinicians in developing productivity goals.

    "Use of productivity standards measured solely by the quantity of billable units is not advised," authors write. "We recommend that clinicians are involved in the setting of productivity standards."

    APTA members Justin Tammany, PT, DPT, MBA, ScD; and Janelle O'Connell, PT, DPT, PhD, were among the authors of the study.

    The issue of productivity pressures is at the heart of a "Consensus Statement on Clinical Judgment in Health Care Settings (.pdf)" collaboratively created by APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association. For more on productivity, check out "Measuring by Value, Not Volume," 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: Light Physical Activity Could Help to Lower Risk of Coronary and Cardiovascular Problems

    No one doubts the positive health effects of regular moderate-to-vigorous physical activity (MVPA), but now researchers are finding that even light physical activity can reduce the risk of coronary heart disease and cardiovascular disease. The latest findings, focused on women age 65 and older, echo revised US Department of Health and Human Services (HHS) activity guidelines strongly supported by APTA.

    The recent study, published in JAMA Network Open, asked 5,861 women with an average age of 78.5 years to wear a hip accelerometer for a week to establish PA rates, and then tracked rates of later coronary heart disease (CHD) and cardiovascular disease (CVD) for nearly 5 years. Researchers were particularly interested in the effect of light physical activity (PA)—between 1.6 and 2.9 metabolic equivalent tasks (METs)—on the risk of experiencing CVD and CHD.

    Researchers divided the participants into 4 groups based on the average amount of time spent per day in light PA: 36-236 minutes, 235-285 minutes, 286-333 minutes, and 334-617 minutes. They also tracked rates of MVPA, as well as demographic, educational, and health information including the presence of chronic conditions, alcohol consumption, smoker or nonsmoker status, and use of antihypertensive and antilipidemic medications. The population studied was a mix of white (48%), black (33.5%), and Hispanic (17.6%) women.

    They found that during the study period, participants in the highest light PA quartile (about 5-10 hours of light PA per day) reduced their risk of both CVD and CHD by significant percentages compared with the lowest light PA quartile (about 30 minutes to 4 hours per day)—by 42% for CVD and 22% for CHD, adjusted for demographic and health variables. The reduction was dose-dependent, with every additional hour of light PA correlating to a 20% reduction in CHD risk and a 10% reduction in risk for CVD.

    When researchers factored in rates of MVPA (METs of 3 and above), they found risk reductions beginning with the second-lowest quartile (27 minutes or more per day). Compared with women in the lowest MVPA quartile, women in the highest MVPA quartile (a difference of 42 minutes per day) reduced risk of CHD by 46% and lowered CVD risk by 31%. Those results, so similar to the light PA risk reductions, told researchers that light PA could play a more important role in long-term health than previously thought.

    Authors acknowledge that women with the highest levels of light PA tended to have healthier levels of HDL-C, triglycerides, and glucose, as well as on-average lower BMI to begin with—factors possibly tied to genetics—but they still believe light PA itself has an important role to play.

    HHS agrees. Its latest revision to national physical activity guidelines emphasizes that "some physical activity is better than none," even while promoting the familiar goals of at least 150 minutes of moderate intensity PA or 75 minutes or more of vigorous PA per week for adults. What's different is that the new guidelines no longer include statements saying that PA must occur for at least 10 minutes to be effective, stressing instead the anything-is-better-than-nothing approach.

    "This study is encouraging, as well as another confirmation of what the new HHS guidelines tell us—that any amount of physical activity can positively affect health," said Hadiya Green Guerrero, PT, DPT, a senior staff specialist in the APTA practice department and a certified sports physical therapy specialist. "What's encouraging here is the emphasis on light physical activity, something that's attainable by adults who are older. It's important to have evidence that further supports the idea that PTs are doing well by their patients when they promote movement through usual and enjoyable physical activities like walking, gardening, dancing, stretching exercises, or playing with grandchildren."

    In an editorial that accompanies the JAMA Network Open article, author Gregory W. Heath, DHSc, MPH, characterizes the study as a "clarion call" for physicians, other health care providers, and health care systems to promote the HHS guidelines. "To temporize such action is to jeopardize the future health and well-being of older women," Health writes.

    Green Guerrero, who represents APTA on the board of directors for the National Coalition for Promoting Physical Activity, and who led APTA's recent collaborative efforts with the National Institutes of Health's "Go4Life" exercise campaign, says that APTA couldn't agree more.

    "APTA supports efforts that look to keep America healthy and level the health disparities playing field rather than continuing to spiral down the exponentially expensive sick care from which only a select few benefit," Green-Guerrero said. "As movement experts PTs intimately understand that blood flowing through arteries, to the brain, and to and from the heart are crucial to function and movement. It only makes sense that movement—any movement—will help things keep churning and, in the case of the evidence presented in this study, significantly reduce risk of preventable cardiovascular disease processes."

    [Editor's note: Visit APTA's prevention and wellness webpage for resources on how physical therapists and physical therapist assistants can help individuals become more physically active, and share the latest PA information from APTA's consumer-focused MoveForwardPT.com with your patients, clients, and others interested in the benefits of exercise and movement. Want to connect with others interested in physical therapy's role in improving health? Join APTA's Council on Prevention, Health Promotion, and Wellness. The association is also an organizational partner in the National Physical Activity Plan Alliance and has a seat on its board of directors.]

    Authors of the JAMA study say that while more clinical trials could help to better define the relationship between light PA and risk reduction, there's no reason to wait on promoting this type of PA.

    "The magnitude of these associations for light PA and their consistency across strata of CVD risk, physical functioning, and MVPA suggest that light PA could have much to offer older women in the prevention of CVD whether or not they can or choose to engage in MVPA," authors write. "Given the low risks of light PA and the abundance of light movements that are part of everyday life, even in the absence of trial data it may be prudent to encourage older women to increase light PA to improve their CVD health and reduce the occurrence of CVD 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.

    Researchers Find 'Only Positive Effects' From PTs in Primary Care Role

    Get thee to a physical therapist (PT): according to a new study from Sweden, patients seeking primary care for musculoskeletal disorders (MSDs) who are triaged to a PT fare just as well—and in some respects, better—than those who are seen by a physician general practitioner (GP). It's a finding consistent with APTA's own investigations into the PT's role in primary care settings.

    Authors of the study, published in Therapeutic Advances in Musculoskeletal Disease, concede that, at 55 participants, their study was small. But they assert that their findings indicate that directing patients to PTs for primary assessment in primary care results in slightly better patient-reported outcomes related to pain, disability, and health-related quality of life (HRQoL) at follow-up, from 2 weeks to a year after initial visit. "Only positive effects were notable, and no adverse events regarding the triaging process were reported," they write.

    Researchers worked with 3 primary care health centers (PHCCs) in Gothenberg, Sweden, each serving a slightly different socioeconomic population (one serving patients experiencing generally lower socioeconomic conditions; one in a more affluent area; and one serving a more mixed population). PHCCs are the usual route taken by patients in Sweden seeking primary care, where patients are first assessed by a nurse, who determines a treatment pathway—including which provider the patient sees next.

    [Editor's note: want to learn more about how PTs are deepening their footprint in primary care? This 2018 article from PT in Motion magazine explores how the landscape is changing and offers links to APTA resources on issues related to primary care.]

    For the study, it wasn't a question of whether PTs should be delivering primary care—they were already doing that at the 3 participating PHCCs—but of how PT primary care affected outcomes. To make this assessment, researchers worked with nurses to randomly assign patients who normally would be referred to a PT to a control group that received "treatment as usual" (TAU) from a GP. The researchers then compared patient-reported outcomes from the PT and TAU groups at various points.

    Patients participating in the study were "working age" (16-67 years old) individuals seeking help for a new musculoskeletal condition; patients were excluded from the study if they required home visits, were receiving ongoing treatment for the current MSD, were seeking help for a chronic condition unchanged for 3 months or more, or possessed insufficient English or Swedish language skills to complete patient questionnaires.

    Both groups were asked to complete patient questionnaires on pain (0-10 rating scale), disability (Disability Rating Index), HRQoL (EuroQol 5), and risk for developing chronic musculoskeletal pain (Orebro Musculoskeletal Pain Questionnaire). Researchers also sought to determine whether the PT patient group developed different attitudes about responsibility for their MSDs, shifting more of that sense of responsibility to the patient and away from employers and/or medical professionals. Researchers asked patients to complete the questionnaires at initial consultation and 2, 12, 26, and 52 weeks later.

    Analysis revealed that while all patients improved at roughly similar rates, the PT group reported consistently better—albeit just slightly better—outcomes. The exception to that trend was in HRQoL scores, which improved for the PT group over the TAU group by a statistically significant margin.

    As for patient attitudes about responsibility for MSDs, the PT group tended to reduce what authors call "externalization" of the condition to health care providers, but a slight drift to greater externalization focused on employers after 1 year. However, researchers found that the changes in attitudes were slight.

    "This study indicates that early contact with both GPs and [PTs] can reduce the risk for patients developing chronic conditions with subsequent need for more comprehensive treatment," authors write. "As the effects of [PT] treatment were at least as good as TAU, it is clearly feasible to impose management modifications which can free medical competence for other patient groups. It is important to take care of even the group of patients with short-term or low-intensive musculoskeletal conditions to prevent development of chronic disorders."

    The researchers acknowledge that besides the small study population, the project also experienced patient dropout over time—particularly among younger patients in the PT group. Still, they contend, the findings support the role of PTs in primary care.

    "While it cannot be irrevocably concluded that initiation treatment by a [PT] is better for all patients with [MSDs] than [is] medical advice and treatment by a GP, there is nothing to indicate that this triage model for managing patients with [MSDs] in primary care is, in any way, detrimental to the patient health or worse than standard care," they write. "Triaging to [PTs] for primary assessment in primary care seems to lead to at least as positive health effects as primary assessment by GPs and can be recommended as an alternative management pathway for patients with MSDs."

    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.

    Researchers: Aquatic Exercise Offers Similar Results With Less Pain for Patients With Chronic LBP

    Aquatic exercise, a common physical therapist intervention for patients with chronic low back pain (CLBP), shouldn't be viewed as "less strenuous or less effective" than land-based exercise, according to authors of a recent study in PTJ (Physical Therapy). In fact, they write, water-based exercise can be beneficial for people whose movement is limited by pain.

    Researchers recruited 40 men aged 18 to 45 with a healthy body mass index. Half of participants had experienced CLBP for greater than 12 weeks; the control group experienced no back pain. Both groups performed 15 aquatic exercises and 15 land-based exercises with movement patterns similar to the aquatic exercises. Fourteen of the exercises included upper extremity dynamic movements, and 16 focused on the lower extremities.

    The authors measured heart rate, rate of perceived exertion, and pain. They also used video motion analysis and wireless, waterproof EMG sensors to measure bilateral activation of the erector spinae, multifidus, gluteus maximus, gluteus medius, rectus abdominis, external oblique, and internal oblique muscles.

    Among their findings:

    There were few significant differences between the CLBP and control groups. Heart rate (HR), rate of perceived exertion (RPE), pain, and muscle activation for both land and water-based exercises were similar for both groups. Patients with CLBP had greater mean left erector spinae activations in one exercise and higher RPE in another.

    Differences were seen when comparing results for exercises performed in water versus land. Muscle activation was greater on land in 29% of cases and in water in 5% of cases. Heart rate was higher on land with all exercises, but RPE was not consistently higher or lower in either environment.

    Pain was reported more than twice as frequently when subjects exercised on land. However, pain levels were generally low in both environments.

    While the study was small, and the researchers say it was the first to examine this data set for aquatic exercises, the fact that results were similar for both groups suggested to them that "exercising in the water can be beneficial for rehabilitation and strengthening by allowing people with CLBP to perform the exercises and activate muscles without their condition adversely affecting them."

    [Editor's note: interested in aquatic physical therapy? Check out the APTA Academy of Aquatic Physical Therapy.]

    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.