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  • Film Star Kathy Bates Helps to Spread the Word on Lymphedema Management in APTA Oncology Section's Journal

    Health care providers are increasing their knowledge of lymphedema management, but there's still much work to be done. Just ask film and television star Kathy Bates, author of a letter to the editor in a special issue of Rehabilitation Oncology (RO) entirely devoted to the disease. RO is the science journal of the APTA Oncology Section.

    Bates' letter, available for free, not only gives an account of her experience with lymphedema after a bilateral mastectomy but also provides insight into how much the patient experience has changed over the decades. Bates explains that her mother experienced lymphedema after cancer surgery in the 1970s, and that, "with no treatment in those days, I watched her spirit defeated as she realized she would have to live with the pain and heartache for the rest of her life."

    Given the experience with her mother and another individual she knew who lived with lymphedema after surviving stage 4 melanoma, Bates was well aware of the effects of lymphedema and pleaded with her surgeon to leave as many lymph nodes intact as possible. Bates writes that when her surgeon later told her that he felt it necessary to remove 19 lymph nodes from her right armpit and 3 from her right, she was "devastated" and experienced what she describes as an "emotionally draining" recovery.

    Eventually Bates came to terms with the necessity of the node removal, but she now lives with the reality of lymphedema. In the editorial, she writes of her treatment and management of ongoing symptoms, and her more recent work with the Lymphatic Education and Research Network (LEARN), where she now serves as spokesperson.

    Bates writes that with an estimated 140 million individuals with lymphedema—some undiagnosed—it's imperative that efforts to educate both patients and providers continue.

    "Lymphedema needs to be recognized as a disease that deserves money for research," Bates writes. "We need awareness. …Please help me spread the word."

    In an accompanying open-access editorial, guest editor Nicole Stout, PT, DPT, FAPTA, and certified lymphedema therapist from the Lymphology Association of North America, describes the advancements that have been made in both lymphedema management and clinical knowledge among health care providers, but she adds that more needs to be done.

    "The true measure of our advancement is in how our patients are impacted by the evolution in the field," Stout writes. "Decreased wait times to access therapy, more knowledgeable therapists, and better and higher-quality materials and treatment devices have emerged in the last decade. However, there are still significant barriers to care and clinical questions that we must set our sights on solving in the next decade," including payment, access to specialty care, and the slow growth of telehealth services.

    Still, Stout believes that continued technological breakthroughs and increased clinician understanding could pave the way for significant positive change, writing that "the future is bright, the future is smart, and we must continue to seize on opportunities to advance novel approaches to lymphedema management."

    This year, APTA's American Board of Physical Therapy Specialties will begin offering its first-ever specialist certification in oncology physical therapy. Deadline for applications is July 31, 2018.

    From PTJ: Office Work Doesn't Have To Be a Pain in the Neck

    Office workers with neck pain may benefit from workplace-based strengthening exercises, especially those focused on the neck and shoulder, say authors of a recent systematic review.

    Among all occupations, office workers are at the highest risk for neck pain, with approximately half of all office workers experiencing neck pain each year. “Workplace-based interventions are becoming important to reduce the burden of neck pain,” researchers write, “due to the increasing responsibility of companies toward employee health, and the potential cost-savings and productivity gains associated with a healthy workforce.”

    The review of 27 randomized controlled trials (RCTs), published in the January issue of Physical Therapy (PTJ), focused specifically on office workers, whereas previous reviews of effectiveness of workplace interventions for neck pain have focused on workers in general. Authors also compared results between subgroups of office workers with and without neck pain. The included RCTs measured “neck and/or neck/shoulder pain intensity and incidence/prevalence” and used control groups for comparison.

    Among the findings:

    • Moderate-quality evidence suggested that workplace-based strengthening exercises reduced neck pain in office workers who were symptomatic, and the effect size was larger when those exercises focused on the neck and shoulder. Higher exercise participation rates resulted in greater benefits.
    • Neck/shoulder-specific strengthening exercises were not effective for a general population of office workers that included both those with and without neck pain.
    • Authors found “low-quality and conflicting evidence” for the effectiveness of ergonomic interventions among office workers in general (not specific to those with neck pain).
    • There was limited evidence for prevention of neck pain in office workers, but 1 trial suggested that “combined neck endurance and stretching exercises might be efficacious” for workers at risk for neck pain.
    • “Exercise interventions are best targeted toward symptomatic or ‘at risk’ office workers,” write authors, but “given that approximately half of office workers may suffer from neck pain within a 12-month period, it could be argued that interventions should be offered to all office workers” regardless of whether they have neck pain.

    Authors note that the studies included only self-reported pain measures, and suggest that future studies include functional outcomes, such as neck disability and sick leave. They also encourage future research to examine effectiveness of interventions for neck pain prevention among “symptomatic, asymptomatic, and possibly ‘at risk’” office workers.

    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: Want more information on the physical therapist's role in employer-based health? Check out APTA's Working With Employers Toward Population-Based Health webpage. Resources include a blog post, magazine articles, and a recorded webinar titled "Direct-to-Employer Physical Therapy—Building Supply and Demand." Also worth checking out: this newly revised clinical practice guideline on neck pain, available at PTNow.

    Survey: HIIT Tops the List of Fitness Trends for 2018

    What's the future of fitness? According to an international survey of exercise professionals, high intensity interval training (HIIT) will be the strongest trend in 2018, outpacing wearable technologies, which held the number 1 position in 2017. Group training, body weight training, and strength training are also on the list of top 10 trends expected to be strong this year, while interest in Exercise is Medicine and exercise and weight loss is expected to drop off.

    The ratings are part of an annual review conducted by Health and Fitness Journal, published by the American College of Sports Medicine. Now in its 12th year, this year's survey included responses from 4,133 exercise professionals from around the world. "Medical professionals"—the category that includes physical therapists (PTs) and physical therapist assistants (PTAs) as well as physicians, nurses, and occupational therapists—made up 4% of the responses.

    The survey asks respondents to make a distinction between trends—changes in behavior over a period of time—from "fads," which tend be enthusiastically embraced for short periods of time. Consequently, the lists don't typically change dramatically from year to year. Still, the 2018 list includes some interesting differences from previous years. Here's a quick rundown of the top 10 trends for 2018:

    1.  HIIT (2017 position: #3)
    2.  Group training (2017 position: #6)
    3.  Wearable technology (2017 position: #1)
    4.  Body weight training (2017 position: #2)
    5.  Strength training (2017 position: #5)
    6.  Educated, certified, and experienced fitness professionals (2017 position: #4)
    7.  Yoga (2017 position: #8)
    8.  Personal training (2017 position: #9)
    9.  Fitness programs for older adults (2017 position: NA)
    10. Functional fitness (2017 position: #12)


    Rounding out the top 20 were, in order: exercise and weight loss, Exercise is Medicine, group personal training, outdoor activities, flexibility and mobility rollers, licensure for fitness professionals, circuit training, wellness coaching, core training, and sport-specific training.

    Falling off the top 20 list for 2018 were worksite health promotion (#16 in 2017), smartphone exercise apps (#17 in 2017), and outcome measures (#18 in 2017). The biggest decrease was for exercise programs for children and weight loss, a trend that appeared in the top 5 lists every year from 2009 to 2013, but began to drop off in 2014. It's now ranked at #32.

    The report lists licensure for fitness professionals, core training, and sport-specific training as possible "emerging trends," but warns that "future surveys will either confirm these as new trends or they will fall short of making a sustaining impact on the health fitness industry and drop out of the survey "—a fate that has befallen indoor cycling, Pilates, and dance cardio.

    Far from being an exercise in crystal-ball-gazing, the survey has some very practical applications, according to ACSM.

    "The benefits [of the annual survey] to commercial health clubs…are for the establishment (or maybe the justification of) potential new markets…" the report states. "Community-based programs…can use these results to justify an investment in their own markets by providing expanded programs serving families and children. Corporate wellness programs and medical fitness centers may find these results useful through an increased service to their members and to their patients."

    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.

    CDC: 40% of Patients With Arthritis Don't Receive Exercise Counseling From Providers

    Better, but still plenty of room for improvement—that's the US Center for Disease Control and Prevention's (CDC's) take on a recent analysis of the rate at which health care providers are counseling patients with arthritis to engage in physical activity (PA). The good news: the percentage of individuals with arthritis who received provider counseling for exercise grew by 17.6% between 2002 and 2014. The bad news: even after that growth, nearly 4 in 10 patients with arthritis still aren't receiving any information from their providers on the benefits of PA.

    The CDC analysis, which appeared in a recent edition of its Morbidity and Mortality Weekly Report, uses data from the National Health Interview Survey gathered in 2002 and 2014. In those years, the survey included a question on whether respondents had been told they have "arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia," as well as a question asking whether "a doctor or other health professional [has] ever suggested physical activity or exercise to help your arthritis or joint symptoms?"

    According to the CDC, in 2002, 51.9% of individuals with arthritis reported receiving PA counseling from a provider; by 2014, that percentage had grown to 61%—a 17.6% increase.

    The overall percentage in 2014 pushes the percentage slightly above the US Department of Health and Human Services' "Healthy People 2020" target of 57.4%, but the growth isn't uniform across subgroups analyzed, according to CDC. Among differences revealed in the analysis:

    • While the overall rate of exercise counseling was 61%, the rate for underweight or normal-weight individuals with arthritis was only 50%. Other subgroups that registered averages below the overall rate were non-Hispanic other races (53.8%), current smokers (56.9%), persons with no primary care provider (50.7%), and individuals who reported being inactive (56.7%).
    • Among the subgroups that reported higher-than-average rates of PA counseling were individuals with obesity (70%), persons whose activities were limited by arthritis (67.7%), those with 3 or more additional chronic conditions (67.6%), black non-Hispanic (63%) races, and Hispanic races (64.7%).
    • All subgroups recorded improvements in the rate of PA counseling between 2002 and 2014, but the most significant gains were made for males (from 44.8% to 58.3%), individuals with no additional chronic conditions (from 46% to 63.3%), the unemployed (from 47% to 61%), individuals with less than a high school education (from 45.9% to 59%), and individuals who reported 1 to 3 primary care provider visits annually (from 45.2% to 56.4%).

    The CDC report acknowledges the positive trends but references other studies that may shed some light on reasons for the less-than-optimal rates of PA counseling by providers. Among the findings are a 2014 survey that found that fewer than one-third of primary care physicians said they provided exercise counseling for arthritis during office visits, and another survey of health care providers that found that 61% of respondents felt unsure of—or lacked—knowledge and skills to provide counseling on exercise to patients with osteoarthritis or rheumatoid arthritis.

    "Incorporating counseling into clinical training curriculum and continuing education programming…might encourage health care providers to provide exercise counseling," the CDC says in its report. Authors also suggest that providers who feel unsure about counseling should consider referring patients to "evidence-based, community programs" such as Enhance Fitness, Walk with Ease, and Active Daily Living Every Day.

    The bottom line, according to the CDC, is that it's not time to rest on any laurels.

    "Prevalence of health care provider counseling for exercise among adults with arthritis has increased significantly over more than a decade," the report states, "but the prevalence of counseling remains low for a self-managed behavior (exercise) with proven benefits and few risks, especially among those who are inactive."

    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: APTA offers resources on encouraging healthy, active lifestyles at APTA's Prevention, Wellness, and Disease Management webpage. Also available: an APTA webpage on arthritis management through community programs. January 2018 also marks the debut of APTA's newest council: The Council on Prevention, Health Promotion, and Wellness in Physical Therapy.

    Study: Referral to Physical Therapy for LBP Reduces Odds of Later Opioid Prescription—Even When Patients Don't Follow Up on the Referral

    There's solid evidence that physical therapy as a first-line approach for low back pain (LBP) improves outcomes, but not many studies have focused on the factors that are associated with referral to physical therapy in the first place, regardless of later participation in treatment. Now authors of a recent study believe they've found associations indicating that the very act of referral for physical therapy may point to the ways a primary care provider's approach to LBP can affect patient perceptions and reduce odds of later opioid use, even when the patient doesn't follow through with the referral.

    The study, published in the Journal of the American Board of Family Medicine (abstract only available for free) looked at data from 454 Medicaid enrollees who were initially treated by a primary care provider for LBP, of which 215 received a referral for physical therapy. While researchers were interested in differences between the referral and nonreferral groups, the target of their study was something they believe is missing in current research: an examination of the entire referral population, regardless of whether those patients followed up with actual physical therapy.

    "Identifying only patients who have participated in [physical therapy] fails to account for the impact of the referral itself," authors write. "The referral potentially represents a provider-patient interaction about the nature of the LBP and prognosis. Improved outcomes among [physical therapy] cohorts may represent a combination of patient compliance with the [physical therapy] recommendation and a provider's beliefs about the nature and severity of the LBP."

    To get at this issue, researchers divided patients who received a physical therapy referral into 2 groups—those who, after a physical therapy consultation, went on to participate in physical therapy, and those who didn't—and compared those groups with each other, as well as with the group that didn't receive any referral to physical therapy. Among the findings:

    • Patients receiving a physical therapy consult tended to be younger, and had received a radiograph and/or prescription for nonsteroidal anti-inflammatory drugs (NSAIDs) or muscle relaxers. Patients less likely to receive a consult were associated with tobacco use, chronic pain, depression, 2 or more comorbidities, and having received a referral for specialty care or advanced imaging.
    • The odds of a patient receiving a physical therapy consult were increased 1.8 times if the patient also received an NSAID prescription.
    • The odds of a patient receiving a physical therapy consult were decreased 25 times if the patient received specialty care or advanced imaging.
    • In terms of actual participation in physical therapy, patients who received multiple orders from the primary care provider (specialty referrals, advanced imaging, etc) in addition to a physical therapy referral were less likely to go to physical therapy, as were older patients and those with 2 or more comorbidities.
    • Opioid prescriptions were the most commonly used interventions during the year after the initial LPB visit. While the strongest predictor of a later opioid prescription was associated with whether an opioid prescription occurred at baseline, patients who received a physical therapy consult were 35% less likely to receive an opioid prescription, regardless of whether they participated in physical therapy after the consult.
    • Participation in physical therapy had a "mixed impact" on health care use and no difference on overall costs.

    "These results highlight the impact of the initial provider visit and provide a foundation for future work understanding patient and provider beliefs surrounding the initial primary care visit for LBP," authors write, adding that "providing a physical therapy consult in place of an opioid prescription is a reasonable alternate strategy for pain management and improved function, particularly in this population of Medicaid enrollees."

    Researchers acknowledge the limitations of their work, including its population of 70% women, its focus on association rather than causation, and a reliance on electronic medical records that can limit insight into clinical decision-making. Still, they assert, the data they were able to tease out from patients who were recommended physical therapy point to some promising possibilities.

    "Patients with a consult to [physical therapy] represent a unique and important subset as the consult may represent a reflection of a provider's values and subsequent communication with the patient," they write. "Recommending [physical therapy] provides reassurance to patients that their LBP is best managed with physical activity and is in line with advice to stay active. This in itself has potential to change cost and health care use."

    Authors of the study include APTA members Anne Thackeray, PT, PhD; and Julie Fritz, PT, PhD, FAPTA.

    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: Look for a special issue of Physical Therapy (PTJ) on nondrug management of pain coming in April.


    From PTJ: New Health Promotion Model May Equip PTs to Address Wellness and Prevention

    Despite organizations such as the Centers for Disease Control and Prevention and the World Health Organization urging health care providers to address modifiable risk factors and risky health behaviors in patients, physical therapists (PTs) are not “routinely” doing so, say authors of a recent study. The researchers believe a new clinical model could help bridge the gap between knowing and doing.

    The model, known as the Health-Focused Physical Therapy Model (HFPTM), was developed by researchers at the University of Alabama at Birmingham (UAB), and is focused on encouraging smoking cessation and regular physical activity among PTs’ patients and clients. Results of their validation efforts were recently published in Physical Therapy (PTJ).

    The HFPTM was developed as a preliminary model based on health promotion and education research. The model integrates community wellness programs with the PT's insight in anticipating health promotion needs for the population at large. From there, the PT screens for health promotion needs among patients and clients and then develops a health-focused management plan for those in need—a plan that could include referrals to other providers, treatment by the PT, or a combination. If the patient’s or client's care is not referred out completely, the PT then delivers "health-focused interventions" and analyzes outcomes. That outcome analysis creates a feedback loop that helps PTs further refine their understanding of health promotion needs at the community level.

    To gather more insight and validate the model, the researchers convened a “Health Promotion and Education Initiative: UAB Summit,” in which a group of 21 health care researchers, educators, and practitioners from backgrounds as diverse as nutrition, medicine, public health, and physical therapy helped to flesh out the model by offering feedback and identifying which lifestyle behaviors are within the PT's scope of practice and which require referral to another discipline.

    Summit participants viewed the interdisciplinary model as appropriate for the physical therapy profession and potentially useful for other professions. However, while participants perceived PTs as “well positioned” to provide health education and promotion services, they also suggested that PTs need to further develop “credibility” in areas such as stress management. Other areas were also identified as being in need of further attention by the physical therapy profession. These included handling payment and liability issues, developing screening tools and education materials, enhancing communication skills, and "building consultancy and referral systems to provide health-focused care for some unhealthy behaviors” outside of PTs’ scope of practice, authors write.

    While the authors assessed the model’s content validity only for smoking cessation and regular physical activity, they hope the model will “prove particularly useful for physical therapists who do not feel equipped to provide health-focused care.” Researchers suggest that this model “could serve as a framework upon which educators may teach the integration of health promotion into customary clinical care to educate physical therapist students and clinicians.”

    Authors of the study include APTA members Donald Lein, PT, PhD; Diane Clark, PT, DSc, MBA; Patricia Perez, PT, DScPT; David Morris, PT, PhD, FAPTA; and the late Cecilia Graham, PT, PhD.

     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 Awards Research Grants, Kendall Scholarships

    The Foundation for Physical Therapy (Foundation) recently awarded Florence P. Kendall Doctoral Scholarships for 2017 to Rachel Bican, PT, DPT, The Ohio State University; Kristina M. Kelly, PT, DPT, EdM, Ohio State; Jesse L. Kowalski, PT, DPT, University of Minnesota; Dana R. Mathews, PT, DPT, MS, University of Delaware; and Lauren M. Pacho, PT, DPT, board-certified neurologic clinical specialist, Ohio State.

    The $5,000 Kendall Doctoral Scholarship is awarded annually to outstanding physical therapists as they begin their first year of graduate studies toward a postprofessional doctoral degree.

    Four researchers also were awarded a total of $230,000 in research grants from the Foundation in support of their projects to evaluate the effectiveness of physical therapist interventions. Awardees and grants are:

    Stephanie Di Stasi, PT, MSPT, PhD, board-certified orthopaedic clinical specialist—Mercer-Marquette Challenge Research Grant. Di Stasi was awarded a $40,000 grant for a study on load modification vs standard exercise for individuals with greater trochanteric pain.

    Kenneth J. Harwood, PT, PhD—Health Services Pipeline Grant. Harwood was awarded a $50,000 grant to pursue a 1-year research project titled "The Effects of Timing of Physical Therapy on Health Care Costs, Utilization, and Opioid Use." The grant was made possible through a donation from APTA.

    Victoria G. Marchese, PT, PhD—Snyder Research Grant. Marchese was awarded the $40,000 Snyder grant for a 1-year research project focused on a strengthening intervention for childhood cancer survivors of lower-extremity sarcoma.

    Charles A. Thigpen, PT, PhD, MS—Magistro Family Foundation Research Grant. Thigpen was awarded $100,000 for a 2-year project titled "Effectiveness of a Physical Therapy First Musculoskeletal Pathway."

    "As the Foundation continues to open doors to deserving physical therapist researchers, we are certain that the emerging generation of investigators will change the face of rehabilitation research and physical therapeutic interventions," said Foundation Board of Trustees President Edelle Field-Fote, PT, PhD, FAPTA, in a Foundation press release. “We look forward to seeing the growth of our funding recipients as they go on to develop innovations that will transform the field.”

    Study: High-Intensity Exercise Shows Promise for Patients With PD

    Could high-intensity treadmill exercise slow the progression of symptoms among individuals with Parkinson disease (PD)? Authors of a new study say that while more research needs to be done, their randomized clinical trial has proven the intervention to be safe, with indications that sufficiently vigorous treadmill work 3 times a week slowed severity at 6 months.

    Their findings, published in JAMA Neurology (abstract only available for free), are based on a study of 128 patients with stage 1 or 2 PD who were within 5 years of diagnosis. Authors wanted to find out whether endurance exercise—particularly the high-intensity variety—had any effect on PD severity over time. Authors say the study is the first to evaluate the effects of exercise at 80% to 85% of maximum heart rate among patients with PD, and 1 of only a handful that focused on disease severity as an outcome, rather than fitness or functional measures.

    Researchers divided the participants into 3 groups: a high-intensity group that received a prescription for 30 minutes of target heart rate (80% to 85% of maximum heart rate) treadmill work 4 times a week, a moderate-intensity group that received a prescription for 30 minutes of treadmill work that reached 60% to 65% of maximum heart rate 4 times a week, and a usual-care group that was told to continue with their current rates of physical activity. Sessions during the first 2 weeks were conducted that the study site; after that participants engaged in the treadmill work at local gyms or health centers. Patients wore heart rate monitors for all sessions and participated in monthly calls with study coordinators.

    At the end of 6 months, participants completed the Unified Parkinson Disease Rating Scale (UPDRS), and researchers compared those scores with UPDRS scores at baseline.

    Authors of the study found that individuals in the usual-care group recorded an average 3.2 point increase in PD severity in the UPDRS motor score component after 6 months, while the high-intensity treadmill group averaged a 0.3 increase—a difference significant enough to warrant further investigation, they believe. But the same couldn't be said for the moderate-intensity group, which averaged a 2 point increase in UPDRS motor scores, representing no significant difference between that group and the usual care group.

    Additionally, researchers found few adverse events associated with the high-intensity group, "demonstrating that patients with [PD] can exercise safely without direct supervision when guided by exercise specialists," they write.

    "In light of a recent report that low-dose, patient-centered, goal-directed physiotherapy and occupational therapy in patients in the early stages of [PD] is not effective, a demonstration of the nonfutility of high-intensity treadmill exercise in patients with mild [PD] is particularly important," authors write.

    Authors acknowledge limitations to their study, noting that only treadmill work was studied (as opposed to other forms of endurance training); that intensities were reached by manipulating both treadmill speed and incline (as opposed to isolating the effects of each); and that the study did not address other types of exercise that are also important in addressing PD, such as strength training.

    The bottom line, however, remains, as far as the authors are concerned: not only is high-intensity treadmill exercise safe for patients with PD, it shows promise as an approach to lessen disease severity. More research should be done, they write, but "meanwhile, clinicians may safely prescribe exercise at this intensity level for this population."

    Authors of the study include APTA members Margaret Schenkman, PT, PhD, FAPTA; Anthony Delitto, PT, PhD, FAPTA; Deborah Josbeno, PT, PhD; and Cory Christiansen, PT, PhD.

    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: Research on Computer Gaming's Effectiveness in Physical Therapy Needs to Level Up

    Playing active computer games (ACGs) may increase older adults’ physical activity, but authors of a recent article published in Physical Therapy (PTJ) say that current data provide "little confidence" that such activity improves physical health or cognition. And it’s not yet clear whether it is safe for older adults to play ACGs unsupervised.

    Active computer gaming such as Nintendo Wii or Microsoft’s Xbox is being used in rehabilitation based in part on an assumption that sounds reasonable enough: because the games are fun and motivating, adherence to physical therapist interventions will improve, which will in turn have an impact on health outcomes such as falls. Authors of the PTJ review wanted to know if that assumption was supported by data.

    Authors analyzed 35 randomized controlled trials with 1,838 total participants to determine whether ACG improved balance, functional exercise capacity, functional mobility, fear of falling, and cognition. They also examined participant adherence to interventions and factors such as dose, frequency, setting, and whether interventions were supervised.

    What they found: playing ACGs had a "significant moderate effect" on cognition and balance, and on functional exercise capacity when participants played more than 120 minutes per week. But ACG had no effect on functional mobility or fear of falling. Researchers interpret the findings with caution, as all of the studies were low or very low quality.

    The fact that ACG had a moderate effect "on one outcome associated with falls risk yet no effect on another…highlights the importance of tailoring ACG interventions to older adults’ specific needs for daily function," authors write. The ACG interventions employed a variety of mechanisms to improve function, they explain, and facing forward while standing in one spot may have helped participants improve balance but not functional mobility.

    Authors also raise safety as an issue for ACGs, which they say hold "promise for self-led exercise interventions for even the most frail." But determining which ACGs are safe to use unsupervised was impossible to determine, as only 3 studies used unsupervised interventions. Further, only 9 studies included individuals with balance impairments—making them less likely to be unable to engage in traditional exercise. This makes it difficult to evaluate effects of ACG for this population, authors say.

    "Findings of this review suggest that ACG may provide positive physical and cognitive health benefits greater than those observed following no treatment, traditional exercise, or rehabilitation interventions for balance, functional exercise capacity, and cognitive function," authors conclude, but higher-quality, "robust" randomized controlled trials are needed "in order to state with confidence" that ACG is effective.

    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.

    Analysis: The 'Big 5' Insurers Are Increasingly Dependent on Medicare and Medicaid for Revenue

    The degree to which the "big 5" private health insurers have come to rely on Medicare and Medicaid for their revenues may surprise you—but that reliance may be the key to increasing their involvement in the Affordable Care Act's individual marketplaces, according to authors of a new analysis in Health Affairs.

    The analysis looked at annual corporate filings with the Securities and Exchange Commission between 2010 and 2016 for the nation's 5 largest insurers—UnitedHealthcare, Anthem, Aetna, Cigna, and Humana—to analyze how revenue streams have shifted, and whether the ACA's marketplaces have had an impact on that shift. Combined, the insurers cover 43% of the total US insured population, or about 125 million people.

    Authors of the study focused on where revenues were coming from: the private group market (including administrative services-only arrangements); the individual market; and federal programs including Medicare Advantage, Medigap supplemental plans, Part D drug plans, and claims payment and network management in Medicaid programs. Here's what the study found:

    Growth was significant—especially in Medicare and Medicaid.
    Overall, membership in the companies' offerings grew by 23% from 2010 to 2016—twice the increase from 2005 to 2010. Between 2010 and 2016, the number of Medicare and Medicaid-related members nearly doubled, from 12.8 million to 25.5 million.

    The revenue landscape has shifted.
    In 2010, total revenue for the 5 insurers was $209 billion, with 44% of those revenues from government-related offerings. By 2016, revenues had increased to $360 billion, with 60% coming from Medicare and Medicaid.

    The individual market—including ACA marketplaces—account for a fraction of membership.
    Between 2010 and 2016, the number of members in individual plans experienced a 72% increase, from 2.3 million people to 3.8 million. But those numbers represent a small segment of the big 5's overall membership numbers—just 2% of the overall members in 2010, and 3% in 2016.

    Medicare and Medicaid programs seem to yield better benefit ratios for the companies.
    Among the 3 companies that reported on medical benefit ratios—the average revenue retained by the company per member given claims that are made—the government-related programs were more lucrative. The companies reported that they retained between 13% and 19% of Medicare and Medicaid premiums for administrative expenses, overhead, and profits, or about $1,500 to $2,000 per year, per member. The rate for commercially insured members was $624 to $912 per year per member. Overhead expenses were higher for Medicare Advantage operations than for the commercially insured, however.

    "In effect, these national insurers have become significant agents of publicly sponsored programs, acting on behalf of the federal government and states to purchase and arrange medical care on behalf of beneficiaries," authors write. Whether that's a good or bad thing by itself they don't say, but what they do believe is that there's a flipside to the situation: a private insurance industry so deeply dependent on public programs for revenue may offer an opportunity to shore up the ACA marketplaces.

    According to the authors, that opportunity is "tying," which would require any large insurance carrier wishing to do business with Medicare or state Medicaid programs to sponsor individual-market plans in those areas as well. "Requiring insurers that participate in Medicare Advantage in a given area to also serve the area's Marketplaces would strengthen state-level efforts to grapple with market stability and enhance the viability of the insurance Marketplaces," they write.

    Authors note that the idea comes with a certain amount of risk. After all, the companies' participation in Medicare and Medicaid is voluntary in the first place, and it's entirely possible that some insurers would back out of government-related programs altogether. Given that the insurance marketplace is increasingly consolidated, such a move by a dominant insurance company could have significant effects. "Without viable alternative insurance choices or a publicly sponsored insurance program, such as traditional Medicare, the threat of exiting could hold public programs hostage to increasing plan payments to retain insurer participation," authors write.

    The analysis was supported by a grant from the Commonwealth Fund.

    APTA offers a wide range of resources for members who want to learn more about the workings of private insurance at the association's Private Insurance webpage

    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.