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  • Consumer Reports Includes Physical Therapy in Pain Relief Feature

    The national dialogue on pain treatment has now been highlighted by Consumer Reports in an article that promotes physical therapy as an effective alternative to opioids and other painkillers.

    The cover story of the June 2016 issue of Consumer Reports magazine, "Pain Relief Now!" takes readers through the basics of pain treatment and the epidemic of painkiller overuse, and provides guidance on different approaches to pain relief, as well as tips on what to do to respond to different kinds of pain.

    Although just 1 of several professional and medication approaches mentioned in the article, physical therapy is well-represented. The article begins with the story of a woman who experienced a sudden onset of back pain that was relieved through physical therapy, and includes a brief description of physical therapy's history and proven effectiveness.

    In an accompanying "Soothing Strategies" article, Consumer Reports suggests physical therapy for low back, neck and shoulder pain, writing that in cases of neck and shoulder pain, "studies show that relief can happen in as few as 1 to 3 sessions [of physical therapy]."

    In the News: Tech-Driven Approaches Improve TKA, THA Surgery and Recovery

    Rehabilitation from total knee arthroplasty (TKA) or total hip arthroplasty (THA) may be a constant, but the time needed for rehab could be shortened, thanks to new ways of performing TKA, THA, and joint restoration surgeries.

    In an April 21 article in the Miami Herald, reporter Caitlin Granfield writes about approaches to surgery that rely on technologies such as robotics and 3-D modeling to help create procedures that, among other recovery-enhancing qualities, minimize impact on surrounding muscles. Techniques include what Granfield describes as "quadriceps-sparing knee replacement, where surgeons lift the muscle and the knee-replacement surgery is performed from the side, with the incision much shorter than traditional knee replacement surgeries."

    "Over time, we've realized that certain muscles and tissues can simply be moved out of the way and don’t need to be detached," one orthopedic surgeon says in the article.

    In addition to the "quadriceps sparing" approach, the article describes other ways orthopedic surgery is focusing on techniques that improve recovery and function, including hip preservation surgery, and the use of a 3-D model of a patient's leg that is uploaded to a computer that in turn directs a robotic arm to make precise cuts and accurately position the joint implant. Granfield also touches on custom-made implants and an even newer approach that uses "cooled radiofrequency energy" to provide pain relief for patients for whom surgery isn't an option.

    Attention to new approaches could well increase, now that the Centers for Medicare and Medicaid Services (CMS) has launched its Comprehensive Care for Joint Replacement (CJR) bundled care program in 67 metropolitan areas. That program requires hospitals performing TKA and THA to participate in payment systems based on an entire episode of care, from admission to 90 days postdischarge, rather than billing on a fee-for-service basis. The CJR system has ramifications for physical therapists (PTs) and physical therapist assistants (PTAs), and APTA has created a CJR resource page to help members stay informed on the program.

    Man With Paralysis Continues to Make Gains Via Technology That Allows Thought-Controlled Movement

    A man who is quadriplegic continues to make advances in his ability to control his hand through an electronic neural bypass system that allows him to grasp, pour, and even play a "Guitar Hero"-type video game by way of a brain implant. Researchers behind the project claim it’s the first time an individual has been able to move and control a previously paralyzed area of the body through thought alone.

    Burkhart and the researchers first made news when the system, called Neurobridge, was demonstrated in the summer of 2014. Burkhart, who lost feeling and control in his hands and legs after he broke his neck in a swimming accident, agreed to allow the researchers to implant a device in his brain that captures brain signals. When Burkhart thinks about moving his hand in specific ways, the captured impulses are translated to electronic impulses and sent to a special sleeve on his arm that stimulates the appropriate muscles, bypassing the spinal cord injury.

    In 2014, the technology only allowed Burkhart to open and close his hand. Since that time, the research team has continued to work with Burkhart to refine the algorithms that translate his brain signals into specific hand and finger movements. A recent video featured in The New York Times shows Burkhart pouring dice from a bottle into a wide jar, and then using his fingers and thumb to pick up a plastic stirrer and stir the objects in the jar. Later in the video Burkhart is shown manipulating the buttons on a video game guitar.

    "This is the first time a completely paralyzed person has regained movement just by using their own thoughts," said Chad Bouton, lead researcher for the project. A research letter on the project was published in the journal Nature.

    The Good Stuff: Members and the Profession in Local News, April 2016

    "The Good Stuff," is an occasional series that highlights recent, mostly local media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    Andrea Coppola Mendes PT, DPT, describes how she's running in the Boston Marathon to honor her sister who was lost to suicide. (North Andover, Massachusetts Eagle Tribune)

    "Why not use the model of the occupational and physical therapist in orthopedics to create a central role for therapists in oncology, advisers who could help cancer patients help themselves in taking small, strengthening steps?" – opinion from Susan Gubar (New York Times)

    "My other beef is that [the Salinas Valley Memorial Hospital] needs to increase its physical therapy staff so that patients can get more than a couple of sessions a day. To me, this only makes sense as it will get patients out of the hospital quicker, thus saving the institution money." – opinion from reporter Jeff Mitchell (Salinas, California, Californian)

    Katherine Harris, PT, PhD, vice president of the Connecticut Physical Therapy Association, comments on the high need for PTs in the Danbury area. (Danbury, Connecticut News-Times)

    Richard Rutt, PT, PhD, ATC, retires from Pacific University. (Pacific University [Oregon] e-newsletter)

    "In fact, one of the emphases of the project is that they are not just treating pain but addressing the cause of the pain." – feature story on the Lebanon, Pennsylvania-area physicians' attempt to shift to more prescription for nonopioid pain treatments, including physical therapy. (Lebanon, Pennsylvania Daily News)

    Eric Robertson, PT, DPT, OCS, provides a PT's take on the importance of posture. (LiveScience)

    "Having direct access to physical therapists can also help save health-care dollars, because patients can get care more quickly and are less likely to get orders for medical imaging." – article on passage of improved direct access legislation in Florida. (Orlando, Florida, Sentinel)

    Cole Galloway, PT, PhD, is the feature of a National Science Foundation video on the GoBabyGo! initiative and a Smithsonian program to inspire young inventors. (National Science Foundation YouTube channel)

    "What is so incredible about her PT appointments is how their structure relates back to life."- blog post from Emily Campbell, on how physical therapy for her children encouraged reappraisal in other areas of their lives. (Utah Mom Click)

    New Ohio State University program "combines traditional strength training with physical therapy." (WBNS 10TV, Columbus, Ohio)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    Zika: Study Finds That Virus Kills Neural Stem Cells; 'Scientific Consensus' Reached on Link to Microcephaly, GBS

    A new study on the Zika virus and its ability to kill neural stem cells is adding to what researchers describe as "the growing body of evidence" connecting the virus to reports of brain malformations. The latest findings arrive on the heels of a World Health Organization (WHO) announcement that there is now "scientific consensus" of a link between Zika and both Guillain-Barré syndrome (GBS) and microcephaly.

    The new findings, e-published ahead of print in the journal Science, describe how the virus killed neural stem cells in laboratory tests. "Our results demonstrate that [the Zika virus, or ZIKV] induces cell death in human...neural stem cells, disrupts the formation of neurospheres, and reduces the growth of organoids, indicating that ZIKV infection in models that mimics the first trimester of brain development may result in severe damage," authors write.

    "Our results, together with recent reports showing brain calcification in microcephalic fetuses and newborns infected with ZIKV reinforce the growing body of evidence connecting congenital ZIKV outbreak to the increased number of reports of brain malformations in Brazil," they conclude.

    The findings published in Science, as well as the WHO announcement, mark an important development, as some public health experts had postulated that the increase in the 2 conditions may be due to better detection. Since October 2015, Brazil has reported 6,909 cases of infant microcephaly or central nervous system deformities. Not all are due to Zika exposure, say WHO experts, but of the 2,860 investigated so far, 36.5% suggested infection in utero. The report also notes that 13 countries have experienced "increased GBS incidence and/or laboratory confirmation of a Zika virus infection among GBS cases."

    Recent patient case studies have noted the appearance in other nervous system conditions as well. In March, a 15-year-old girl in Guadeloupe developed acute myelitis after Zika infection, and an elderly man in Paris was diagnosed with meningoencephalitis after being exposed to the virus.

    The new reports change the debate on public health preparedness, with researchers cautioning that health care providers should prepare for a host of other neurological conditions or side effects related to Zika. "If you have a virus that is toxic enough to produce microcephaly in someone, you could be sure that it will produce a whole series of conditions that we haven't even begun to understand," Dr Alberto de la Vega, an obstetrician at University Hospital in San Juan, Puerto Rico, told Reuters.

    Accordingly, WHO is urging governments to assess their health care systems for detection, treatment, and care for those who experience complications from the virus, and recommending the development of robust mosquito control plans. It published interim guidance for identification and management of GBS and released a Zika app for health care workers, with the latest news, guidelines, research, and training. The app is available for Android and iPhone in English, French, Portuguese, and Spanish.

    Program Lets Children Create Their Own 'Superhero Cyborg' Prostheses

    Kids with upper-limb differences are getting an opportunity to create their own prostheses in a project that involves engineers, designers, 3-D printers—and for 1 young woman, lots and lots of glitter.

    Recently, a FastCompany article profiled Superhero Cyborgs, a San Francisco-based program that allows children with upper-limb differences to think about designing a prosthesis from "a superhero context," with no rules on how it should look, or what it should do. The program includes a 5-day workshop that pairs the children with engineers and design experts, with the children moving from sketch stage to actual construction and testing.

    The FastCompany article focuses in particular on the prosthesis designed by 10-year-old Jordan Reeves, whose goal was to "transform her arm into a cannon that spread a delightful cloud of glitter wherever she went." A video that accompanies the article shows that she pretty much nailed it.

    According to the report, the Superhero Cyborgs project aims to foster not just creativity and fun, but ongoing relationships between the children and their engineer mentors, who will be encouraging them to continue designing prostheses that may have more practical day-to-day applications.

    Or not. As Jordan's mother says in the article, when it comes to practicality, at this stage, "Who cares? It's fun and it's exciting and it's a really cool way to empower kids."

    Study on Race-Based Misperceptions Among Med Students Makes Headlines

    A new study that describes the racial misperceptions of some white medical students is drawing attention from national media not just for the ways it exposes bias, but for the relationship this bias may have to disparities in pain treatment.

    The study, published in Proceedings of the National Academy of Sciences (abstract only available for free), compared the responses of white "laypersons" with responses from white medical students to a set of 15 statements about the supposed biological differences between whites and blacks. Most of the statements were false, and included beliefs such as white people have larger brains than black people, black people have stronger immune systems, and black people's nerve endings are less sensitive than the nerve endings of white people.

    Though the ratio of respondents who said the statements were "possibly," "probably," or "definitely" true was higher among the non-medical students, the rates at which the medical students believed the statements were significant: half of the 222 medical students rated at least 1 of the false statements as possibly, probably, or definitely true. The statement asserting that black people feel less pain than white people was supported by 8% of first-year students, 14% of second-year students, 0 third year students, and 1 resident.

    Researchers then followed up with the medical students by presenting them with 2 case studies—1 describing the patient as black and the other describing the patient as white—and asked the students to assess the level of pain the patient was likely feeling. The students who supported the false racial statements typically rated the black patient’s pain as lower than the white person's pain, and made less accurate treatment recommendations.

    The results gained the notice of news outlets including National Public Radio (NPR), The Washington Post, and the Los Angeles Times, among others. Most coverage describes the study as supporting what the Post characterized as "one of the most vexing problems in treatment today: That whites are more likely than blacks to be prescribed strong pain medications for equivalent ailments."

    "What's striking is that these beliefs seem to operate kind of independently of individual prejudice," lead author Kelly Hoffman, a psychologist, told NPR. "It's not the case that these particular medical students and residents are just more racially biased. It's just these are very common beliefs that are very pervasive across our society."

    The study arrives at a time when the treatment of pain—and possible overuse of opioids—is receiving national attention. From new US Centers for Disease Control and Prevention (CDC) guidelines on prescribing opioids to a White House initiative on battling the opioid abuse and heroin use epidemic, much of the focus has centered on the ways in which physicians understand and treat pain, particularly chronic pain.

    The findings also surfaced not long after the US Department of Health and Human Services released a report that asserts some of the most common approaches to achieving "cultural competence" in health care don't result in any changes to disparities experienced by racial and ethnic minorities.

    ATPA is involved on both fronts. The association has partnered with the White House campaign, and supports the CDC guidelines, which recommend nondrug, nonopioid approaches as the first-line treatment for chronic pain. APTA has been offering resources on cultural competence and health care disparities for some time through webpages dedicated to the topics.

    New Website Includes 'Visualization' of PT, PTA Wages, Required Skills, More

    A new project from the Massachusetts Institute of Technology (MIT) is aiming to make government-collected data—including data related to the physical therapy profession—easier to access, understand, and visualize.

    Called Data USA, the project compiles and repackages data from federal, state, and local governments to create what it calls "the most comprehensive visualization of US public data." The website is intended for more casual users as a way to "transform ideas into stories," according to a report in The New York Times.

    And those "stories" include physical therapists (PTs), physical therapist assistants (PTAs), and physical therapy aides, though the narrative could be a little murky given the kinds of data used, and the ways they were organized.

    The page devoted to PTs is full of eye-catching graphics (once users scroll past a stock photo of what appears to be surgical health care workers, not PTs) that include national average wage, average wage by state (North Dakota, Wyoming, and South Dakota top the list), regions with the highest concentrations of PTs, and the "skills generally required" of PTs, among other areas. The PTA page is organized in roughly the same way, but combines PTAs with physical therapy aides.

    Data USA also includes information on physical therapy education, but the site does not specify what it means by the term "physical therapy degree," on which the graphs and charts were based.

    Report: To Succeed in New CMS Bundle Model, Hospitals Need to Pay More Attention to Postdischarge TKA, THA Care

    According to estimates from a Washington, DC-based health consulting firm, about 60% of the hospitals required to participate in the Centers for Medicare and Medicaid's (CMS) Comprehensive Care for Joint Replacement (CJR) bundled care program may have a rough road ahead, because their spending on total knee arthroplasty (TKA) and total hip arthroplasty (THA) episodes of care exceeds regional averages.

    And what should hospitals do to rein in those costs? Pay more attention to what happens after hospital discharge, the consultants say.

    Avalere estimates the overall average Medicare payment for an episode of care for TKA and THA at $25,565. Of that amount, $13,193 is tied to the initial hospital stay. The rest is associated with postacute care, including skilled nursing facilities ($5,034), inpatient rehabilitation facilities ($1,568), home health agencies ($2,123), and other "outpatient" care ($604). Hospital readmissions were averaged at $1,155.

    The report was released just 2 days before the April 1 launch of the CJR, a new payment system that will require hospitals in 67 metropolitan areas to adopt bundled systems for Medicare patients undergoing TKA and THA.

    Avalere believes that to lower costs, hospitals will need to pay close attention to postacute care, an area that accounts for about 39% of payments, and one that isn't always on the hospitals' radar.

    "The reality is that most hospitals don't know where their patients go after they are discharged," noted Fred Bentley, vice president at Avalere in the report. "Their success under CJR will hinge on being able to track patients and partner with high-performing postacute care providers."

    According to Avalere, it's important to get a sense of the regional costs of care, because those estimates will figure heavily into the CMS formula for the CJR. Under the model, CMS will determine a single target payment for an entire episode of care (from admission through 90 days postdischarge) based on a predetermined amount derived in part from average costs in the area. If the hospitals report spending less than the predetermined amount, they could be eligible to receive additional payments; if they spend more than the bundle target, they could be subject to penalties, though the penalty phase won't start until 2017 and will be phased in over a 3-year period.

    According to Avalere, the launch of the CJR marks a shift in how CMS is approaching alternative payment models, and providers everywhere should take note, even if bundled systems are not yet required in their settings.

    "Most past CMS initiatives have stimulated activity among early adopters, but the mandatory programs are CMS' attempt to bring the remaining hospitals into a value-based payment world," said Josh Seidman, senior vice president at Avalere Health. "For many of those providers sitting on the sidelines of alternate payment models, this new initiative will be a wake-up call."

    CJR is here. The APTA CJR webpage contains extensive information on both the nuts-and-bolts of the program, and the considerations physical therapists should weigh when making practice decisions. The online resource also includes links to evidence-based clinical information and community programs, as well as a free webinar on the system.

    Obama Says Change in Pain Treatment Must be Part of Fight Against Opioid, Heroin Addiction

    Recently released US Centers for Disease Control and Prevention (CDC) prescription guidelines supporting nondrug, nonopioid treatments for chronic pain are among the resources that could help physicians and drug companies be held "more accountable" in the battle against opioid abuse and heroin use, according to President Barack Obama.

    Obama made the comments during a meeting of the National Rx Drug Abuse and Heroin Summit held in Atlanta on March 29. The event, moderated by physician and media figure Sanjay Gupta, featured a panel of former addicts, physicians, and public health experts, and was aimed in part at highlighting White House efforts to gain support for an additional $1.1 billion requested this year to fight the abuse epidemic.

    The conversation at the summit touched on the need for more and better-funded addiction treatment resources, reduced restrictions on the use of buprenorphine to treat opioid addiction, and an overall shift toward the view of addiction as a treatment problem rather than a law enforcement issue. But the discussion also addressed the ways in which the medical community has approached the treatment of pain through the use of opioids, and how that approach needs to change.

    "It seemed like for a period of time … that pain relief was talked about only in the context of giving out drugs," Gupta said. "The CDC has released some of these new guidelines regarding opioid prescriptions … pretty plainly stated … saying that these opiates should not be a first-line treatment for chronic pain. And that’s not the way the medical culture has thought about this for some time."

    Obama agreed with Gupta's comments, as well as comments from Leana Wen, MD, Baltimore's commissioner of health, who said that physicians aren't trying to create addicts but do need resources, "whether they are the guidelines as issued by the CDC, or whether they are other efforts by our medical societies to assist us, to make better decisions for our patients."

    "And so the doctor is right," Obama said in response to Wen. "We have to have a chance in the medical profession and the drug companies, and we have to hold them more accountable. We, as consumers and as parents have to be more accountable, as well, in terms of how we approach keeping our families well, in order for us to be able to prevent this massive gateway into addiction that can cause real problems."

    In addition to requests for increased funding, the Obama administration's efforts to fight addiction include an initiative involving public and private entities engaged in educating their constituents and the public. APTA is among the participants in that initiative, and recently attended a working group meeting to discuss the CDC guidelines.