Tell Your Story on Capitol Hill at the APTA Federal Advocacy Forum
By Katy Neas
The Federal Advocacy Forum is right around the corner (March 31-April 2, 2019), and you're not going to want to miss it.
This year is a historic year for APTA advocacy: For the first time in more than 2 decades, the Medicare therapy cap is not the lead priority on the association's public policy agenda. Thanks to you, the hard cap has been permanently addressed. But more work remains.
Our nation is at a crossroads between health and the health care delivery system. Too many Americans are limited by chronic conditions such as diabetes, hypertension, and obesity. Too many people with disabilities struggle to secure appropriate support services that allow them to live independently in the community. Too many lives have been shattered by opioid addiction. Our health care system too often pays for treating illness rather than advancing the wellness and prevention services necessary to achieve and support good health. The United States spends more per capita on health care than any other developed country, yet our citizens are limited by poor health. This must change.
Daunting though these challenges may seem, progress is possible through effective advocacy. Your elected officials need to hear directly from you about your efforts to build a community that advances the profession of physical therapy to improve the health of society. The Federal Advocacy Forum will enable you to make your collective voices heard on the issues affecting physical therapy and your patients and clients.
The APTA 2019–2020 Public Policy Priorities are grounded in 4 overarching goals. The association wants Congress and the Administration to:
- Enact policies that empower people to live healthy and independent lives,
- Eliminate barriers to health care services,
- Support efforts to increase efficiencies in the delivery of health services that reduce administrative burden to providers and ensure transparency to patients, and
- Prioritize research and clinical innovation to access appropriate value-based health care services.
When you come to Washington, DC, next month, you'll have the opportunity to share your expertise with Congress. There are many new faces on Capitol Hill: 10 new senators and 101 new members of the House of Representatives. Some of these individuals may not be expert in health policy and may not understand fully the contribution this profession makes to children, adults, and seniors in their community. They may not realize how specific policy changes could impact the health of their constituents.
That's why your stories are so important. In addition to asking legislators to support specific bills, you will want to educate them about your practice, your area of expertise, and how you empower your patients to achieve positive outcomes. I can assure you, when they know more about you, what you do, and who you serve, they will be impressed.
Have no fear—the APTA government affairs staff will provide you with all the tools that you'll need to make this Federal Advocacy Forum the best one yet!
Finally, please accept a note of sincere thanks from me. I have seen the significant contribution that physical therapists make in acute hospitals, critical care units, inpatient rehabilitation facilities, and home health over the past 7 months, as my husband continues a very long recovery from Guillain-Barré syndrome. During his 179 days in a hospital, I have witnessed the strength and grace of the physical therapists who have helped him regain strength after each of his 5 relapses. Each of these amazing professionals played critical roles in his recovery—teammate, coach, cheerleader, advocate, and friend. I will always be grateful. My family's experience only reinforces my commitment to APTA's work to expand patient access to physical therapist services and to secure fair and adequate payment for these important interventions.
I look forward to seeing you in March, and I thank you for all that you do!
Katy Neas is executive vice president, public affairs, at APTA.
To attend the Federal Advocacy Forum, register now at www.apta.org/FederalForum. Registration closes March 18.
Vision, Courage, Compassion: Black Physical Therapists Who Transformed the Profession
Photos courtesy of American Physical Therapy Association Archive. From left: Lynda Woodruff, Vilma Evans, Arnold Bell, Thelma Brown Pendleton, Mary McKinney Edmonds, and Leon Anderson.
For this Black History Month, we dug into APTA's Archive to take a look back at some truly ground-breaking African American physical therapists who achieved greatness despite obstacles, transforming the profession along the way. Now deceased, they offer us all examples to strive for as individuals and as a profession, urging us to keep "moving forward" and challenge the status quo.
Lynda D. Woodruff, PT, PhD, was a trailblazer since 1962 when, at age 13, she was 1 of 2 African American students to desegregate E. C. Glass High School in Lynchburg, Virginia—an experience that greatly influenced her approach to life: "I could never trust anyone. I ceased asking by the time I was 14 for help, because if you asked for it, and they gave you something, 9 times out of 10 it would be the wrong information, or the wrong feedback. And that was more detrimental than having no feedback."
After receiving her master of physical therapy degree from Case Western Reserve University, Woodruff went on to become the first African American to join the physical therapy department at University of North Carolina at Chapel Hill. She was a founding director of the department of physical therapy at North Georgia State College and established the first DPT program at Alabama State University. She joined the faculty of Georgia State University in 1978, where she received her PhD. Woodruff was appointed to the appointed Georgia State Board of Physical Therapy and served for 10 years. As an APTA member, Woodruff was a strong advocate for diversity and inclusion, helping to establish APTA's Advisory Council on Minority Affairs, as well as for true mentorship, especially for women and minorities.
Woodruff was a founding member of the Section on Clinical Electrophysiology, at a time when PTs who conducted electromyography testing were being charged with practicing medicine without a license. She received numerous awards for her leadership, including the Lucy Blair Service Award. In recognition of her many achievements, the Georgia Senate declared February 24, 2006, as Dr Lynda D. Woodruff Appreciation Day.
One of Woodruff's mentors, Mary McKinney Edmonds, PT, PhD, FAPTA, had originally intended to be a physician. But just a few weeks from her 1953 graduation from Spelman University, Edmonds attended a lecture by physical therapist Wilmotine Jackson. "[Jackson] spoke about raging polio epidemics, and I just got totally excited," Edmonds said in an oral history recorded for APTA. She earned her physical therapy certificate from the University of Wisconsin. Before the phrase "social determinants of health" was popularized, she noticed how black and white women with diabetes who came to rehab would have above-the-knee amputations vs toe amputations, leading her to complete graduate degrees in sociology at Case Western Reserve University. During her postdoctoral fellowship at University of Michigan, Edmonds examined how social class affected people's experiences with health and health care.
Edmonds founded Cleveland State University's physical therapy program, was dean of Bowling Green State University's College of Health and Community Services, and was vice provost at Stanford University, as well as a professor at Stanford Medical School. She was a prolific author and presenter on issues related to cultural competency throughout her career. As a member of the APTA Commission on Accreditation (precursor to the Commission on Accreditation in Physical Therapy Education), Edmonds helped lead the fight for autonomy from the American Medical Association. Edmonds was the first African American PT to become a Catherine Worthingham Fellow of the American Physical Therapy Association.
Edmonds was hired for her first physical therapy position by Leon Anderson Jr, PT, who was then chief physical therapist at Highland View Hospital in Cleveland, Ohio. Anderson, who completed his degree in physical education at Johnson C. Smith University, didn't know much about the profession before he attended physical therapy school at Boston University, he just knew he "didn't want to preach or teach"—prominent professions for black Americans at the time. Ironically, after getting his master's degree in education, Anderson did spend several years as an assistant professor at Case Western Reserve University. After 20 years as director of physical therapy at University Hospitals of Cleveland, Anderson left to start a private practice with 6 colleagues. The first African American member of APTA's board of directors, Anderson held more than 15 elected positions at APTA throughout his career and chaired the Advisory Council on Minority Affairs.
Thelma Brown Pendleton, PT, and Vilma Evans, PT, EdD, were among the first black physical therapists in the United States. Pendleton originally was a nurse; although she aspired to be a PT, black students were not allowed to enroll in physical therapy programs at the time. In the mid-1940s she was finally able to enroll at Northwestern University and get her PT certificate, becoming the fifth African American PT. She founded and headed the physical therapy program at Provident Hospital and later was chief physical therapist at La Rabida Children's Hospital and Research Center. Pendleton also supervised clinical instructor education programs at Northwestern University for many years, and was an active member of the Illinois Physical Therapy Association.
Evans was born in New York City, attended school in Jamaica, and returned to New York for high school. Like Brown Pendleton, Evans had a hard time applying to PT school due to her race. She earned a degree in zoology from Hunter College, a physical therapy certificate from University of Pennsylvania in 1951, a master's in physical therapy in 1956 from New York University, and later a doctorate in education. Evans was director of physical therapy at St Elizabeth Hospital in Danville, Illinois, for 26 years. A lifetime APTA member, she received the Illinois Chapter's Outstanding Service in Physical Therapy Award in 1976 and APTA's Lucy Blair Service Award in 1985, and was a member of the APTA sections for education, geriatrics, and health policy and administration. Early on, Evans decided she "wanted to be part of the ‘inner workings' [of APTA] because that's that way I—or anyone else—could make changes. Members can't all sit on the outside and expect someone else to carry on. If you want change in your organization, you have to get involved."
Arnold Bell, PT, PhD, ATC, was one of the first African American ABPTS-certified clinical specialists in sports physical therapy. Born in the Bronx, he earned his bachelor's degree from Springfield College, a physical therapy certificate and a master's degree in exercise science at Columbia University, and a PhD at Florida State University. He established Florida A & M University's physical therapy program, teaching there for over 30 years. Bell was an athletic trainer at the 1984 and 1996 Olympic Games, and was inducted into the Springfield College Olympic Alumni Hall of Fame and the Florida A & M Sports Hall of Fame. A longtime APTA member, Bell was a member of the Advisory Committee on Minority Affairs.
Another PT with an Olympic connection was Theodore "Ted" Corbitt, PT, MPT, Army veteran, professor, and clinician for 44 years at the International Center for the Disabled in New York City. After returning from World War II, Corbitt earned an MA in physical therapy from New York University (NYU)—and 2 years later became the first African American Olympic marathon runner to represent the United States. He is known as the "father of American distance running." A professor at Columbia University for 20 years, he was one of the first PTs to teach connective tissue massage, proprioceptive neuromuscular facilitation, progressive resistance exercise, and applied kinesiology. Always setting records, Corbitt walked 303 miles in a single 6-day race—at age 82. Corbitt was active in the New York Chapter of APTA. Read more about this American pioneer.
Another NYU graduate, Roberta F. Cottman, PT, MEd, from Greensboro, North Carolina, received her bachelor's degree from Bennett College in 1945. According to her oral history, "as a young black woman" it was not possible for her to attend North Carolina medical schools. So she went to PT school. For one of her clinicals in a New York state-owned rehab facility, she was not allowed to stay in the dormitory with the white students and had to stay in a private home. She found that, once she entered the field, "nobody cared then what color you were or where you came from. As long as you knew your skills and were able to translate that…into clinical practice." Later, as director of the physical therapy department at Henry Ford Hospital in Detroit, she hired a PT named Jane S. Mathews-Gentry, PT, MS—who later became APTA president.
Cottman received a scholarship from APTA to pursue her doctorate and was the first female student in the department of anatomy at Wayne State University in Michigan. However, the physical therapy department asked her to assist them as they navigated a crisis, and she never finished her dissertation. Still, she became a tenured professor there.
A charter member of APTA's Committee on Minority Affairs, Cottman also served on the Congressional Black Caucus' Health Braintrust, was a consultant to members of the US Congress, and attended the United Nations Fourth World Conference on Women, held in Beijing in 1995. She observed that health care in the United States is not a human right but "is still based on privilege and the ability to pay. We must begin to look at individuals and the issues of health which surround our citizens, not wait until they become ill."
Do you know of a PT or PTA who deserves to be recognized? Do you have your own stories to share? Let us know in the comments.
The Physical Therapist Assistant Profession Turns 50
While APTA's centennial may be a couple years away, there's another cause for celebration right here, right now: 2019 marks the 50th anniversary of the first physical therapist assistant (PTA) graduates.
Though a half-century may seem like a long time, the rise of the PTA from something that seemed like a good idea to a recognized, well-established, and in-demand profession integral to health care represents a remarkably short ascendance. Today, it's hard to imagine the delivery of physical therapy without PTAs on the team.
Here's a look at how the PTA profession came into being, and what's happened since.
The 1973 graduating class of PTAs from Greenville Technical College. Photo courtesy of APTA Library & Archive.
The Beginnings: A Clear Need, and a Creative Solution
The American Physical Therapy Association (APTA) first began to consider the idea of a physical therapist assistant in the 1940s, when physical therapists were treating soldiers injured in World War II, just as a new polio outbreak emerged. The United States had experienced 2 world wars, the Great Depression, and multiple polio outbreaks, resulting in high demand for the services of the approximately 2,500 physical therapists working at that time. Helen Blood, PT, FAPTA, a California Chapter member, introduced the House of Delegates (House) resolution to create a committee to consider a "physical therapy assistant occupation."
First PTA Programs Established
In 1967, the House adopted the policy statement "Training and Utilization of Physical Therapy Aides and Assistants" to establish educational standards, scope of practice, licensure, and eligibility for APTA membership. That same year, the first PTA education programs were established at Miami-Dade Community College in Florida and St Mary's Junior College in Minnesota (now St. Catherine University).
In 1968, Green River Community College in Washington admitted its first class of 26 students.
By 1971, APTA had approved 10 PTA education programs.
The number of PTA education programs grew steadily in the 1970s and 1980s, reaching the 100-program mark in the early 90s. After that, things really took off: today there are 393 accredited PTA programs across the United States.
The first graduating PTA class of St Mary's Junior College, Minnesota, in June 1969. Photo courtesy of APTA Library & Archive.
The PTA's Impact on APTA
PTAs were granted affiliate APTA membership in 1973. By 2018, PTA membership had grown from less than 100 to 7,736, along with 4,641 PTA students. APTA launched a #PTA10K initiative at the Component Leadership Meeting in June 2018 in an effort to reach 10,000 PTA members.
As PTA numbers and engagement in APTA continued to grow, so did a PTA sense of identity. In 1983, the Affiliate Special Interest Group (ASIG) was created, holding its first annual education conference in Topeka, Kansas, in 1987. Two years later, the House established the Affiliate Assembly, which succeeded the ASIG. In 1992, the House voted to give PTAs the opportunity to hold chapter and section officer positions.
To increase PTAs' knowledge and skills in a select area of physical therapy, in 2004 APTA established the Recognition of Advanced Proficiency for the Physical Therapist Assistant program, which was succeeded in 2016 by the PTA Advanced Proficiency Pathways (APP) program.
In 1974, APTA successfully petitioned the American Medical Association's Council on Medical Education to recognize the PTA as a health care occupation. That same year, "Physical Therapist Assistant" was added to the US Department of Labor's Employment and Training Administration's Dictionary of Occupational Titles, assigned the code 076.224-010s.
By the early 1980s, there was once again a shortage of PTs and PTAs, and federal funding for education assistance was reduced. In response, many potential employers began offering health coverage, continuing education, association dues, and licensure fees—and some even offered to pay for the last year of school in exchange for signing a 1- or 2-year employment contract.
A 1983 survey found that only 37 states and Puerto Rico included physical therapist assistants in their state practice acts, 32 of which required PTAs to take a special examination in order to practice. All 50 states, the District of Columbia, Puerto Rico, and the US Virgin Islands now include PTAs in their practice acts.
The Bureau of Labor Statistics projects that PTA employment will grow 31% between 2017 and 2026. The median PTA salary in 2017 was $57,430—a far cry from the median 1977 salary of $8,500–$9,999.
In June 2018, APTA successfully lobbied for federal legislation to include PTAs as authorized providers under TRICARE. (The rule is not yet in effect.)
First PTA to serve in the United States Peace Corps: Carol McClaugherty, PTA, served in Rio de Janeiro, Brazil, beginning in 1974.
First PTA program designed for PTA students who are blind or visually impaired: In 1977, St Mary's Junior College in Minneapolis became the only school in the country with special facilities for teaching physical therapy and occupational therapy to students with blindness or visual impairment.
First PTA student to receive APTA's Mary McMillan Scholarship: Melinda Hong, De Anza College, earned the scholarship in 1980.
First PTA students to receive APTA's Minority Scholarship Award: Karen Aitken-Douyon, Essex County College; James Lee Howlett, Wallace State College; and Mary Man, Tulsa Junior College, received scholarships in 1996.
PTA student Melinda Hong receives the Mary McMillan Scholarship in 1980. Photo courtesy of APTA Library & Archive.
First PTA to receive APTA's F. A. Davis Award for Outstanding Physical Therapist Assistant Educator: Barbara J. Behrens, PTA, received the award in 2000.
First recipients of the APTA Outstanding Physical Therapy/Physical Therapist Assistant Team Award: Edie Knowlton Benner, PT, PhD, and Juliana Robine, PTA, were recognized in 2006.
First recipient of the APTA Outstanding Physical Therapist Assistant Award: Roy Christopher Junkins, PTA, ATC, was awarded in 2007.
Lisa Finnegan, PTA, lead accreditation PTA programs specialist, became one of the first physical therapist assistants to work at APTA in 2006. "I've never believed that I'm ‘just a PTA,'" says Finnegan. "PTAs have many rewarding job opportunities—I've had the pleasure of treating patients in clinical settings, teaching in a PTA program, writing books for PTA students, and working for APTA and CAPTE. I'm proud to be a PTA and an APTA member."
For more on the history of the PTA, watch for PT in Motion magazine's special feature in the upcoming May issue.
Editor's Note: This post previously listed the current name of St. Mary's Junior College as St. Mary's Campus of the University of St. Catherine. The institution is currently called St. Catherine University.
Got MIPS Questions? We Have Answers.
The Merit-based Incentive Payment System (MIPS) is now in effect for many physical therapists. At a recent live webinar, APTA answered some of our members' most pressing questions. (In case you missed it, you can listen to the recorded webinar in its entirety.)
We've recapped some popular questions here. Not finding the question you need answered? You can email email@example.com. APTA members can also post questions, and review answers to other member questions on the Medicare MIPS Discussion Board on the Medicare Quality Reporting Hub.
What is the quickest way to find out if my practice is required to participate?
The Centers for Medicare and Medicaid Services (CMS) website has an easy lookup tool. Just type in your national provider identifier (NPI) number and you'll see whether you are required to participate as a practice, or as an individual.
APTA's MIPS resource page has a lot of information, including a decision tree to help you understand MIPS eligibility and required vs voluntary participation.
In brief, you must participate if you are an individual PT in private practice and exceed all 3 criteria for the "low-volume threshold":
- Receive more than $90,000 in Medicare part B payments each year
- Provide care for more than 200 Part B-enrolled Medicare beneficiaries annually
- Bill more than 200 professional services annually
My small practice is going to participate in MIPS. Because we have fewer than 15 PTs, we are allowed to report via claims instead of through a registry or QCDR. What are the business considerations for choosing one method or the other? Can we switch from claims to registry reporting later, or are we stuck with whatever choice we make?
If you report via claims, you can submit your quality data on your claim form. However, you will not get feedback on your performance until after the end of the reporting year, when it will be too late to make changes that could help your MIPS score. Even though you will incur a cost using a registry, it will provide you with feedback throughout the year. The type and frequency of feedback may vary by registry. You can switch data submission methods mid-year. CMS will base your score on your top 6 measures.
Does MIPS apply to hospital-based outpatient practices?
No. For 2019, if you practice in a facility-based setting such as a hospital outpatient department, skilled nursing facility (part B), or rehabilitation facility you are not able to participate in MIPS.
Our physical therapy clinic is part of a multispecialty practice in which the physicians already report as a group. The PTs do not meet the low-volume threshold as individuals. Do we need to report as part of the group?
It may depend on your specific multispecialty practice. You can contact us at firstname.lastname@example.org to address your questions.
We have 6 PTs in our practice, and none of them exceed the low-volume threshold individually. But as a group, we do. Do we have to report?
The group is not required to participate, since MIPS only mandates individual PT participation. However, because the practice as a whole exceeds the threshold, it can choose to participate in MIPS to take advantage of the potential 7% incentive payment.
Our practice exceeds the threshold, but only 1 of our PTs does individually. How does that work?
You have 2 options: The PT participates alone, or the practice can participate as a group. Only the PT who exceeds the threshold is required to participate. However, because the whole practice also exceeds the threshold, it can participate in MIPS. If you choose group participation, all therapists will be considered fully participating in the program.
What are my options for reporting improvement activities? Do you have recommendations?
CMS offers over 100 improvement activities, which can be found on the CMS QPP website. APTA has created a condensed list of activities that may appeal to PTs.
How can we follow our performance scores to tell if we are meeting expectations throughout the year?
This is a great question. If you report via claims, you will not know your score until the end of the reporting year. This is why APTA recommends using a vendor for reporting. It can help you improve your scores throughout the year. If you report using a "qualified registry," check with your vendor to see how frequently you will be able to get feedback. Some may only be quarterly or monthly.
As a qualified clinical data registry (QCDR), APTA's Physical Therapy Outcomes Registry gives you continual real-time feedback.
If you are attending CSM, Heather Smith, PT, MPH, APTA director of quality, and Kara Gainer, JD, director of regulatory affairs, will be presenting "Emerging Issues in Medicare: Quality Programs and Alternative Payment Models" on Friday at 11:00 am, where a CMS representative will be available to address attendees' questions. Heather Smith also will host a Q&A session at 2:00 pm on both Thursday and Friday at the Physical Therapy Outcomes Registry booth #1433 in the Exhibit Hall.
CSM Preview: Genomics and Precision Physical Therapy With Richard K. Shields and Eric D. Green
In his 2017 McMillan Lecture, "Turning Over the Hourglass," Richard K. Shields, PT, PhD, FAPTA, predicted that, as we learn more about the effects of exercise on genetic pathways that influence health, "precision physical therapy will emerge side by side with precision medicine." Genomic analysis, he said, is "laying the groundwork for physical therapists to dose movement in ways that we never considered possible."
Shields and colleague Eric D. Green, MD, PhD, will dive deeper into this topic at the upcoming APTA Combined Sections Meeting in January 2019. In "Personalized Physical Therapy: The Time Is Now," sponsored by APTA's Frontiers in Rehabilitation, Science, and Technology (FiRST) Council, the speakers will explore the implications of genomics for exercise science and performance and how knowledge of a gene's function could alter a patient's medical management and clinical outcomes.
The session will be moderated by FiRST Council co-chair Steven L. Wolf, PT, PhD, FAPTA, and was organized by Catherine Curtis, PT, EdD.
#PTTransforms spoke with Shields (RS) and Curtis (CC) to get some quick takes.
First, what is the FiRST Council?
CC: APTA's Board of Directors established the Frontiers in Rehabilitation Science and Technology (FiRST) Council to help prepare its members for innovative medical technologies and approaches to clinical care, such as sensing technologies and robotics, regenerative medicine, precision medicine, telehealth, and imaging. Any APTA member in good standing can join the FiRST Council. Non-PT or PTA individuals who are in related disciplines, such as bioengineering or genetics, are eligible to be "Council Partners."
What was the genesis for this session?
CC: Completion of the first reference sequence of the human genome in 2003 gave rise to a sea change in the biological and medical sciences. Francis Collins, director of the National Institutes of Health (NIH) and former director of the National Human Genome Research Institute (NHGRI), has said that virtually every human ailment, except some cases of trauma, is considered to have some genetic basis. Medicine is becoming more personalized, with a shift toward early risk identification and diagnosis, and targeted therapy. Physical therapists need to be aware of the effects of genetic variants on health and disease and be prepared to devise individualized lifestyle interventions for both prevention and wellness.
How close are we to understanding how to use a patient's genetic information to tailor their physical therapy treatment?
RS: Physical therapists and their patients already are armed with new knowledge about genomics and how a patient's genetic makeup may influence personal health and health care treatments. Many patients will bring their own genotype to the clinic, whether acquired through a medical center screening program or a private vendor. Research is providing clinicians with increasing information about the effects of genotypes on health conditions. For example, we know that the homozygous ACTN3 577X genotype has been consistently associated with delayed onset muscle soreness and muscle damage after eccentric exercise. Clearly, dosing eccentric exercise may vary based on whether an individual has this known allele.
While we must be careful not to overstate, we must be cognizant of the power of regular, repetitive movement (exercise) on the epigenome—the system that can promote healthy genes and repress damaged genes. Physical therapists must understand the power of their own prescriptions from a fundamental science perspective.
CC: While genetic testing for rare disorders is available, regular testing for common disease variants is not routinely performed in clinical practice. There are issues with screening accuracy and sensitivity, and even if variants are identified, their clinical significance is still unclear. As we learn more, testing for common disease variants will likely become more routine, and genetic information will be increasingly available in clinical settings. These are some of the topics Eric D. Green will cover in his presentation, as well as how the NIH All of Us Research Program seeks to extend precision medicine to all diseases by building a national research cohort of 1 million or more US participants. By taking into account individual differences in lifestyle, environment, and biology, researchers will uncover paths toward delivering precision medicine.
What are some opportunities and challenges regarding application of genomic research in practice?
RS: The key challenge is that public opinion may race ahead of scientific evidence. A great number of studies have found evidence for higher prevalence of certain genotypes in various populations. The public may infer causality where none exists, so physical therapists must be able to accurately interpret genomic information.
Physical therapists will have many opportunities to speak truthfully about the meaning of the genomics movement and continue to advance knowledge about the power of regular movement-based treatments. Accordingly, they should participate in educational programming that helps jump-start their knowledge of genomics and epigenetics.
CC: The Genomic Era is upon us, with advances relevant to health and wellness now emerging. The translation to clinical physical therapist practice is still very new, and the initial challenge for the profession is that all therapists must expand their knowledge in this area beginning with basic concepts and an awareness of the potential impact on the health and wellness of individuals. With this background, the opportunity for more and more research on direct application to practice will emerge.
What other physical therapy–related genomic research is on the horizon?
CC: Physical therapists—including members of the FiRST Council genomics group—are increasingly engaged in genetics-related research relevant to clinical practice. Steve Cramer, MD, and Steve Wolf, PT, PhD, FAPTA, are studying how brain-derived neurotrophic factor (BDNF) Val66Met genotype is associated with greater brain atrophy after stroke. Cameron Mang, PhD, MSc, and Laura Boyd, PT, PhD, are exploring how genetic influences underlying acute aerobic exercise affect motor learning. Allon Goldberg, PT, PhD, is researching how angiotensin I-converting enzyme gene (ACE) polymorphism affects grip-strength correlations with balance and walking speed in older adults. And Laura Case, PT, DPT, and colleagues are examining phenotypic traits of infants with Pompe disease identified by newborn screening.
RS: There are many studies examining the relationship between genetic markers and functional outcomes in people with Parkinson disease, total hip/knee replacement, stroke, spinal cord injury, and diabetes. We are looking at the relationship between muscle exercise and tagging certain genes known to be strong signatures of metabolic health. The outcomes of all of these types of studies will help chart the course for using genetic biomarkers to guide us as we determine who will benefit from our prescribed movement-based interventions.
What should people take away from this session?
RS: Be ready. Get your minds around the fact that genomics is and will continue to be a part of our profession. Start incorporating the needed content into curricula, but don't panic and don't "jump the gun" by promoting false information that sets the health care world back. There is still a long way to go before the evidence is sufficient to drive care. Stay calm and become a par excellence consumer of genomic and epigenetic literature so that you add value to the overall movement of precision health among the health care team.
For more in-depth discussion, listen to this recent podcast interview between PTJ Editor-in-Chief Alan Jette, PT, PhD, MPH, FAPTA, and Richard Shields.
To attend this exciting CSM session, register now at www.apta.org/CSM/. CSM advance registration discounts end December 5.
Easing Administrative Burden: APTA Makes It Easy to Make Your Voice Heard
Everyone hates unnecessary paperwork and red tape—it cuts into your time with patients, adds to a clinician's workload, and often can delay care. The Centers for Medicare & Medicaid Services (CMS) seems to have gotten the message, going so far as to propose a rule on reducing administrative burden. And you have an opportunity to weigh in on the issue: CMS is asking for public comment on regulatory burdens as it considers ways to streamline processes in future rules. Comments are due by November 19.
Carol Zehnacker, PT, DPT, has worked in a multitude of practice settings, including acute care, skilled nursing facilities, home health, and private practice. Zehnacker says, "There has been an explosion of regulations and administrative burdens that hamper our ability to provide quality care, and can lead to provider burnout."
"We all went into this profession with a desire to help others," says Theresa Marko, PT, DPT, MS. "The health care system sometimes inhibits progress due to unnecessary regulations. How do we fix any of this? How can one person make a difference? APTA has a team of people working to improve the system in which we operate. If we can rally together with one collective voice to let the powers that be know how we feel, wouldn't that be great? For this proposed rule, APTA has created an easy-to-use template you can download, edit with personalized comments, and send in to CMS."
Both Zehnacker and Marko are submitting comments using APTA's template, which provides therapists with some specific content areas they can customize by providing their personal stories and highlighting other regulations that are overly burdensome on physical therapists. The content areas in the template letter include the following:
Streamline the Medicare credentialing process.
Institute a permanent moratorium on the direct supervision requirement for outpatient physical therapy services in critical-access hospitals.
Eliminate or modify the outpatient therapy plan of care 30-day initial certification and 90-day recertification requirements.
Eliminate prior authorization for Medicare Advantage patients or require same-day authorizations.
Better ensure accurate beneficiary eligibility data.
In her comments to CMS, Zehnacker, a private practice owner who has a contract with a home health agency, described the "unnecessary requirement" of notifying the physician when the plan of care changes, such as a missed visit or a treatment or service as required by the plan of care. "This is time consuming for both the therapist and the staff at the physician's office. The physician has already ordered physical therapy in the home health setting. In reality, it is the physical therapist who develops the physical therapy plan of care and awaits the physician's sign-off."
You don't have to go to Capitol Hill to make your voice heard. Rather, you can use your voice, through written comments, to educate and influence executive and independent agencies, the bodies that create or publicize regulations by the authority of Congress.
"When regulatory agencies propose to take action on a certain subject that is of interest to you, it's important to take that opportunity to use your voice," says Kara Gainer, APTA's director of regulatory affairs. "It's the individuals who often provide the most compelling comments, offering the agency a different perspective that is both personal and closely connected to the issue at hand."
Although comments submitted by APTA, representing the physical therapy profession, are incredibly influential, "when CMS is making important decisions that will affect our everyday operations in our professions, they will take into consideration all the comments submitted by providers," says Marko. "Personalizing APTA's template and uploading it to the CMS website is easy—I was able to do it in about 15 minutes! As a private practice orthopedic PT I have experienced much unnecessary burden throughout my career. The template is an easy way for all of us to impact the system in which we operate and produce a positive outcome."
Visit APTA's website to download the template and submit your comments. (Scroll down to "CMS Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction.")
Understanding Trauma and Chronic Toxic Stress in Your Pediatric Patients
By Jessica Barreca, PT, DPT
In our profession, the word "trauma" typically leads us to think of a catastrophic injury, emergency medical care, and comprehensive rehabilitation services. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), however, trauma also includes "events or circumstances experienced by an individual as physically or emotionally harmful or life-threatening, which result in adverse effects on the individual's functioning and well-being."
ACEs Are More Prevalent Than You Might Think
The first study to examine trauma's long-term health effects was the CDC-Kaiser Permanente Adverse Childhood Experiences Study, which collected confidential surveys of over 17,000 Kaiser Permanente patients. Respondents were asked about their exposure to adverse childhood experiences (ACEs)— neglect, abuse, and "household dysfunction" such as domestic violence—and their current health status, risk behaviors, and disease. The study found that over 50% of participants had experienced at least 1 ACE and 25% had experienced 2 or more.
In 2013, the Philadelphia Urban ACE study (.pdf) surveyed a more racially diverse sample of adults and expanded survey questions to include topics such as community violence, racism, and neighborhood safety. More than 80% of those surveyed had experienced at least 1 ACE and nearly 40% had experienced 4 or more. Children of all ages and backgrounds experience ACEs, but poverty is a risk factor (.pdf).
To achieve optimal health outcomes for children who have or are experiencing trauma, physical therapists (PTs) and physical therapist assistants (PTAs) should practice SAMHSA's "Four Rs" (.pdf):
- Realize trauma's impact
- Recognize signs and symptoms
- Respond by integrating knowledge of trauma-informed care
- Resist retraumatizing patients
Realizing the Impact of Trauma and Toxic Stress
The brain is most plastic and develops most rapidly during early childhood. The influences of the environment and an infant's relationships with adults can significantly impact neural development. Stress plays a large role in all of our lives and is in fact essential to the development of a healthy stress response system, but the presence of a positive, caring adult is what helps a child avoid toxic stress, defined as "strong, frequent, or prolonged activation of the body's stress response systems in the absence of the buffering protection of a supportive, adult relationship."
According to the National Scientific Council on the Developing Child, our bodies respond to stress in different ways. A positive stress response may occur, for example, on a child's first day of kindergarten: The child's heart rate will increase and there will be a minimal rise in stress hormones. Under more challenging circumstances, such as the death of a caregiver or a natural disaster, a child experiences an elevated stress response system for a temporary period of time. In both of these scenarios, children learn to manage stress and regulate their stress response by receiving support from an adult who creates a nurturing environment and models effective coping strategies.
However, when a child is exposed to prolonged, significant, and/or cumulative trauma ranging from abuse, neglect, witnessing violence in their community, or living in poverty—without ongoing support from a caring adult—a toxic stress response occurs.
Research shows that trauma and toxic stress experienced in childhood negatively impacts the physical, mental, social, and emotional development of children, from developmental delays to learning and behavior problems. In the long term, ACEs are linked to risky health and lifestyle behaviors, chronic diseases, and even premature death.
Even when children experience significant trauma, there is still the capacity to develop resilience.
Recognize Signs and Symptoms of Trauma in a Pediatric Patient
The National Child Traumatic Stress Network provides a comprehensive list of signs and symptoms of trauma for individuals from infancy through early adulthood.
Infants and toddlers often don't have the ability to verbally express the events, experiences, and feelings of trauma. Be aware of sudden changes in a young child's behavior—all behavior is communication. Young children who have experienced trauma may exhibit increased separation anxiety, excessive clinginess, crying and/or whining, increased fear and anxiety, regression in global developmental progress, or failure to achieve developmental milestones.
Elementary school students ages 6–12 who have experienced trauma may exhibit a variety of different behaviors, such as increased anxiety, fear, and distress, as well as withdrawal and avoidance. These kids may also demonstrate decreased ability to focus, overreaction to auditory stimuli (a door slamming shut or fire alarm), a change in academic performance, poor impulse control, and challenges with authority figures or constructive criticism. Increased physical complaints (stomachaches and headaches) may be observed as well.
Respond by Integrating Trauma-Informed Principles Into Your Care
SAMHSA's trauma-informed principles can be incorporated into any type of health care setting or organization, and all patients and families, with or without a lived experience of trauma, can benefit from PTs adopting a trauma-informed approach. By adopting these principles, we shift our own internal dialogue from "What is wrong with you?" to "What happened to you?" and view our patients through a trauma-aware lens.
Often a family will miss multiple therapy appointments and will be labeled as a "no-show." By taking a trauma-informed approach, the PT recognizes the multitude of social, economic, and contextual factors that may contribute to missed therapy appointments. Instead of discharging the patient, the PT incorporates trauma-informed principles and meets with administrators, office staff, other team members, and the family to identify pertinent issues and create a solution that allows the child to regularly attend physical therapy. As a next step, the office administrator invites families, office staff, and the therapy team to review policies regarding the clinic's attendance policy. Through this process, policies are amended in a culturally sensitive and collaborative manner with all involved stakeholders to ultimately promote a more inclusive environment for children and their families.
Resist Retraumatizing Patients Inadvertently
PTs working with children and families can take concrete steps to build a culture of emotional and physical safety in their clinical, school, or hospital settings. When the health care team uses trauma-informed principles in partnership with a family-centered approach, it creates a safe environment with reduced potential for retraumatizing children and families. Often individuals who have experienced maltreatment as children are distrustful of authority figures, including health care professionals. By ensuring that families and children have a voice in their plan of care, we can work toward empowering patients through choice.
Jessica Barreca is a physical therapist with over 17 years of experience working with children in a variety of settings including outpatient, early intervention and school systems. She is the community site coordinator in the Center for Interprofessional Education & Research and adjunct instructor of physical therapy at Saint Louis University. Jessica is an ambassador for Alive and Well STL and is passionate about spreading knowledge and awareness regarding the widespread prevalence and impact of childhood trauma on families and children in our communities.
Interested in learning more about this topic? The 2019 APTA Combined Sections Meeting will be holding several presentations related to trauma, including: Sexual Assault and Communities of Color: PT Roles, Pain Science With Vulnerable Populations: Transforming the Human Experience, and A Trauma-Informed Pathway to Caring for Patients and Providers. Register now at www.apta.org/CSM/.
Jessica Barreca will be presenting Using a Trauma Sensitive Lens to Promote Shared Decision Making in Pediatric Practice at the Academy of Pediatric Physical Therapy Annual Conference in November, 2018.