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  • Study: For Children With Autism, Yoga Improves Motor Skills, May Buffer 'Cascading' Effects

    In this review: Creative Yoga Intervention Improves Motor and Imitation Skills of Children With Autism Spectrum Disorder
    (PTJ, November 2019 )

    The message
    There's mounting evidence that motor impairments are particularly prevalent among children with autism spectrum disorder (ASD), but research on how to address these impairments is scant. Authors of a new study believe they may have hit upon an approach: physical therapist-led "creative yoga," which they say improved both gross motor skills and the ability to imitate movement patterns among children with ASD. Those gains, they believe, could play a role in improving social communication and behavioral abilities.

    The study
    Researchers divided 24 children with ASD, ages 5 to 13, into 2 groups: the first group received an 8-week "academic intervention" that focused on reading, arts, crafts, and other "sedentary activities usually practiced within school settings"; the second group participated in an 8-week yoga intervention, led by a physical therapist (PT), that "was made fun and creative through the use of songs, stories, games, and props." The children were assessed for motor skills using the Bruininks-Oseretsky Test of Motor Performance-2nd Edition (BOT-2) at baseline and after completion of the programs, and tested for imitation skills at 3 points (baseline, midpoint, completion) using a researcher-created instrument. Sessions were conducted 4 times a week for 8 weeks, divided into 2 expert-led sessions lasting 40 to 45 minutes per week and 2 parent-led sessions lasting 20 to 25 minutes per week.

    Participants included in the study had a confirmed ASD diagnosis and showed social communication delays. All scored at average or below on the BOT-2 at baseline, and the groups were matched for baseline mobility scores as well as demographic, IQ, and other characteristics.

    APTA members Maninderjit Kaur, PT, and Anjana Bhat, PT, coauthored the study.


    • After 8 weeks, the yoga group improved subtest scores for gross motor performance and bilateral coordination, whereas the academic group showed no statistically significant improvements in these areas.
    • The academic group improved scores related to fine motor precision and integration, but not so the yoga group, which recorded no statistically relevant changes.
    • Imitation skills improved for both groups, but at different points: the yoga group began showing improvements in imitation skills by the midpoint assessment, while the academic group's improvements didn't register significant change until the last assessment.
    • Among child-specific factors such as age, autism severity, and IQ, the only element that seemed to correlate to improvement in scores was IQ: in the academic group, children with higher IQs tended to achieve larger individual gains in imitation skills, while in the yoga program, children with lower IQs were the cohort that achieved larger individual gains in imitation (specifically, pose imitation).

    Why it matters
    A growing body of evidence suggests that children with ASD also tend to experience motor impairments of balance, postural control, gait, and coordination, as well as worse dexterity skills than do children with typical development (TD). In fact, authors write, researchers have estimated that children with ASD typically display motor development that is consistent with children half their age. Deficits in the ability to imitate demonstrated behaviors or movements are also associated with ASD.

    The concern, according to authors, is the possibility that these impairments could have "cascading effects on the social, communication, and cognitive development of children with ASD."

    "Given the evidence for motor impairments and their broader impact on social communication development," authors write, "there is a clear need to devise interventions that could offer opportunities to improve both motor skills and their use in developing social communication skills in children with ASD."

    More from the study
    Authors were surprised that the yoga group didn't report any improvements in balance, but they speculate that the unchanged BOT-2 scores may be related to the test's reliance on a mix of static and movement-based activities, as opposed to the yoga classes' focus solely on static balance. Additionally, they write, the BOT-2's balance subtest includes assessments with and without visual input, whereas the yoga classes consistently used visual input to help children hold poses.

    As for the academic group's improvements in fine motor skills, the effect sizes were relatively small, but researchers believe that may be due to the fact that most of the children were already engaged in similar activities in their school settings, creating a "smaller scope for improvement."

    Keep in mind…
    The study population was small and heterogenous, and the training duration was relatively short. Additionally, researchers weren't able to assess the long-term effects of the classes.

    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.  

    Does Everyone Have a Unique Muscle Activation 'Fingerprint?' Researchers Say Yes

    In this review: Individuals have unique muscle activation signatures as revealed during gait and pedaling
    (Journal of Applied Physiology, October 2019 )

    The message
    It's no secret that people move differently, but researchers who carefully tracked muscle movements of study participants during exercise think the differences may go even deeper than variation in movement styles. Their conclusion: humans possess muscle activation "signatures" that are as unique to each individual as fingerprints or iris structure. Not only could these patterns be used to identify an individual, they write, but finding a person's activation strategies could help to identify the potential for future musculoskeletal problems, and better tailor treatments to individual patient needs.

    The study
    Researchers analyzed movement patterns of 53 individuals using surface electromyography (EMG) on their legs as they pedaled on a stationary bicycle and walked on a treadmill. Using a machine learning protocol, authors of the study tracked activation patterns from 8 muscles of the right leg: the vastus lateralis (VL), rectus femoris (RF), vastus medialis (VM), gastrocnemius lateralis (GL), gastrocnemius medialis (GM), soleus (SOL), tibialis anterior (TA), and biceps femoris-long head (BF). They used the data to establish unique muscle activation signatures recorded during an initial session. Participants then returned for a second round of the same activities between 1 and 41 days after the first (average, 13 days), allowing researchers to evaluate the similarities between activation patterns observed at each session.

    Participants were in good health. Most were male (77%), with an average age of 23.1 years and average BMI of 23.2 for males and 21 for females.


    • Researchers found "substantial" variability in activation patterns among individuals, especially in the RF, GL, BF, and SOL muscles, with the same types of variability recorded on both days of activity.
    • The machine learning system was able to identify individual muscle activation patterns during the first session with a high degree of accuracy, particularly when more of the tracked muscles were factored into the mix. The classification rate was just over 99% for pedaling and 98.86% for treadmill gait.
    • Recognition rates were nearly as accurate when focused on the second session, where accuracy was 89.80% for 7 muscles in pedaling, and 86.20% for 7 muscles during walking. Authors of the study think the differences between the first and second sessions are due to variations in placement of the EMG sensors, but they believe that given the highly similar results, the differences in placement only strengthen their conclusions.
    • The RF, GM, GL and SOL muscles provided the best recognition data for pedaling, while the TA and BF muscles were tied strongly to better recognition data related to gait.

    Why it matters
    Earlier studies have established that movement patterns such as gait can be consistently linked with individuals—a kind of signature—but those studies stopped short of an examination of identifying the muscle activation strategies that may (or may not) influence the movement pattern. Authors of the EMG study believe theirs is the first to look into activation itself as a biomarker.

    Although they call for further study, authors believe that individual muscle activation signatures may have "specific mechanical effects on the musculoskeletal system" and could help identify individuals who are at greater risk of musculoskeletal disorders. For example, they write, the activation patterns of the GM, GL, and SOL muscles tended to vary significantly between individuals; because these muscles are attached to the Achilles tendon in different fascicle bundles, "different activation strategies might induce unique load patterns of load distribution within the Achilles tendon, with some strategies being more likely to lead to tendon problems."

    More from the study
    Authors didn't land on a single explanation for why muscle activation patterns might be individualized, but they write that both "optimal feedback control" and "good enough" theories of motor control could be at play in activation signatures.

    Activation patterns may be consistent with the optimal feedback control theory in that "it is possible that each individual optimizes their movement with the muscle activation strategies that are best, given that individual's mechanical and/or neural restraints," they write. On the other hand, they add, it's also possible that the signatures develop according to the "good-enough" concept, "through motor exploration, experience, and training, leading to habitual rather than optimal strategies." It's a debate that likely won't be settled without "retrospective studies on large cohorts or longitudinal studies performed at different lifespans," authors note.

    Keep in mind…
    The study population was small, and homogenous. While the homogeneity was intentional to tease out the accuracy of the machine learning process, the approach limited researchers' ability to identify potential motor control theories at play, and whether at least some of the activation strategies are innate.

    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.

    APTA Cosponsored Study: Direct Access to Physical Therapy for LBP Saves Money, Lowers Utilization Better When It’s Unrestricted

    In this review: Unrestricted Direct Access to Physical Therapist Services Is Associated With Lower Health Care Utilization and Costs in Patients With New-Onset Low Back Pain
    (e-published ahead of print in PTJ, November 2019 )

    The message
    Does unrestricted direct access to a physical therapist (PT) make a difference compared with "provisional" direct access systems that include restrictions such as visit limits and referral requirements for specific interventions? A new analysis of insurance claims records from nearly 60,000 adults across the US says yes.

    The study, cosponsored by APTA, reveals that for patients with new-onset low back pain (LBP), seeing a PT first in states with unrestricted direct access resulted in lower health care costs and use compared with patients seeking care in provisional access states. And the differences don't end there: researchers found that patients in provisional access states who saw a PT first tended to incur higher costs than those who saw a primary care provider (PCP) first, while data from unrestricted direct access states showed relatively equal, if not slightly lower, costs for seeing a PT first compared with PCPs.

    The study
    Researchers reviewed private and Medicare Advantage insurance claims from 59,670 adults with new-onset LBP between 2008 and 2013 to explore health care cost and utilization from 2 perspectives: first, in terms of differences between patients who saw a PT first for LBP in states with unrestricted direct access versus those who sought PT care in states with provisional direct access provisions; and, second, in terms of differences between patients who saw a PT first versus those whose first meeting was with a PCP.

    The deidentified data was provided by OptumLabs®, which worked collaboratively with APTA and UnitedHealthcare to produce this and 2 other research articles related to access to PTs first for LBP. Authors of this study included APTA member Christine McDonough, PT, PhD.


    • Of the patients who met inclusion criteria for new-onset LBP (no previous LBP diagnosis, no previous back procedures for at least 12 months before the index event, no patients diagnosed with neoplasm 12 months prior and 3 months after the first visit, and insurance enrollment for at least 12 months before and after the index date), nearly 98% initially met with a PCP. Overall, more women than men sought care for LBP, with around 21% of all patients reporting prior physical therapy use. Among patients who sought treatment from a PCP, experience with physical therapy was much lower—about 2.1%.
    • Among patients who saw a PT first, those in provisional-access states recorded 31% more physician visits and had 58% higher odds of having imaging in the first 30 days of the index visit, compared with patients from unrestricted states.
    • Average 30-day costs were lowest for patients in unrestricted states who saw a PT first for LBP, at $511. The next-to-lowest costs were associated with patients who saw a PCP first in unrestricted-access states ($556), followed by patients in provisional-access states whose first visit was with a PCP ($632). The highest costs were for patients in provisional-access states whose index visit was with a PT, at $726. After 90 days, the rankings shifted, but only slightly: seeing a PT first in a provisional-access state was associated with the highest costs ($1,269), followed by index visits with a PCP in provisional-access states ($1,046), PT-first visits in unrestricted states ($1,032), and PCP-first visits in unrestricted states ($948).
    • Patients in provisional-access states who saw a PT first averaged LBP-related costs that were 19% higher than PCP-first patients at 30 days. It was a different story in unrestricted-access states, where patients who visited a PT first averaged costs that were 4% lower than PCP-first patient costs, a difference that authors call "insignificant."

    Why it matters
    This large-scale retrospective study—authors believe it's the first to analyze how state limits on PT access affect utilization and costs—adds to the evidence that direct access to a PT for LBP (and seeing a PT first) achieves effective results. The cost differences alone are potentially significant, given the estimate that as many as 70% of people will experience LBP in their lifetimes, making it "the third most costly medical condition in the United States," according to authors.

    More from the study
    Authors were particularly interested in the findings that patients in provisional-access states who saw a PT first tended to incur higher cost and utilization than those whose index visit was with a PCP. Authors believe the explanation for the difference may have something to do with the way the restrictions tend to increase the need to visit physicians following the initial PT visit to comply with requirements around, for example, imaging or specific procedures.

    Similarly, authors theorize that the cost ratio—in other words, the magnitude of the differences—may also be due to the pressures provisional-access systems bring to bear on LBP treatment.

    "Given that patients in provisional-access states often are required to see a PCP after a certain number of physical therapist visits or required a PCP shortly after the initial physical therapist visit, these additional visits likely increase the cost of care in provisional-access states," authors write. "Since physician gatekeeping does not occur in unrestricted-access states, which would increase the cost of care, we would postulate that this restriction accounts for the differences in 30-day costs between provisional-access states and unrestricted-access states."

    APTA's role
    APTA has been working with UHC and OptumLabs to investigate both the efficacy of physical therapy as a first treatment option for LBP as well as the effects insurer payment policies have on patient access to more conservative approaches to the condition. Those efforts yielded 3 research articles: a study affirming that higher copays and payer restrictions steer patients away from conservative LBP treatments; an analysis that found lower odds of early and long-term opioid use among patients who see a PT first for LBP; and the investigation included in this review. APTA cosponsored all 3 studies

    Keep in mind…
    Because the study was based on claims data only, researchers couldn't account for the severity of the LBP being experienced by patients and were limited to evaluation of only "certain variables." Additionally, data from patients in states that changed their access regulations between 2008 and 2016 were excluded, reducing sample size.

    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.

    [Editor's note: McDonough is the recipient of a 2015 Foundation for Physical Therapy Research Magistro Family Foundation Research Grant and of the 2009 New Investigator Fellowship Training Initiative in Health Services Research.]

    Study: Despite Guidelines for OA, Rates of Physician Referral to Physical Therapy Remained Low, Orthopedic Surgeon Narcotic Prescriptions Increased between 2007 and 2015

    In this review: Recommendation Rates for Physical Therapy, Lifestyle Counseling, and Pain Medications for Managing Knee Osteoarthritis in Ambulatory Care Settings
    (e-published ahead of print in Arthritis Care & Research, October 2019)

    The message
    Despite longstanding guidelines that recommend physical therapy and lifestyle changes over pharmacological approaches as a first line of treatment for knee osteoarthritis (OA), orthopedic surgeons and primary care physicians (PCPs) don't seem to be getting the message, according to researchers. If anything, they say, the situation deteriorated between 2007 and 2015, with orthopedic surgeons moving in the opposite direction from the guidelines, and PCPs making no significant changes apart from increasing a tendency to prescribe nonsteroidal antiinflammatory drugs (NSAIDs).

    The study
    Researchers reviewed data from National Ambulatory Medicare Care Surveys (NAMCS) administered between 2007 and 2015. The surveys, conducted by a branch of the US Centers for Disease Control and Prevention, focus on non-federally employed office-based physicians in direct patient care, and involve collection of data over a 1-week period, as well as practice visits and physician interviews.

    For the study, researchers focused on visits associated with a knee OA diagnosis, tracking whether the physician prescribed physical therapy, provided advice on exercise and/or weight reduction, or provided pain medications during the visit. The prescribed pain medications were categorized as NSAIDs, "narcotic analgesics," or "other." Researchers also tracked patient demographic data, as well as physician specialty, practice location, type, and ownership, among other characteristics.

    Researchers crunched the numbers to establish triennial rates of various recommendations during the 9-year study period. The results were based on 2,297 knee OA-related visits, which they approximated to about 8 million visits per year between 2007 and 2015. APTA members Samannaaz Khoja, PT, PhD; Gustavo Almeida, PT, PhD; and Janet Freburger, PT, PhD, coauthored the study.


    • Authors found a "significant decline" in rates of physical therapy referral by orthopedic specialists, from 158 per 1,000 visits in 2007-2009 to 86 per 1,000 in 2013-2015. Lifestyle counseling also dropped, from 184 per 1,000 to 88. During the same 9-year period NSAID prescriptions increased from 132 per 1,000 visits 2007-2009 to 278 per 1,000 in 2013-2015. Even more concerning, prescription rates for narcotics tripled during the study period, from 77 per 1,000 visits in 2007-2009 to 236 per 1,000 by 2015.
    • Among PCPs, low initial rates of referral to physical therapy increased but remained low throughout the study period, moving from 26 per 1,000 visits to 46 per 1,000 visits. Recommendations for lifestyle changes remained about the same during the study period, ranging from 243/1,000 to 221. Researchers noted a slight uptick in prescriptions for narcotics (233 per 1,000 to 316 per 1,000), and a notable increase in NSAID prescriptions, from 221 per 1,000 visits in the 2007-2009 study period to 498 per 1,000 visits during 2013-2015.
    • Patients who visited an orthopedic specialist were more likely to be prescribed narcotics and NSAIDs if they were Hispanic, and more likely to receive a physical therapy referral if they were non-white and non-black. A decreased likelihood of receiving a physical therapy referral or lifestyle counseling was associated with orthopedic surgeons in rural areas.
    • In terms of referrals and prescriptions, patient demographics were not as much of a factor among patients who visited a PCP for knee OA, although there was a slightly higher likelihood of receiving narcotics among females and individuals who were black. Visits that included imaging were more likely to include narcotics prescriptions; visits covered by workers compensation were less likely to result in a prescription for NSAIDs.
    • Narcotic prescriptions were more likely among advanced practice orthopedic surgeons. That wasn't the case for PCPs.
    • The study sample was mostly white, female, and non-Hispanic, with an average age of 64. A chronic problem was the most common reason for the visit.

    Why it matters
    Knee OA is widely experienced, and its prevalence is on the rise, growing from an estimated 9 million individuals with the condition in 2005 to 15 million in 2012. Guidelines stressing the effectiveness of physical therapy and lifestyle modifications have been around since as far back as 1995, authors write, and the evidence supporting those recommendations has only increased. At the same time, the nation faces an opioid crisis at least partly linked to the use of prescription medications.

    Authors believe their study suggests a "counterintuitive" picture—"adherence to guideline-based care for non-pharmacological, non-surgical treatments such as [physical therapy], exercise, or weight loss is low for knee OA and does not seem to be improving over time." They write that "this contrasting trend suggests that knee OA is primarily managed from a perspective of symptom control and not from the perspective of improving physical function, fitness, and overall well-being."

    Related APTA resources
    The study's results are consistent with the policy recommendations in a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches. In addition, APTA offers a wide range of consumer-focused resources on pain and pain management at its ChoosePT.com website.

    APTA offers multiple resources to help physical therapists and physical therapist assistants develop community-based arthritis programs, including a reference guide to various programs, a consumer-focused webpage that helps patients and clients understand the importance of movement to address OA, and links to offerings from the US Bone and Joint Initiative, such as its "Experts in Arthritis" program. Further information is available at PTNow, including tests and clinical guidelines.

    Keep in mind…
    Authors write that because the study was based on visits and not the patient, the analysis may have missed referrals to physical therapy or counseling on lifestyle that was not a part of the NACMS data collection effort. The study was also limited by drug groupings that did not distinguish between types of opioids, and a lack of indicators for disease severity and degree of disability.

    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, CoHSTAR Offer Fellowship and Scholarship Opportunities

    Research-minded postdoctoral physical therapists (PTs) and PTs currently enrolled in a doctoral studies program, take note: multiple opportunities for fellowships and scholarships are now available. Here's a quick take on recent calls for applications.

    The Foundation for Physical Therapy Research (Foundation) is now accepting applications for 2 major funding programs.
    Eligibility and application information for the postprofessional 2020 Promotion of Doctoral Studies (PODS) Scholarship and the New Investigator Fellowship Training Initiative (NIFTI) (a $100,000 award over a 2-year period) is posted on the Foundation website. The deadline to apply is January 8, 2020.

    Applicants are encouraged to start the submission process early to allow for potential questions to be answered. Award recipients will be notified in June.

    Contact lizjackson@foundation4pt.org for more information, or call 800/875-1378, ext 1378.

    Important tip: Thoroughly read through all instructions and funding mechanism deadlines before beginning your application. Want to stay on top of what's available? Sign up for the Foundation newsletter and be first to know about Foundation funding opportunities.

    The Centers on Health Services, Training, and Research (CoHSTAR) is accepting fellowship applications for 4 opportunities.
    All fellowships have a February 15, 2020, application deadline. The positions are:

    • Full-time postdoctoral fellowships: Trainees may focus their activities on a unique research focus area or craft an individual experience that involves activities at 2 or 3 collaborating sites.
    • Part-time faculty fellowship: Faculty fellows will retain their faculty appointments at their home institutions while using CoHSTAR support to maximize their protected time for research activities.
    • Part-time faculty fellowship at Brooks Rehabilitation: The selected faculty fellow will retain current faculty appointments while using CoHSTAR support to maximize protected time to engage in research activities as a Brooks visiting scientist. The fellow will be paired with a CoHSTAR faculty mentor and a Brooks Rehabilitation mentoring team.
    • Postdoctoral fellowship at Johns Hopkins: This part-time fellowship provides an opportunity to work with data, administrators, researchers, and clinicians at Johns Hopkins. The focus will be on measurement of function of patients and promotion of hospital inpatients’ activity and mobility. Investigating the relationship between activity and mobility and key outcomes such as falls, discharge disposition, and other hospital associated harms is also a key part of this work.

    CoHSTAR was established with a grant of $2.5 million from the Foundation for Physical Therapy Research. Funding for this initiative was made possible with a $1 million lead gift from APTA, gifts from 50 APTA components, and donations from physical therapists, foundations, and corporations with a shared passion for the field of physical therapy.

    JAMA: Easing Administrative Complexity, Eliminating Low-Value Care Among Ways to Reduce Health Care Waste and Lower Expenditures

    In this review: Waste in the US Health Care System: Estimated Costs and Potential for Savings
    (JAMA, October 7, 2019)

    The message
    A review of published research and government reports found that the estimated annual cost of health care waste ranged from a total of $760 billion to $935 billion in the areas of failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. Interventions that reduce waste could significantly "reduce the continued increases in US health care expenditures," authors write.

    The study
    Researchers analyzed data from peer-reviewed articles and government reports published between 2012 and 2019 that focused on US cost of health care waste or savings from interventions to address waste. The study categorized waste by the following domains identified by the Institute of Medicine: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity.

    Authors were interested in a number of causes of waste, including clinician-related inefficiencies, lack of adoption of preventive care practices, unnecessary admissions or avoidable complications and readmissions, low-value interventions and tests, payer-based health services pricing, and administrative burden.

    Studies of savings from interventions addressing waste included initiatives targeting the reduction of adverse hospital events and hospital-acquired infections, bundled payment models to reduce unnecessary variability in care, care coordination within accountable care organizations (ACOs), prior authorization, payer-focused interventions, and strategies to reduce fraud and abuse.


    • The cost of waste from failure of care delivery ranged from $102.4 billion to $165.7 billion. Authors estimate that interventions to address this category could save from $44.4 billion to $93.3 billion annually.
    • Waste from failure of care coordination costs from $27.2 billion to $78.2 billion each year. Implementing initiatives in this area could save anywhere from $29.6 billion to $38.2 billion.
    • Overtreatment or low-value care costs between $75.7 billion and $101.2 billion annually. Researchers project that successful initiatives to minimize such care could result in savings ranging from $12.8 billion to $28.6 billion.
    • Overpriced medication and other health services cost an estimated $230.7 billion to $240.5 billion each year. Interventions such as pricing transparency initiatives could save between $81.4 billion and $91.2 billion.
    • Medicare fraud and abuse cost from $58.5 billion to $83.9 billion. Legislative, administrative, and integrity strategies could result in annual saving of $22.8 billion to $30.8 billion.
    • Annual cost of waste due to administrative complexity was $265.6 billion—the largest contributor of all 6 categories. However, no studies addressed savings from interventions in this area.

    Why it matters
    The United States spends more money each year than any other country on health care costs—projected to be more than $3.8 trillion for 2019, approximately 18% of the nation’s gross domestic product. According to authors, addressing unnecessary waste could reduce total health care expenditures by 25%.

    Value-based arrangements, "payer-health system collaboration to improve care coordination and transitions in care," and "greater alignment between payers and clinicians" could greatly reduce waste, as well as low-value care, authors write.

    More from the study
    "Fragmentation in the health care system is one of the causes of costs from administrative complexity, the largest contributor to waste," authors write. They believe that as value-based care models continue to be more widely adopted, there will be "increasing interdependency" among all 6 categories of waste. They estimate that interventions to address waste in care delivery, failure of care coordination, and overtreatment or low-value care categories alone could reduce cost of waste by as much as half.

    Related APTA resources
    APTA's Integrity in Practice website offers resources and information on reducing fraud, waste, and abuse. The association continues to advocate for reducing administrative burden, and members can encourage their House representatives to address the burden of prior approval by supporting H.R. 3107, the "Improving Seniors' Access to Care Act," through the Legislative Action Center or the APTA Action app.

    Keep in mind…
    Authors note several limitations in the existing studies reviewed for this study. Much of the research comes from data on Medicare enrollees, which may not be generalizable to the entire Medicare population or private insurance. Thus, the resulting costs estimated are conservative. Similarly, some studies included multiple sites, rather than nationwide data, limiting the generalizability of the results. In addition, more realistic estimates of cost savings from interventions to address waste would be possible if studies included data on costs of implementing the interventions. Estimates do not include pediatric health care spending, because research in this area is limited.

    APTA Co-Sponsored Study: Seeing a PT First for LBP Lowers Odds of Early and Long-Term Opioid Use

    In this review: Observational retrospective study of the association of initial health care provider for new-onset low back pain with early and long-term opioid use
    (BMJ Open, September, 2019)

    The message
    An analysis of more than 200,000 commercial and Medicare Advantage insurance beneficiaries has revealed what researchers describe as a "significant" pattern: among patients seeking treatment for low back pain (LBP), those whose initial visit was with a physical therapist (PT), chiropractor, or acupuncturist decreased their odds of early opioid use by between 85% and 91%, and lowered their odds of long-term opioid use by 73% to 78% compared with those whose index visit was with a primary care physician (PCP).

    The study
    Researchers reviewed insurance claims from 216,504 adults with new-onset LBP between 2008 and 2013 to explore the relationship between the type of provider seen at the initial (index) visit and subsequent opioid use. The study looked at opioid use in terms of both "early" use, defined as a filled opioid prescription within 30 days of the index visit, and "long-term" use—a filled opioid prescription within 60 days of the index visit and either an opioid supply of 120 days or more over 12 months or a supply of 90 days and 10 or more opioid prescriptions over 12 months. The analysis included claims for patient visits, inpatient and outpatient treatment with initial providers, and pharmacy services.

    Authors of the study were also interested in gauging the impact of varying levels of direct access to PT visits as allowed in state laws, and evaluated rates of initial physical therapy use in states with access laws they defined as "limited," "provisional," and "unrestricted."

    The de-identified data, provided by OptumLabs®, included both commercial insurance and Medicare Advantage claims, and are described by authors as "representing a diverse mix of ages, ethnicities, and geographical regions across the USA." The study itself was sponsored by the American Physical Therapy Association (APTA) and UnitedHealthcare®, and included APTA members Christine McDonough, PT, PhD, and Julie Fritz, PT, PhD, FAPTA, among the authors.


    • Of the patients who met inclusion criteria for new-onset LBP (no previous LBP diagnosis, no previous back procedures for at least 12 months before the index event, and insurance enrollment for at least 12 months before and after the index date), 53% initially met with a PCP. Among what authors call "conservative providers"—PTs, chiropractors, and acupuncturists—chiropractors were the most frequently seen, drawing 23.1% of patients, followed by PTs (1.6%), and acupuncturists (0.8%).
    • About 18% of patients filled an opioid prescription within 3 days of the index visit, and 22% received a fill within the first 30 days. Only 1.2% of patients met the researchers' criteria for long-term use.
    • In terms of early opioid use, patients who saw a PT first had 85% decreased odds of receiving an opioid fill within the first 30 days after the index visit compared with patients who saw a PCP first. Patients whose index visit was with an acupuncturist were associated with 91% decreased odds compared with PCPs, and those who saw a chiropractor first were correlated with 90% decreased odds.
    • The decreased odds of opioid use with conservative treatment also carried over to long-term use, with 73% decreased odds associated with a PT index visit, 74% decreased odds for acupuncturists, and 78% decreased odds for chiropractors compared with patients whose index visit was with a PCP.
    • Compared with states in which direct access to PTs is limited, patients in states with provisional access to PTs—for example, states that impose time or visit limits—had 21% increased odds of seeing a PT at index. Those odds increased to 67% in states with unrestricted direct access.
    • Compared with patients whose index visit was with a PCP, patients who saw other types of physicians, such as orthopedic surgeons and neurosurgeons, tended to have lower odds of early opioid use—but those lower odds disappeared when it came to long-term use.

    Why it matters
    This large-scale retrospective study—authors believe it's one of a very few to look at opioid use patterns across multiple providers—adds to the evidence that conservative approaches to LBP can significantly lower the odds of opioid use, an important consideration as the country continues to struggle with its opioid crisis.

    The bottom line, according to authors is that "early engagement of conservative therapists may decrease initial opioid prescriptions in association with MD visits by providing the opportunity to incorporate evidence-based nonpharmacological approaches."

    More from the study
    Authors believe several factors might be at work when it comes to lower opioid use among patients whose index visit was with a conservative care provider:

    • These providers can't prescribe opioids, which may lower short-term use rates.
    • Patients who seek out conservative care providers may be doing so because they don't want to take opioids.
    • Conservative therapies tend to decrease LBP, lowering the need to seek other treatment.

    Related APTA resources
    The study's results are consistent with the policy recommendations in a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches. In addition, APTA offers a wide range of consumer-focused resources on pain and pain management at its ChoosePT.com website.

    Keep in mind…
    Because the study was based on claims data only, researchers couldn't account for the severity of the LBP being experienced by patients, a factor that could influence the decision about which type of provider to see first. Researchers were also unable to dive more deeply into patient preferences and behavioral factors that might influence index visits and opioid use.

    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.

    [Editor's note: McDonough and Fritz are also the recipients of grants from the Foundation for Physical Therapy Research: McDonough received a Magistro Family Foundation Research Grant in 2015 as well as a New Investigator Fellowship Training Initiative in Health Services Research grant in 2009; Fritz was awarded an Orthopaedic Research Grant in 2002.]

    PTs in Pain: Study Finds Relationships Between PTs Who Experience MSK Pain and Hours Worked, Patient Volume, and Years of Experience

    In this review: Professional experience, work setting, work posture, and workload influence the risk for musculoskeletal pain among physical therapists: a cross-sectional study
    (International Archives of Occupational and Environmental Health, August, 2019)

    The message
    A survey of physical therapists (PTs) in Spain revealed that about half of all respondents had experienced moderate-to-high levels of low back pain in the last 30 days, and nearly 3 in 5 had experienced neck pain in the same time frame. Researchers analyzed those and other areas of pain in relation to work conditions and demographic variables, and found several elements that they believe increase—and sometimes decrease—the odds of experiencing musculoskeletal pain (MP). Among the connections: larger patient loads, more hours worked per week, and more frequent use of machines and manual therapy raised the odds of some types of MSK pain, while more years of experience in the field tended to have the opposite effect.

    The study
    Members of Spain's physical therapy professional association were invited to participate in an online survey that asked them about any MP they may have experienced in the past 30 days, including the pain site as well as the severity of the pain on a 0-10 scale. For purposes of the study, researchers focused on pain episodes with ratings of 3 and above, and limited pain sites to neck, shoulders, upper back, low back, elbow/forearm, and hand/wrist.

    The pain episodes were then compared with self-reported work-related factors including years of experience, work in the public vs private sector, hours worked per week, number of patients per week, prevalence of treating multiple patients at a time, primary patient type, and primary type of treatment used. A total of 981 questionnaires were analyzed. The study population had an average age of 34.3 years, with females making up 70.6% of respondents.


    • Overall, 57% of respondents reported experiencing moderate-to-significant neck pain within the past 30 days, and 49.4% reported low back pain (LBP). Upper back pain was the third most reported site at 36.1%, followed by shoulders (33.8%), hand/wrist (32.7%), and elbow/forearm (16.7%)
    • Higher odds of experiencing LBP were associated with treating more than 1 patient at the same time (2.14 times as likely than treating individual patients), working more than 45 hours per week (1.73 times as likely compared with working fewer than 35 hours per week), and working in a seated position (2.04 times as likely compared with standing work).
    • PTs who reported using exercise interventions as their primary type of treatment tended to have lower rates of neck pain compared with PTs whose primary approach was manual therapy. PTs who primarily used machines "consistently reported higher rates of upper back pain," compared with the use of manual or exercise therapy, according to the study's authors.
    • In addition to its correlation to LBP, working more than 45 hours per week was also associated with higher prevalence of upper back pain compared with PTs who worked fewer than 35 hours per week.
    • Patient load was found to have a weak-to-moderate effect on increased rates of shoulder pain, with PTs who treated 30 or more patients per week reporting a higher prevalence than those who treated fewer than 30 patients per week.
    • PTs with 6 to 15 years of experience were found to have lower odds of experiencing shoulder, low back, and elbow/forearm pain compared with PTs reporting 5 or fewer years of experience. PTs with more than 15 years' experience were found to have lower odds of experiencing pain in those same areas, as well as lower odds of neck pain, compared with the 0-5 year group.

    Why it matters
    While MP is common among health care providers, PTs tend to be at higher risk, with a recent systematic review predicting that as many as 91% of PTs will experience MP in their lifetimes. Authors of this study hope that their findings could help in the development of clinical guidelines and interventions "to prevent work-related MP and better working conditions among PTs."

    More from the study
    Authors were particularly interested in the reasons why more experienced PTs reported a lower prevalence of MP. They suggested 4 possible explanations:

    • Better patient management skills and "the dearth of practice about how to reduce the risk of MP"
    • Better injury prevention strategies among more experienced PTs such as "modification of treatment techniques or increasing the use of support staff"
    • Attrition as PTs who experience MP early in their careers leave those careers sooner (the "healthy workforce effect")
    • The possibility that "more experienced PTs developed a higher pain threshold due to higher work volume"

    Related APTA resources
    APTA's Safe Patient Handling webpage offers resources for avoiding injury, including links to online courses, US Food and Drug Administration guidelines on proper use of patient lifts, and a bibliography of journal articles from multiple disciplines.

    Keep in mind...
    The study, based on survey results, looked at exposure and outcomes simultaneously, which can influence the ways associations are established. Additionally, researchers didn't know how many PTs received the initial survey, so they couldn't determine a response rate—data that could also color the findings.

    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.

    Posture and Movement Coordination, Sensorimotor Integration May Affect Motor Skills in Children With Autism

    In this review: Postural Control and Interceptive Skills in Children With Autism Spectrum Disorder
    (PTJ, August 2019)

    The message

    In children with autism spectrum disorder (ASD), problems with sensorimotor integration and difficulty in coordinating posture and arm motions may result in impaired motor planning and control. These children also exhibited fewer anticipatory postural adjustments and demonstrated more corrective control during arm movements. Compared with typically developing peers, children with ASD were less likely to use visual cues to plan for motions required to catch an item, such as a ball.

    The study

    To examine the interplay of sensory cues, postural demands, and arm movement during ball-catching, researchers in Taiwan asked children with and without ASD to catch a ball rolling down a ramp toward them. Of the children, 15 had ASD and 15 were typically developing age- and sex-matched peers.

    During the task, each child was asked to catch a foam ball rolling down 3 stationary tubular ramps inclined at 4 degrees. The first ramp was placed directly in front of the child, while 2 others each were placed 35 degrees to the left and right. The first 59-centimeter section of each ramp was enclosed so that the child could not see the ball. A sensor within the tube activated a beep as the ball passed through, and, to test catching with and without visual cues, a second sensor lit up an arrow sign during half of the catching attempts.

    A real-time motion-capture system measured the children's arm movements while catching the ball. The authors measured center of pressure (COP) displacements using a computerized pressure plate and recorded ball-catching on video, both synchronized with the motion capture system.


    • Children who were typically developing had a significantly higher success rate for all 3 ramps than did their peers with ASD.
    • Children with ASD were more successful in catching on the left side and right side ramps than they were in catching on the center ramp.
    • Visual pre-cues had no effect on rates of ball catching. However, children with ASD used visual information to plan their arm movements significantly less often than did their typically developing peers.
    • Overall, children adjusted their posture before moving their arms in nearly half of catching attempts. While children with ASD had a lower rate of postural adjustment for lateral ramps compared with their peers, all of the children were more likely to adjust their posture for lateral directions than they were for the middle ramp. Children with ASD made anticipatory postural adjustments later than did children who were typically developing, and all children adjusted their posture earlier when presented with visual pre-cues.
    • Amplitude of shoulder excursion was greater in children with ASD, and was higher overall when visual pre-cues occurred. In contrast, elbow displacements were larger when no visual pre-cues were present. Visual pre-cues were associated with slower arm movements for lateral catches. In general, children with ASD moved their arms faster than did their peers.
    • During lateral catches, both groups demonstrated larger COP displacements and greater COP velocity, but visual pre-cues resulted in slower COP velocity.
    • Children with ASD demonstrated more corrective control during arm movements than did their typically developing peers.

    Why it matters

    Physical therapist interventions for children with ASD, the researchers write, "could focus on the integration between perception and motor components as well as motor adaptability of the motor skills."

    Related APTA resources

    The association offers a Cochrane systematic review and several clinical practice guidelines through the PTNow resource area. Individuals who want to learn more about physical therapist treatment for autism spectrum disorder can visit APTA's consumer-friendly guide at MoveForwardPT.com, the American Physical Therapy Association's consumer website.

    Keep in mind…

    The study excluded children with intellectual disability and attention deficit and hyperactivity disorders, which might reduce generalizability to the entire ASD population. Also, the small sample size limited the authors' ability to analyze the effect of any comorbidities.

    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, where's you'll also find a clinical summary on Autism Spectrum Disorder in Children.

    New Clinical Guidelines Find Strong Evidence Supporting Exercise Therapy for Knee Pain

    In this review: Patellofemoral Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association
    (The Journal of Orthopaedic and Sports Physical Therapy, September 2019)

    The message    
    It's all about movement: In its first-ever comprehensive clinical practice guideline (CPG) on patellofemoral pain (PFP), APTA's Academy of Orthopaedic Physical Therapy (Academy) lays out a set of recommendations that stress exercise therapy as the best approach to improve functional performance in the short, medium, and long term. But that's just 1 facet of the guidelines, which also include recommendations on diagnosis, classification, and examination.

    The study
    A panel of content experts from the Academy conducted an extensive review of scientific articles associated with PFP from 1960 to 2018, evaluating each for its evidence related to physical therapist (PT) clinical decision-making around the condition. From an initial field of 4,691 articles, reviewers winnowed the studies down to 271 that addressed diagnosis and classification (120), examination (56), and interventions (95). The panel then analyzed the overall strength of evidence, and shared a draft of its recommendations with members of the Academy and, later, with a panel of consumer representatives and other stakeholders that included claims reviewers, coding experts, researchers, and academic and clinical educators.

    Recommendations were assigned letters according to the strength of the evidence evaluated: A-"strong," B-"moderate," C-"weak," D-"conflicting," E-"theroretical/foundational," and F-"expert opinion."  

    Among the Recommendations
    Recommendations within the following CPG categories include:

    • Interventions. CPG authors found strong evidence supporting exercise therapy with combined hip- and knee-targeted exercises to reduce pain and improve outcomes, stressing that a combination of hip and knee exercises is better than a focus on knee exercises alone.
      The guidelines also find strong evidence that dry needling shouldn't be used for PFP, and moderate evidence that clinicians should stay away from the use of "biophysical agents" including ultrasound, cryotherapy, electrical stimulation, and laser treatments.
      Taping was supported by moderate-level evidence. The guidelines state that clinicians should combine physical therapist interventions such as foot orthoses, taping, mobilizations, and stretching when appropriate, but that "exercise therapy is the critical component and should be the focus in any combined intervention approach."
    • Diagnosis. Use of diagnostic tests that reproduce retropatellar or peripatellar pain during squatting received an A-level recommendation as a diagnostic tool, as did "performance or other function activities that load the patellofemoral joint in a flexed position, such as stair climbing or descent."
    • Examination. Strong evidence supports the Anterior Knee Pain Scale, the patellofemoral pain and osteoarthritis sub¬scale of the Knee Injury and Osteoarthritis Outcome Score (KOOS-PF), and the visual analog scale (VAS) for activity or the Eng and Pierrynowski Questionnaire (EPQ) as ways to measure pain and function. Moderate-level evidence supports the use of "clinical or field tests" that reproduce pain and allow for assessment of movement. Authors write that "these tests can assess a patient's baseline status relative to pain, function, and disability; global knee function; and changes in status throughout the course of treatment."
    • Classification. The guideline panel found no "previously established valid classification system" for PFP, so it developed one. The system is based on impairment and function-based categories that include overuse/overload, muscle performance deficits, movement coordination deficits, and mobility impairments.

    Why the CPG Matters
    PFP is estimated to affect 1 in 4 adults every year, with women reporting knee pain twice as often as men do. Authors of the CPG write that while the recommendations shouldn't be considered a standard of care that guarantees a successful outcome for every patient, they are a reflection of the best-available evidence around the condition. They add that "significant departures" from the CPG "should be documented in the patient's medical records."

    APTA's Role
    The association provided funding and technical support during development of the CPG. This support is part of an ongoing APTA initiative to work with its sections and academies to produce a range of guidelines that highlight the evidence base for physical therapy in treatment of a variety of conditions. For synthesized research and evidence-based practice information, visit the association's PTNow website.