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  • Coronavirus Update: April 6, 2020

    HIPAA enforcement relaxed, PTs and PTAs among the health care workers who could be "exempted" from expanded sick leave, COVID-19's link to CVD, and more.

    HIPAA

    April 2: HHS Allows Disclosure of Some Protected Information
    The U.S. Department of Health and Human Services has issued notification that it is "exercising discretion" in how it applies HIPAA privacy rules during the COVID-19 national health emergency. HHS says it won't impose penalties against covered entity or business associate disclosure of private health information if the disclosure was made in "good faith" by the business associate as a part of public health efforts, and if the business associate notifies the covered entity of the disclosure within 10 days. Those "good faith" disclosures include information shared with the CDC "for purposes of preventing or controlling the spread of COVID-19," or with CMS in efforts to provide "assistance for the health care system."

    From CMS

    April 3: New CMS Nursing Home Recommendations Stress Collaboration, Consistent Staffing Assignment
    The U.S. Centers for Medicare & Medicaid Services issued new recommendations for nursing homes around the COVID-19 pandemic that urge states to attend to the personal protection equipment needs of long-term care facilities, and press nursing homes to establish separate staff teams for COVID-19-positive residents. The recommendations also include universal testing in the facilities and use of PPE "to the extent PPE is available."

    From the U.S. Department of Labor

    April 3: PTs, PTAs Could be "Exempted" From Receiving Additional COVID-19 Leave
    Emergency paid sick leave and expanded family and medical leave provisions will be implemented broadly in response to the COVID-19 pandemic, but PTs, PTAs, and other health care providers employed in certain settings can be prevented from receiving the additional relief if their employers say so: That's how the U.S. Department of Labor has laid out its plans for implementing the Families First Coronavirus Response Act signed into law on March 18. The exemption provisions could also be applied to first responders.

    April 3: OSHA Issues Guidelines to Permit Extended Use and Reuse of Respirators
    In a memorandum to its compliance safety and health officers, OSHA announced that it is seeking greater "enforcement discretion" that would allow for extended use and reuse of respirators. In the case of N95 masks, the same worker is now permitted to continue using the respirator "as long as the respirator maintains its structural and functional integrity" and the filter remains undamaged. The relaxed requirements also allow for use of N95 respirators that have passed their expiration dates—although the agency does not recommend the use of expired N95s when performing surgery on patients with diagnosed or suspected COVID-19, or when procedures are likely to create poorly controlled respiratory secretions.

    In the Media

    April 6: COVID-19 Virus May Damage Heart
    From Kaiser Health News: “As more data comes in from China and Italy, as well as Washington state and New York, more cardiac experts are coming to believe the COVID-19 virus can infect the heart muscle. An initial study found cardiac damage in as many as 1 in 5 patients, leading to heart failure and death even among those who show no signs of respiratory distress." Some cardiac specialists think that the virus could damage the heart in multiple ways.

    April 5: Researchers Investigating Links Between COVID-19 and Neurologic Effects
    According to Medscape, U.S. neurologists "are now reporting that COVID-19 symptoms may also include encephalopathy, ataxia, and other neurologic signs." In late March, doctors in Michigan reported on the first case of encephalitis linked to COVID-19, while researchers in China linked the development of Guillain-Barre syndrome to COVID-19 in a 61-year-old woman in China.

    Visit APTA's Coronavirus webpage for more information and updates.

    CDC: Fall-Related TBI Death Jumped 17% 2008-2017

    Significant increases were reported in 29 states, with residents of rural areas and individuals 75 and older seeing the most dramatic annual rise in deaths.

    In this review: Deaths from Fall-Related Traumatic Brain Injury — United States, 2008-2017
    (U.S. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, March 6, 2020)

    The Message
    The rate of deaths related to traumatic brain injury received in a fall has climbed 17% in 10 years, with 29 states recording what CDC officials call a 'significant" increase in deaths. The trend was present in all demographic groups, with males, those in rural areas, and individuals 75 or older seeing the most notable increases. Authors of the CDC analysis think that the country's aging population and better survival rates from cancer, stroke, and heart disease may have something to do with the increase. No matter the underlying causes, they say, the numbers point to a need for greater emphasis on falls prevention.

    The Study
    Using data from the National Vital Statistics System, a database of death certificates filed across the U.S., researchers looked at ICD-10 cause-of-death codes — first for codes indicating an unintentional fall as a cause of death, and then for multiple cause-of-death codes that included a diagnosis of traumatic brain injury, or TBI. Data was further analyzed for various demographic groups, including metropolitan versus nonmetropolitan settings, as well as by state. The study spanned 10 years of data, from 2008 to 2017.

    Findings

    Overall, national age-adjusted rates of fall-related TBI deaths rose from 3.86 per 100,000 individuals in 2008 to 4.52 per 100,000 in 2017, a 17% increase. Increases were present in nearly all demographic groups and in 49 of 51 jurisdictions.

    In 2017, the highest rate of fall-related TBI death was among adults 75 and older, at 54.08 per 100,000 — eight times higher than the 55-74 age group.

    Between 2008 and 2017, individuals living in "noncore nonmetropolitan counties" — mostly more rural areas — experienced the highest rate of annual increase in deaths, averaging a yearly 2.9% increase, followed by the 75-and-older cohort with an average annual increase of 2.6%.

    At the state level, the largest average annual increases in fall-related TBI deaths were recorded in Maine (6.5%), South Dakota (6.1%), and Oklahoma (5.2%), with "significant" increases reported in 26 other states and no changes reported in 21 states. Alabama reported the lowest 2017 death rate, at 2.25 per 100,000 individuals; South Dakota had the highest rate, at 9.09 per 100,000.

    In 2017, males had a higher rate of death than females, at 6.31 per 100,000 compared with 3.17.

    Why It Matters
    According to the CDC, 10% of U.S. residents 18 and older report falling annually, with falls now being estimated as the second leading cause of TBI. Authors of the study believe the rise in deaths attributed fall-related TBI point out the need for more focus on falls prevention programs, writing that "health care providers and the public need to be aware of evidence-based strategies to prevent falls."

    "Health care providers might consider prescribing exercises that incorporate balance, strength, and gait activities, such as tai chi, and reviewing and managing medications linked to falls," authors write. "Actions the public can take to prevent falls include talking to their health care provider about their or their parents' risk of falls, performing strength and balance exercises, having an annual eye exam, and making the home safer."

    [Editor's note: APTA and its components offer multiple resources on falls prevention: Check out this PT in Motion News story from 2019 for suggestions on ways to get up to speed.]

    More From the Study
    Authors offered a few theories to explain the higher death rates in certain groups and in the overall increase. The general increase, as well as the particularly notable increase among the 75-and-older population is likely attributable to the country's aging population and better survival rates after diseases such as cancer, stroke, and heart disease, they write. As for the higher rates among rural populations — in addition to an even higher aging rate in those areas compared with urban settings, rural areas tend to have greater "heterogeneity in the availability and accessibility of resources (e.g., access to high-level trauma centers and rehabilitative services)."

    Keep in Mind …
    The study has three main limitations, according to authors. First, it's possible that some deaths were misclassified; second, race and ethnicity may have been inaccurately recorded on death certificates; and third, when multiple trauma was experienced, a non-TBI factor may have contributed to the death.

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

    Study: Even in After-Hours Settings, Seeing a PT First for MSK Conditions in the Emergency Department Saves Time, Reduces Opioid Prescriptions

    An Australian study found that when patients' primary ED contact was with a PT, treatment times, orthopedic referrals, and analgesic prescriptions decreased — all in an after-hours setting, and with most PTs having no prior ED experience.

    In this review: Emergency department after-hours primary contact physiotherapy services reduce analgesia and orthopedic referrals while improving treatment time.
    (Australian Health Review, February 2020)
    Abstract

    The Message
    The beneficial role PTs can play in emergency departments is fairly well-established in research, but now a study from Australia takes that support even further, with authors finding that even in after-hour settings, patients with musculoskeletal issues whose primary contact was with a PT tended to leave the ED with fewer orthopedic referrals and opioid prescriptions than did those for which the PT was a secondary contact, all in less time than for patients who were seen by another professional first. And those improvements were accomplished with a cohort of PTs who, with one exception, had no prior ED experience.

    The Study
    Researchers analyzed data from an Australian ED that treated patients between 4:30 and 8:30 p.m. from a Saturday through a Tuesday, focusing on patients who presented with a musculoskeletal or orthopedic diagnosis. Those patients, just over 1,000 included in the study, were divided into two treatment groups — one group that saw a PT as primary contact, and a control group of patients whose first contact was with an ED medical officer and only later with a PT. Authors of the study then compared rates of referral for orthpedic consultation, prescriptions for analgesics (defined as "any restricted medication requiring a script from a medical officer, primarily opioid-based medication"), and overall treatment times. A total of 12 physiotherapists provided ED services. Overall professional experience among the PTs ranged from three to 16 years, but only one had prior ED experience.

    Findings

    Orthopedic referrals. Among patients in the primary PT group, 36.7% were referred for orthopedic consultation in the ED; the rate was 57.1% among the secondary PT group. Just over 48% of patients in the primary PT group were referred to an orthopedic clinic after discharges from the ED, compared with 69.4% among the control.

    Analgesic prescriptions. In all, 16.2% of the primary PT patients received prescriptions for analgesia on discharge. That rate rose to 24.7% among patients in the secondary PT group.

    Treatment times. The percentage of patients discharged from the ED or admitted to the hospital within four hours — a goal in the Australian health care system — was 89.6% for the primary PT group. Fewer patients in the secondary PT group, 64.4%, were treated within that four-hour window.

    Why It Matters
    Authors of the study characterize the findings as not just consistent with previous research but also ones that "build on" earlier studies by demonstrating "similar outcomes … using an ED PCP [primary care physiotherapist] workforce consisting of less-experienced physiotherapists than in previous studies, and in an after-hour setting."

    More From the Study
    Researchers believe the findings reflect well on the diagnostic abilities of PTs in the ED, writing that the study "supports the notion that [PTs] may be more confident than ED medical officers with diagnostic accuracy for musculoskeletal and simple orthopaedic presentations, as well as in establishing an effective treatment regimen that may not require orthopaedic consultation." They add that the reduced analgesia rates suggest that "either patients managed by ED PCPs require less analgesia in general or that ED PCPs seek non-pharmacological forms of analgesia to manage soft tissue injuries."

    Authors also pointed out that the results were achieved by PTs without previous ED experience, a detail that "suggests that even physiotherapists without prior ED experience can provide a safe effective service."

    Keep in Mind …
    The researchers acknowledge a few limitations to their study, primary among them that the control group was composed of patients with secondary contact with a PT, a factor that could necessitate longer overall treatment times or point to more complex presentations. Still, they argue, the study was limited to patients with an ICD-10-AM diagnosis code, which mitigated some of those potential confounders, making them "highly unlikely" to explain the magnitude of differences noted in outcomes. Authors also acknowledge that the particular study setting — a hospital ED with after-hours radiology and orthpedic services on-site — may make generalizing findings more difficult, and they advise that "confirmation of findings of this study across a range of ED settings and times would be beneficial."

    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.

    Fall-Related Injury and Death Remain Global Problems

    In this review: The global burden of falls: global, regional, and national estimates of morbidity and mortality from the Global Burden of Diseases Study 2017
    (BMJ, January, 2020)

    The Message
    Around the world, falls continue to pose a significant health care burden, but it's a burden that varies from region to region in a variety of ways, according to a recent analysis of global falls data from 2017. For example, the highest incidence rates for falls occur in Central Europe, Australia, and New Zealand, but that incidence doesn't correlate to higher falls-related mortality rates, which tend to surface in South Asia. And while age-standardized incidence of falls decreased slightly overall between 1990 and 2017, most of that decrease was accounted for in wealthier and more educated populations, while those in lower socio-demographic groupings actually experienced an increase in falls incidence.

    The Study
    Authors took a deep dive into data from the 2017 edition of the Global Burden of Disease Study, or GBD, a research effort that gathers information on hundreds of diseases in 195 countries and territories. The GBD amasses data not only on disease incidence and prevalence, but years lived with disability — YLD — mortality, and risk. For the BMJ study, researchers analyzed data related to falls, focusing on specific geographic areas, ages of those experiencing falls injury, and types of injuries sustained, among other data points.

    Findings

    • Overall, the age-standardized incidence of falls globally was 2,238 per 100,000 people in 2017 — a 3.7% decline from 1990 levels. The prevalence (rate of those who have sustained an injury from a fall over time, not just those who experienced a falls-related injury during 2017) rate was 5,186 per 100,000 in 2017, a 6.5% drop from 1990 rates.
    • Worldwide, incidence decreased by 8.8% between 1990 and 2017 for the highest socio-demographic group, but increased in the middle and lower groups.
    • The global age standardized mortality rate attributed to falls was 9.2 per 100,000 in 2017, which equated to nearly 700,000 deaths.
    • Central Europe led the world in falls incidence rates, averaging 11,434 falls per 100,000 people. Australia wasn't far behind, at 8,147 per 100,000, followed by Eastern Europe with an incidence rate of 8,187. The U.S. and Canada recorded incidence rates of between 3,000 to 4,000 per 100,000.
    • Falls-related mortality rates were highest in South Asia, with countries such as Cambodia, Myanmar, and Vietnam reporting that on average, more than 3 deaths occur for every 100 falls. The South Asia region as a whole registered a rate of 22 deaths per 100,000 people. Globally, total falls-related deaths have nearly doubled since 1990, authors report.
    • After adjusting for comorbidities and calculating YLD, researchers estimate that the average person who experienced a fall in 2017 lost 4% of her or his full-life status. In all regions studied, the leading cause of falls-related disability was a patella, tibia, fibular, or ankle fracture.

    Why It Matters
    The GBD estimates that falls are the 18th leading cause of age-standardized disability-adjusted life years, or DALYs — more than kidney disease, Alzheimer disease, and asthma. Additionally, falls are second only to auto/road injuries as the leading cause of accidental death.

    "Given that many fall incidents are preventable, occur in any population, and can lead to substantial morbidity and mortality," authors write, "it is surprising that falls do not draw more attention as an important global issue."

    More From the Study
    Authors believe that the wide variability in falls-related mortality "reveal that certain areas of the world likely have inadequate capabilities of responding to injurious falls." Given the aging world population, they add, "it is important for all countries to ensure that their older adult populations as well as their aging population share adequate access to caretaking and treatment resources now and in the future."

    As for the pockets of higher incidence and DALY rates, authors speculate that there may be two factors at play — a higher than average percentage of people living in rural areas, and an older-than-average population in those countries.

    Keep in mind …
    Authors point out that their study couldn't account for care-seeking behavior in various locations around the world. That may in turn affect incidence rate estimates, which they based on medical care records. Additionally, because their data was related to injury that led to medical care, authors concede that their mortality estimates may be slightly lower than if all falls were included. Finally, authors note that reporting to the GBD is not consistently reliable in all areas of the world.

    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.

    Updated Guideline for Management of Hand, Hip, Knee OA Strongly Recommends Exercise-Based Approaches

    In this review: 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee
    (Arthritis Care & Research, February, 2020)

    The Message
    Although researchers were not able to recommend precisely what kind and how much, exercise interventions in general have once again emerged as one of the most strongly recommended approaches to treating knee, hip, or hand osteoarthritis, according to an updated practice guideline issued by the American College of Rheumatology and the Arthritis Foundation. The recommendation for exercise is the result of an extensive review of physical, psychosocial, and pharmacological approaches that evaluated the evidence base for their use. Other strongly recommended approaches for all three types of OA included self-management programs and oral nonsteroidal anti-inflammatory drugs, or NSAIDs. Weight loss (when appropriate) and tai chi were also strongly recommended approaches for individuals with hip or knee OA.

    The study
    Authors based their recommendations on an extensive review of studies, most of them randomized controlled trials, conducted through August 2018. The literature identification, review, and ultimate recommendation process involved five teams that included both provider subject matter experts and patient panel, ending with a voting panel that included PTs, rheumatologists, an internist, occupational therapists, and patients.

    Analysis was focused on approaches available in the U.S. and used what’s called the GRADE system that resulted in recommendations for or against a particular approach, accompanied by a note of either "strong" or "conditional" support for each recommendation, as well as an intended range of patients (hip, knee, or hand OA alone or in combinations). APTA members Carol Oatis, PT, PhD; Louise Thoma, PT, DPT, PhD; and Daniel White, PT, were among the authors of the guideline.

    Findings
    The recommendations were divided into two broad areas: physical, psychosocial, and mind-body approaches; and pharmacologic management. Here are a few of the recommendations included in the guideline.

    Physical, Psychosocial, and Mind-Body

    • Exercise, self-management programs (strongly recommended for hip, knee, or hand OA).
    • Weight loss, tai chi (strongly recommended for hip or knee OA).
    • Cognitive behavioral therapy, acupuncture, thermal interventions (conditionally recommended for hip, knee, or hand OA).

    Pharmacologic Management

    • Oral NSAIDs (strongly recommended for hip, knee, or hand OA).
    • Intraatricular glucocorticoid injections (strongly recommended for hip or knee OA).
    • Acetaminophen, Tramadol, Duloxetine (conditionally recommended for .hip, knee, or hand OA).

    The guideline also includes strong and conditional recommendations for approaches limited to a specific OA location, including balance exercises (conditionally recommended for knee or hip OA), yoga (conditionally recommended for knee OA), and topical NSAIDs (strongly recommended for knee OA).

    Approaches recommended against using

    As with the recommended-for approaches, the guideline contains a mix of strong and conditional recommendations against certain approaches, usually applicable to some but not all three OA locations. Among the approaches authors recommend against using:

    • Massage therapy, transcutaneous electrical stimulation, modified shoes, lateral and wedged insoles (conditionally recommended against for knee or hip OA).
    • Fish oil, vitamin D, glucosamine (strongly recommended against for knee, hip, or hand OA).
    • Platelet-rich plasma treatments, stem cell injections (strongly recommended against for hip or knee OA).

    Why it matters
    As the most common form of arthritis, OA is a leading cause of disability among older adults and a condition that can be present for decades. Authors view the guideline as a tool for pursuing a "comprehensive, multimodal approach … offered in the context of shared decision-making with patients to choose the safest and most effective treatment possible."

    More from the study
    Authors write that while "current evidence is insufficient to recommend specific exercise prescriptions," the evidence is strong that exercise can lessen pain and improve function. The guideline urges providers to provide exercise advice "that is as specific as possible" for the patient, and assert that "overall, most exercise programs are more effective if supervised, often by physical therapists and sometimes in a class setting."

    The "self-management programs" are described by authors as those that "use a multidisciplinary, group-based format combining sessions on skill-building … education about the disease and about medication effects and side effects, joint protection measures, and fitness goals and approaches."

    One of the more notable changes in the most recent version of the guideline was around the use of glucosamine, a popular supplement thought to improve joint health. While glucosamine was a conditionally recommended approach in the previous guideline, authors moved it to "strongly recommended against" status due to "a lack of efficacy and large placebo effects."

    Keep in mind …
    Authors point out that in addition to a lack of clarity as to what types and dosages of exercise were most beneficial for OA (and for which joints), the current guideline also was unable to assess factors such as optimal footwear types, broader outcomes such as falls prevention, and the "role of integrative medicine, including massage, herbal products, medical marijuana, and additional mind-body interventions."

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

    PTJ: New CPG Supported by APTA Provides Guidance on PT Treatment of Individuals With Heart Failure

    In this review: Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure
    (PTJ, January 23, 2020)

    The Message
    A new clinical practice guideline supported by APTA and developed by the Cardiovascular and Pulmonary Section of APTA includes nine evidence-based action statements for the evaluation and management of patients diagnosed with heart failure and two clinical algorithms to support clinical decision making. Physical therapy interventions can improve activity level, participation, and quality of life, as well as reduce hospital readmissions for individuals with heart failure, authors write, and PTs should "work collaboratively with other members of the health care team" to achieve these goals.

    The Study
    Authors developed the algorithms and action statements based on 127 systematic reviews, meta-analyses, and previously published CPGs that tested interventions used by physical therapists, reviewed randomized controlled trials, tested outcomes relevant for physical therapist practice, and included only patients who acquired heart failure as adults.

    A team of Cardiovascular and Pulmonary Section members representing both educators and clinicians appraised the quality of CPGs using the Appraisal of Guidelines, Research and Evaluation (AGREE II) tool, systematic reviews using the Assessment of Multiple Systematic Review (AMSTAR) tool, and RCTs using the University of Oxford Centre for Evidence-Based Medicine critical appraisal tool. Members of the CPG’s Guideline Development Group formulated and graded nine key action statements, which were then reviewed by internal and external stakeholders for comment.

    Development of the CPG was supported through an APTA-sponsored program that assists APTA sections — in the case, the Cardiovascular and Pulmonary Section — with funding and tools for CPG activities related to drafting, appraisal, planning, and external review (for more detail on the program, visit APTA's CPG Development webpage).

    Findings
    Nine broad action statements were recommended by the authors based on evidence strength identified as "strong" or "moderate." Each statement includes specific details on benefits, risks, benefit-harm assessment, role of patient preferences, and a summary of the supporting evidence. The recommendations for physical therapy prescriptions include specific parameters, which are detailed in the CPG.

    For all patients with heart failure:

    • PTs should advocate for a "culture of physical activity as an essential component of care in patients with stable heart failure." (Strong recommendation)
    • "Make appropriate nutrition referrals, perform medication reconciliation, and provide appropriate education on preventive self-care behaviors to reduce the risk of hospital readmissions." (Strong recommendation)

    For patients with stable, Class II to III heart failure as defined by the New York Heart Association:

    • PTs should prescribe aerobic exercise training. (Strong recommendation)

    For patients with stable, NYHA Class II to III heart failure with reduced ejection fraction, also known as HFrEF, PTs should prescribe:

    • Resistance training for the upper and lower body. (Strong recommendation)
    • Neuromuscular electrical stimulation. (Strong recommendation)
    • Inspiratory muscle training with a threshold (or similar) device (Strong recommendation)
    • High-intensity, interval-based exercise — HIIT — for patients without contraindications. (Moderate recommendation)

    For patients with stable, NYHA Class II to III HFrEF, PTs may prescribe:

    • Combined aerobic and resistance training. (Moderate recommendation)
    • Combined inspiratory muscle training and aerobic exercise training. (Moderate recommendation)

    Authors developed two separate algorithms for patients with heart failure: the first to help PTs determine whether a patient is stable enough to proceed with an intervention and recognize when a person's signs and symptoms may require emergency medical treatment, and the second to assist in identifying which of the CPG's action statements are "most appropriate for a particular patient based on participation, activity, endurance, and signs of exercise intolerance."

    Why it Matters
    Noting the increasing readmissions rate and rising health care costs associated with heart failure, authors hope the CPG will "provide physical therapists with evidence-based recommendations that assist in improving functional capacity and [health-related quality of life] and reducing hospital readmissions for individuals with HF."

    As "integral members of the interprofessional team assisting with early detection of HF exacerbation and directing medical follow-up," PTs are urged by the authors to "work within their health care systems to determine how these or similar algorithms for identification of HF exacerbation can be utilized within their specific contexts and patient care environments."

    More From the Study
    In addition to their recommendations, authors described a number of areas needing further research, including but not limited to associations for variations in outcomes; effectiveness of specific exercise options; and appropriate exercise, dosing, and parameters for patients in different care settings. Small sample sizes, strict patient selection criteria, lack of functional outcome measures, study in limited settings, and other factors in existing research limited findings and recommendations in some areas.

    Keep in Mind …
    As with most CPGs, authors caution therapists that the recommendations are directed at a patient population but can't "address each unique situation of an individual patient."

    Authors also point out that the second algorithm, developed to help determine which recommendations are most appropriate for a particular patient, is based on expert opinion. The Guideline Development Group notes that the available research "did not address specific examination-based criteria for when any of the interventions reviewed herein are appropriate."

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

    Study: Home Health Physical Therapy Improves Abilities of Individuals With Dementia

    In this review: The Impact of Home Health Physical Therapy on Medicare Beneficiaries With a Primary Diagnosis of Dementia
    (Health Policy and Economics, January 2020)
    Abstract

    The Message
    Physical therapy delivered at home has a role to play in improving the lives of individuals with dementia, according to authors of a study that found any physical therapy increased the probability of improvement in activities of daily living — ADLs — by 15.2%. Although those probabilities improved in relation to the number of visits received, the greatest rate of increase in ADL function seemed to occur in patients who received between six and 13 visits.

    The Study
    Researchers analyzed CMS data drawn from the 2012 Outcome and Assessment Information Set and the Home Health Research Identifiable File, focusing on patients 66 and older who had a primary diagnosis of dementia and received in-home care. A total of 1,477 patients were included in the analysis.

    The study focused on whether patients with dementia improved ADL performance during the course of their care, and whether physical therapy visits could be correlated to increased chances of improvement. ADL items assessed included grooming, upper body dressing, lower body dressing, bathing, toilet transferring, toileting hygiene, transferring to bed or chair, ambulation, feeding and eating, the ability to prepare light meals, and the ability to use a phone.

    APTA members Cherie LeDoux, PT, DPT; Jason Falvey, PT, DPT, PhD; and Jennifer Stevens-Lapsley, PT, MPT, PhD, were among the authors of the study.

    Findings

    • Patients who received no physical therapy had a 60% probability of ADL improvement; that probability jumped to 75% for patients receiving any physical therapy.
    • The probability of ADL improvement increased with the number of physical therapy visits received, with improvement probability rising to 80.3% for patients receiving six to 13 visits, and to 88.9% for patients who received 14 or more visits.
    • Among all 1,477 patients, 62% received at least one physical therapy visit, with an overall median of four physical therapy visits received.
    • Among the patients who received physical therapy, 52% received between six and 13 visits, 41.3% received one to five visits, and 6.7% received 14 or more visits.
    • Authors believe the most significant improvement rates were associated with the six to 13-visit range, writing that the improvement rates associated with 14 visits and more as statistically insignificant.

    Why It Matters
    The authors write that their study comes when changes to home health payment "may produce downward pressure on home health rehabilitation services … generally discouraging therapy use and potentially increasing avoidable functional decline for [persons with dementia]." Their findings, they assert, help to establish the role of physical therapy in a provider environment that "incentivizes functional improvement."

    "In this study, skilled PT utilization is significantly associated with greater mobility and ADL function in individuals with a primary diagnosis of dementia," the authors write, adding that "our results suggest patients [with dementia] should receive a PT evaluation at minimum as a standard of care."

    Keep in Mind …
    Authors cite limitations in their study, including an inability to correct for possible variation in treatment allocation such as patient participation levels and clinician bias. The study also has a relatively small sample size and did not account for variations in dementia types among patient data analyzed.

    [Editor's note: author Jason Falvey was awarded a 2019 Foundation for Physical Therapy Health Services Research Pipeline Grant. Author Stevens-Lapsley has also received Foundation funding, and author LeDoux is the recipient of a 2019 Foundation Promotion of Doctoral Studies grant.]

    Paul Rockar Named Foundation President

    The Foundation for Physical Therapy Research (FPTR) has named former APTA President Paul Rockar Jr., PT, DPT, MS, as its president. Rockar, who served as a foundation trustee for three years prior, assumed his new role on January 1, 2020.

    Rockar is a well-known figure in the physical therapy profession, having served as a member of the APTA Board of Directors, as its vice president, and finally, as president of the organization from 2012 to 2015. Rockar is the former CEO of the Centers for Rehab Services.

    APTA and the foundation have a more than 40-year relationship focused on promoting physical therapy research. As a designated Pinnacle Partner of the foundation, APTA invested over $500,000 to support foundation initiatives including scholarships and fellowships in 2019.

    In his role as president, Rockar will work alongside his fellow Board of Trustees members to continue the foundation’s 2019-2022 strategic plan.

    “I am honored to have been chosen by my fellow trustees to lead FPTR at a time when research is so important to the profession,” said Rockar. “I look forward to collaborating with our partners and like-minded supporters — including APTA — to support research that leads to the best clinical guidelines and excellent patient care.”

    Rockar succeeds Edelle Field-Fote, PT, PhD, FAPTA, who concluded her term at the end of 2019.

    Separate Studies, Similar Conclusions: Bundling for Knee, Hip Replacement Seems to be Working

    Has all the bundling been worth it? Two new studies of bundled care models used by the Centers for Medicare and Medicaid Services (CMS) conclude that, at least for lower extremity joint replacement (LEJR), the answer is yes. Taken as a whole, the studies make the case that while the savings achieved through some bundled care models may not be dramatic, they do exist — and aren't associated with a drop in quality.

    The studies, published in Health Affairs, take different approaches to answering questions about the effectiveness of bundling programs mostly associated with CMS' voluntary Bundled Payments for Care Improvement (BPCI) initiative: one was a systematic review that analyzed existing research (abstract only available for free) on the programs, while the other focused on data from hospitals that did and did not participate in BCPI (abstract only available for free) over a three-year period. Their conclusions, however, had much in common.

    The bottom line, according to both studies, is that bundled care models for LEJR seem to be lowering overall costs without sacrificing quality.

    The systematic review revealed that most studies that evaluated spending recorded decreases in overall postacute care spending of between $591 and $1,960, while the hospital data researchers identified an average 1.6% decrease in episode spending for LEJR — about $377 per patient. At the same time, neither study uncovered evidence of reduced quality outcomes, with the hospital study finding variances between BPCI and non-BPCI care for LEJR of less than 2%. The systematic review found that, if anything, research indicates that bundled care tends to lead to lower rates of hospital readmission, a datapoint strongly associated with quality.

    The studies did have some differences. The hospital data researchers focused solely on LEJR data, which they describe as the most common procedure associated with BPCI, while the systematic review included a bundled care model for a range of procedures. In the end, authors of the systematic review found that bundled payment "has yet to demonstrate [benefits similar to those associated with LEJR bundling] for other clinical episodes," including spinal fusion, shoulder arthroplasty, and cardiac surgery. Another difference between the studies: The systematic review included data from CMS' Comprehensive Care Joint Replacement (CJR) model mandated for use in some 450 facilities across the country; the hospital data review excluded CJR facilities.

    [Editor's note: APTA offers multiple resources on bundling, including separate webpages devoted to BPCI Advanced participation and the CJR.]

    Each study offered its own takeaways. The systematic review emphasized the effectiveness of bundling for LEJR and suggested that CMS "scale up” its bundling programs in those areas, while cautioning that more work needs to be done on bundling programs for other procedures, especially those that tend to be associated with higher baseline patient complexity. The hospital data study, focused on LEJR only, found that most of the savings associated with bundling came from early adopters (which maintained their savings over time), and less so from facilities that joined later, which "may have been less able to influence episode spending." That study also acknowledged that while voluntary bundling models may be subject to cherry-picking of less complex patients, data revealed that "it does not fully account for associated savings."

    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.

    New APTA-Supported CPG Looks at Best Ways to Improve Walking Speed, Distance for Individuals After Stroke, Brain Injury, and Incomplete SCI

    In this review: Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury
    (Journal of Neurologic Physical Therapy, January, 2020)

    The message
    A new clinical practice guideline (CPG) supported by APTA and developed by the APTA Academy of Neurologic Physical Therapy concludes that when it comes to working with individuals who experienced an acute-onset central nervous system (CNS) injury 6 months ago or more, aerobic walking training and virtual reality (VR) treadmill training are the interventions most strongly tied to improvements in walking distance and speed. Other interventions such as strength training, circuit training, and cycling training also may be considered, authors write, but providers should avoid robotic-assisted walking training, body-weight supported treadmill training, and sitting/standing balance that doesn't employ augmented visual inputs.

    The study
    The final recommendations in the CPG are the result of an extensive process that began with a scan of nearly 4,000 research abstracts and subsequent full-text review of 234 articles, further narrowed to 111 randomized controlled trials (RCTs), all focused on interventions related to CNS injuries, with outcome data that included measures of walking distance and speed. CPG panelists evaluated the data and developed recommendations, which were informed by data on patient preferences and submitted for expert and stakeholder review.

    Development of the CPG was supported through an APTA-sponsored program that assists APTA sections — in the case, the Academy of Neurologic Physical Therapy — in the development stages such as drafting, appraisal, planning, and external review (for more detail on the program, visit APTA's CPG Development webpage).

    Findings

    • Moderate- to high-intensity (60%-80% of heart rate reserve or up to 85% of heart rate maximum) walking training was associated with the strongest evidence for improvements in walking speed and distance.
    • Walking training using VR also fared well, due in part to the ability of a VR treadmill system to allow "safe practice of challenging walking activities," something that's hard to do in a more traditional hospital or clinic setting.
    • Strength training, while not included among the interventions that should be performed, was designated as an intervention that may be considered. Authors cite inconsistent evidence on the connection between strength training and improved walking speed and distance, but they acknowledge potential benefits.
    • Also among the list of interventions that "may be considered": circuit training, as well as cycling training. In both cases, authors cite a paucity of evidence related to how the interventions affect walking speed and distance. They note that these interventions may be revisited during a future reevaluation of the CPG.
    • Body-weight supported treadmill training was labeled as an intervention that should not be performed in order to increase walking speed and distance, with authors finding little evidence supporting the approach, which is often associated with a greater cost. However, they write, the individuals included in the studies reviewed for the CPT were able to ambulate over ground without the use of a body-weight support device, and "different results may occur in those who are nonambulatory or unable to ambulate without the use of [body-weight support]."
    • Both static and dynamic (nonwalking) balance training and robotic-assisted walking training were also characterized as interventions that should not be performed. Authors acknowledge the ways that postural stability and balance are associated with fall risk and reduced participation, but they were unable to find sufficient evidence to support these particular interventions as effective in increasing walking speed and distance (although static and dynamic balance training with VR fared a bit better). As for robotic-assisted walking training, CPG authors note that while ineffective for individuals with CNS who were already ambulatory, "this recommendation … may not apply to nonambulatory individuals or those who require robotic assistance to ambulate."

    Why it matters
    Authors note that "the implementation of evidence-based interventions in the field of rehabilitation has been a challenge," and they believe that the new CPG offers a real opportunity for clinicians to "integrate available research into their practice patterns." Further, they believe that the CPG has arrived at an important moment in the evolution of health care, with its greater emphasis on evidence for the cost-effectiveness and outcomes of various interventions.

    More from the study
    The CPG also offers tips for clinicians to implement its recommendations, including acquiring equipment to help providers monitor vital signs, implementing "automatic prompts in electronic medical records that will facilitate obtaining orders to attempt higher-intensity training strategies," providing training sessions for clinicians, establishing organizational policies to promote use and documentation of the recommended interventions, and simply keeping a few copies of the study on hand for easy reference.

    Keep in mind …
    Authors acknowledged that the CPG has a few limitations. While the review of RCTs only is a strength, they write, some of those studies involved small sample sizes, and many lacked details on intervention dosage. Additionally, the CPG does not fully address the potential costs associated with its recommendations — specifically VR — which could impact a clinic's ability to implement a particular intervention. Authors also acknowledge that walking speed and distance are not the only important outcomes related to mobility among individuals with CNS injury, and that other factors such as dynamic stability while walking, peak walking capacity, and community mobility may be incorporated in an assessment of walking function.