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

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

    The message

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

    The study

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

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

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

    Findings

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

    Why it matters

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

    Related APTA resources

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

    Keep in mind…

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

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website, where's you'll also find a clinical summary on Autism Spectrum Disorder in Children.

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

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

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

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

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

    Among the Recommendations
    Recommendations within the following CPG categories include:

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


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

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

    What a Difference a Day Makes: Researchers Say That for TKA, Post-Op Same-Day Physical Therapy Reduces Opioid Use and Shortens Length of Stay

    In this review: Same-Day Physical Therapy Following Total Knee Arthroplasty Leads to Improved Inpatient Physical Therapy Performance and Decreased Inpatient Opioid Consumption
    (The Journal of Arthroplasty, August 2019)

    The message
    Total knee arthroplasty (TKA) patients who received physical therapy on the same day as their surgeries were able to walk more while in the hospital and had lower rates of opioid consumption during their stay compared with patients who didn't receive physical therapy until the day after their surgeries. The same-day patients also tended to have shorter lengths of stay and higher rates of discharge to home.

    The study
    Researchers at the New York-based Columbia University Medical Center tracked 687 patients with knee osteoarthritis (OA) who received TKA at the facility between July 2016 and December 2017. A total of 295 "PT0" patients received postoperative physical therapy on the same day as their surgeries (POD0), consisting of a 30-minute session that included information, education, knee exercises, and activities-of-daily-life training. The remaining 392 "PT1" patients received the same session, but not until the day after surgery (POD1). Patients weren't randomized into the groups; instead the "PT0" and "PT1" groups fell into place, depending on whether factors such as patient motivation, fatigue, or pain during physical therapy prevented same-day physical therapy.

    All patients were asked to participate in 2 physical therapy sessions on postoperative day 1 if willing and able. Researchers evaluated ambulation distance, morphine equivalents consumed, pain levels, length of stay, and discharge disposition among the PT0 and PT1 groups. They also analyzed demographics, treatment details such as length of surgery, and preoperative function and outcome measures using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Knee Society Score (KSS).

    Findings

    • The PT0 group experienced an average 76% increase in "physical therapy performance" (number of steps taken) compared with the PT1 group. Authors of the study think the difference may be attributable to the idea that "early interaction with the physical therapist (PT) motivates and affirms patients that they can ambulate with full weight-bearing immediately postoperatively." That confidence-building, they write, paves the way for better progress in subsequent sessions.
    • While self-reported pain levels between the groups were similar, the PT0 group consumed about 25% less opioids than the PT1 group while in the hospital.
    • Average length of stay for the PT0 group was less than for the PT1 group—2.7 days compared with 3.2 days for the PT1 patients. The PT0 patients also tended to be discharged to home at a greater rate than the PT1 group, with 81.7% of the PT0 cohort sent home, compared with 54.8% of the PT1 patients.
    • Factors including gender, pain scores, preoperative KSS and KOOS, and age-influenced results, but did so similarly between the 2 groups. The groups showed no major differences in baseline characteristics.

    Why it matters
    TKA is an ever-increasing procedure predicted to rise to a rate of 1.3 million surgeries a year by 2030. Expenditures are high, with hospital length of stay and postacute care figuring heavily into costs—2 factors that seem to be positively affected by starting physical therapy the same day as surgery. Additionally, as authors point out, "any intervention that can demonstrate decreased opioid consumption is beneficial."

    Related APTA resources
    The association offers a TKA clinical summary, the Knee Outcome Survey-Activities of Daily Living test, and the Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement through the PTNow resource area, and individuals considering TKA can find a consumer-friendly guide at MoveForwardPT.com, the American Physical Therapy Association’s official consumer website. APTA's highly successful #ChoosePT campaign is helping to spread the word about effective nonopioid approaches to pain management, while the association continues to work for increased patient access to physical therapy for pain through direct advocacy and publications, such as its white paper on physical therapy's role in pain management. And be on the lookout: APTA's own clinical practice guideline on TKA is coming soon.

    Keep in mind…
    The research didn't employ a formal randomization process.

    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: Mothers Who Exercise During Pregnancy Give Their Infants a Motor Skills Boost

    In this review: Effects of Aerobic Exercise During Pregnancy on 1-Month Infant Neuromotor Skills
    (Medicine and Science in Sports and Exercise, August 2019)

    The message
    Infants of mothers who engaged in aerobic exercise during pregnancy tend to show better motor development at 1 month compared with infants of nonexercising mothers, according to authors of a new study. The researchers believe that aerobic exercise during pregnancy could be a hedge against childhood overweight and obesity.

    The study
    Researchers analyzed data from 60 healthy mothers (ages 18 to 35, with an average age of 30) and their infants. During their pregnancies, 33 women participated in 45-50 minutes of supervised aerobic exercise, 3 days a week. The remaining 27 women in the control group were asked to engage in a 50-minute supervised stretching and breathing program 3 days a week, but were otherwise advised to continue with "normal" activities. The infants of both groups were then evaluated for motor skills development at 1 month using the Peabody Developmental Motor Scales, second edition (PDMS-2), a tool that tests reflexes, locomotion, and a child's ability to remain stationary. The measure also provides a composite score, known as the Gross Motor Quotient (GMQ).

    APTA member Amy Gross McMillan, PT, PhD, was lead author of the study.

    Findings

    • The PDMS-2 scores, expressed as percentiles, were higher for the exercise group in the areas of stationary (45.5 compared with 39.5 for the control group), locomotion (55.7 compared with 50), and overall GMQ (56.3 compared with 52.5). They were lower in the reflex category (63.1 for the exercise group, compared with 66.2 for the control).
    • In the control group, male infants performed better than female infants in most tests—a finding that researchers expected given what's known about the role of testosterone in male infant development. However, in what authors describe as an "intriguing" finding, female infants in the exercise group tended to close that gap and even outperformed males, albeit slightly, in reflex, stationary, and GMQ scores.
    • There were no significant between-group differences in maternal age, BMI, number of live children, or education; and all infants included in the study were born healthy and full-term with no congenital abnormalities.
    • In the exercise group, compliance averaged 83%, with 81% of the exercising mothers reaching at least 70% compliance during pregnancy.

    Why it matters
    With childhood obesity and overweight rates continuing to rise, the pressure is on to promote healthy rates of physical activity (PA). Authors of this study point to previous research that links better motor skills in infancy to higher rates of PA through childhood and adulthood, and write that "the promotion of exercise during pregnancy may positively impact childhood health outcomes."

    More about the findings
    Authors aren't sure what exactly is happening through aerobic exercise in pregnancy, but they speculate that it may have to do with the release of growth hormone and intrauterine growth factor-1, which do not cross the placenta but can increase the supply of nutrients to the fetus. Additionally, they believe that the improved blood flow and oxygenation associated with aerobic exercise may also contribute to the differences.

    Keep in mind…
    The research involved only healthy women and didn't control for other factors that contribute to mother and infant health, including sleep, diet, sedentary behavior, occupation, and the infant's environment after birth.

    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: Knee, Hip OA May Increase Risk of CVD-Related Death, Underscoring Need for Emphasis on Physical Activity in OA Treatment

    In this review: Cause-specific mortality in osteoarthritis of peripheral joints
    (Osteoarthritis and Cartilage, June 2019)
    Abstract

    The message
    Researchers from Sweden found that among individuals studied, those with hip or knee osteoarthritis (OA) died from chronic ischemic heart diseases and heart failure at a greater rate than both the non-OA population and those with OA in other peripheral joints. No other significant correlations were found between the presence of OA and other causes of death, including diabetes, dementia, neoplasms, or diseases of the digestive system.

    The study
    Researchers tracked 469,512 health records from individuals in southern Sweden who were between the ages of 25 and 84 in 2003, including individuals who received an OA diagnosis between 1998 and 2003. Authors of the study then compared causes of death among the OA and non-OA group reported over an 11-year span, from 2004 to 2014. The researchers wanted to find out the degree to which the presence of OA in a peripheral joint (or joints) increased the hazard risk for various individual causes of death.

    Findings

    • Among all individuals studied, the most common causes of death were neoplasms and cardiovascular diseases (CVD), accounting for 66% of all deaths.
    • Compared with the non-hip/knee OA groups, those with hip OA were 1.13 times as likely to die from CVD, while the knee OA group was found to be 1.16 times as likely to die from CVD. Those differences increased as the individuals aged.
    • The CVD-related deaths among the hip and knee OA groups were primarily related to heart failure and ischemic heart disease, and rates didn't differ significantly between men, women, and when adjusted for other demographic variables.
    • Researchers found no correlation between OA and other causes of death studied: diabetes, hypertension, cerebrovascular disease, neoplasm, dementia, and liver disease.
    • Among the knee OA group, 26% underwent knee replacement during the study period. Of the hip OA group, 55% had a joint replacement procedure; however, the mortality results were similar even when both replacement groups were excluded from the hazard ratio analysis.

    Why it matters
    The bulk of research related to OA and causes of death tend to focus on all-cause mortality. This large-scale study took a more granular approach to identify possible relationships between types of OA and specific causes of death. Authors believe the findings further underscore the importance of emphasizing physical activity in the treatment of OA.

    What APTA's doing
    APTA is a strong supporter of the importance of physical activity in the treatment of OA. The association offers resources on encouraging healthy, active lifestyles at APTA's Prevention, Wellness, and Disease Management webpage as well as information on arthritis management through community programs. Members also can dive deeper into the issues by joining APTA's Council on Prevention, Health Promotion, and Wellness in Physical Therapy, and by checking out evidence-based resources such as this clinical practice guidelines on hip pain mobility deficits, available at the association's PTNow website. Patient-focused resources are available through APTA's MoveForwardPT.com website; additionally the Osteoarthritis Action Alliance offers a free booklet to help consumers participate in its "Walk With Ease" program.

    Keep in mind…
    Researchers were unable to adjust for body mass, a factor related to both the presence of OA and higher all-cause mortality. Additionally, the individuals with OA included those at all stages of the disease, and were limited to those who received an OA diagnosis—authors acknowledge it's likely that the non-OA group included individuals with undiagnosed OA.

    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.

    Military System Study: PTs in Primary Care Provide Safe Treatment and Are Less Likely to Order Ancillary Services or Make Referrals

    While civilian health care policymakers and stakeholders in the US continue to debate whether physical therapists (PTs) should be included as primary care providers, the country's military health systems have marched ahead with the concept. A new study adds to the evidence that the idea is working, both in terms of patient safety and reduced health care utilization.

    Authors of the study, published in Military Medicine (abstract only available for free) and first presented as a poster at the 2019 APTA Combined Sections Meeting, frame their research as an exploration of the potential for PTs to address the nationwide physician shortage by lowering costs and increasing access to care. They assert that the potential for more team-based, effective care could be at least partially realized if civilian PTs were treated like their military counterparts and included as primary care providers. It's a position that APTA strongly supports in its strategic goals and is consistent with APTA's own investigations into the PT's role in primary care settings. In addition, in 2018 the association conducted a practice analysis aimed at determining the feasibility of primary care as a specialty area recognized by the American Board of Physical Therapy Specialties and the American Board of Physical Therapy Residency and Fellowship Education.

    The study tracked 3 years' worth of patient data from the Malcom Grow Medical Clinic and Surgery Center (MGMC), a facility at Maryland’s Andrews Air Force Base that treats active-duty personnel and their families. MGMC patients with musculoskeletal complaints can choose their care pathway, receiving care through either a family health clinic (FHC) or the facility's physical therapy clinic (PTC). Authors describe the PTC as engaging in "advance practice" physical therapy that, in addition to its direct access status, allows PTs to order diagnostic imaging and lab studies, make referrals, and prescribe a limited range of medications.

    Researchers were interested in answering what they say is 1 of the main reservations about the PT as primary care provider—that patients would face increased risk of harm—and along the way wanted to find out what they could about the PT's use of ancillary services such as imaging and referrals. They analyzed data from nearly 250,000 provider encounters (207,241 from the FHC and 41,656 from the PTC), including information from an internal patient safety reporting database (PSR) that tracks "safety events" in which patients were exposed to or experienced various degrees of harm. Here's what they found:

    • Over the 2015-2017 study period, the FHC recorded 56 documented safety events, compared with 16 reported in the PTC. Adjusting for overall caseload, patients in the FHC were determined to be 1.9 times as likely to experience an actual or "near-miss" safety event (a potential safety event that never reaches a patient) as were the PTC patients.
    • While both clinics reported the majority of their safety events as near-miss, the PTC's near-miss events made up 75% of its total safety events during the study period, compared with a 50% rate at the FHC. A 72% near-miss rate is the MGMC’s benchmark.
    • Imaging was the most frequently used ancillary service in the PTC, but use rates were still significantly lower than the FHC rate, with 1 study per every 37.13 encounters in the PTC and 1 per 4.99 encounters in the FHC. Because of the frequency of imaging use in the PTC, authors believe that "pursuing diagnostic imaging authority may be of utmost importance if pursuing advanced practice physical therapy within a practice act or within a health care organization."
    • No adverse events were associated with the 1,817 thrust manipulations (197 in FCH, 1,621 in PTC) or the 2,910 dry needling procedures (PTC only) provided to patients during the study period.
    • Referrals to other providers were lower among PTs, with a rate of 1 per every 51.88 encounters, compared with 1 per every 3.06 encounters at the FHC.
    • Both the rate of prescriptions and orders for lab studies were dramatically lower among PTs, who wrote prescriptions at a rate of 1 per every 1,487 encounters and ordered lab studies at a 1 per 1,301 rate. Providers in the FHC had rates of 1 per 0.99 for prescriptions and 1 per 2.91 for lab work.

    Authors warn against interpreting the lower PT rates of additional service use as an endorsement of PTC superiority; instead, they are an indication of differences in necessary care pathways in the 2 clinics. Providers in the FHC, they write, must order lab tests "for other functions such as tracking disease progression or identifying proper [pharmaceutical] dosages," something that's not done as frequently in the PTC. Similarly, they write, "the number of images ordered by the PTC may be deflated if the patient had already received the imaging at the FHC."

    Setting aside those factors, they argue, the data show what they hypothesized—"that [physical therapy] has a similar safety profile to primary care within the specified domains of advanced practice [physical therapy]." Additionally, they write, their study supports findings from earlier research that found "significant reductions in health care utilization including pharmaceuticals and imaging services when patients accessed physical therapy first."

    APTA members Lt Col. Lance M. Mabry, BSC, USAF (Ret.), PT, DPT; Jeffrey Notestine, PT, DPT, ATC; Col. Josef Moore, MSC USA, PT, PhD; and Jeffrey Taylor, PT, DPT, PhD, were among the authors of the study.

    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.

    #Fail? Study Says Physical Therapy's Reach on Social Media Comes up Short

    When it comes to using social media to promote the profession, physical therapy may be missing out: that's the conclusion of a recent study that analyzed physical therapy-related tweets and found that, for the most part, Twitter discussions about the profession are occurring in an "echo chamber"—if they even rise to the level of a discussion in the first place.

    The study, published in APTA's journal PTJ (Physical Therapy), looked at a random sample of 1,000 tweets from a collection of 30,000 tweets gathered over a 12-week period. Researchers sorted out each message according to its author, intended audience, tone, and theme, and—when it occurred—the "pattern" of the twitter conversation, which includes shares as well as actual online exchanges. The collection was based on 9 search terms: physical therapy, physiotherapy, physical therapist, physiotherapist, #physicaltherapy, #physiotherapy, #physical therapist, #physiotherapist, and #physio. Hashtags associated with "known physical therapy campaigns," such as APTA's #ChoosePT, were not included in the searches. [Editor's note: the article appears in the August edition of PTJ, which is the journal's 1,000th issue—help celebrate by checking out the PTJ website for original research, perspectives, podcasts, and more.]

    Here's what they found:

    • Of the tweets that generated shares and discussions, most were what the Pew Research Foundation calls "tight crowd" and "brand cluster"—discussions that "tended to cluster on the periphery, dominated by a small group of highly connected people with few isolated participants," according to authors.
    • A substantial number of tweets, authors write, were from "disconnected participants" whose messages "resulted in no interaction with anyone other than the tweet's original author." The exceptions tended to be when APTA, other national organizations, and celebrities tweeted about physical therapy. As an example, authors offered up a 2016 physical therapy-related tweet by wrestler and actor John Cena, which at the time of the study had 1,550 retweets and 4,403 likes.
    • Almost half the tweets (48.5%) were characterized as "marketing" in nature. Employment-related tweets were a distant second at 17.7% of the total, followed by patient experience (15.7%), education (15.7%), advocacy (14.6%), conversation (14.3%), opinion/editorial (13.8%), physical therapist (PT) education (11.3%), research (7.7%), and continuing education (3.2%).
    • Recruiters and corporations were responsible for 86% of all employment-related tweets. PTs, physical therapist assistants (PTAs), and clinics were the authors of the majority of messages related to patient education, continuing education, and marketing.

    The big takeaway, according to authors, is that if PTs and PTAs want to heighten the profession's profile on social media, they need to do more than just show up.

    "The results of the present study reveal that simply being present on social media may not be enough," authors write. "The power of social media is in the conversation, and information becomes influential through 'likes,' 'retweets,' 'shares,' and 'mentions.' Physical therapy professionals and the hospitals and clinics that employ them need to understand the function and structure of online health conversations so they may influence and effectively engage in these conversations."

    Moving physical therapy discussions beyond what the researchers describe as a social media "echo chamber" will require a more savvy approach, according to the authors. They suggest "leverage[ing] the power and reach of broadcast networks and popular events" such as the Olympic Games, and using more generic hashtags (#rehabilitation, for example), as well as hashtags that "infiltrate another distinct mode of professionals" (#sportsmedicine, for instance) as ways to increase the reach of their messages.

    Authors acknowledge that the samples they studied provide a "limited" and "superficial" view of the entirety of physical therapy-related social media activity, and further admit that the average of 300 physical therapy-related tweets per day is a drop in the bucket compared with Twitterverse activity as a whole. Still, they argue, the profession needs to understand—and leverage—the power of social media as a provider of health information.

    "Online health information seekers have a high level of trust [in information accessed online] and often use it to make health decisions," authors write. "Rehabilitation-related information is not immune to this influence."

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

    APTA, Alliance for Physical Therapy Quality and Innovation Report Explores Relationship of 'Baseline' Patient Factors and Patient-Reported Outcomes

    Many patients who see a physical therapist (PT) bring more than just a movement system issue to the clinic: they bring a host of "baseline" factors that can impact patient-reported outcomes (PROs). That reality raises a big question: given a patient's individual mix of comorbidities, socioeconomic status, payer type, and other elements at the onset of treatment, how can PTs, payers, and patients know what constitutes a "typical" amount of improvement—and can currently available data provide any insight?

    APTA and the Alliance for Physical Therapy Quality and Innovation (Alliance) are aiming to get a handle on those questions and already have taken a significant step forward in the release of a report that explores benchmarks of quality care. In a joint news release, the 2 organizations describe the document as "the largest multipractice analysis of open-source, risk-adjusted clinical outcomes in the outpatient physical therapy industry."

    To tackle this project, APTA and the Alliance contracted with the Center for Effectiveness Research in Orthopaedics to take a close look at baseline and PRO data from 375,000 patient episodes in 50 states, all related to outpatient orthopedic physical therapy involving spine, shoulder, and knee care. The data were supplied by WebPT, Intermountain, ATI, and PTNorthwest. Those 4 companies, along with APTA, the Alliance, Select Medical, BMS Practice Solutions, ATI Physical Therapy, and US Physical Therapy compose the Physical Therapy Industry Outcome Workgroup responsible for developing the final report

    Among the workgroup's findings:

    Baseline patient data currently available through typical electronic medical records (EMRs) can explain a lot.
    "Payer type, patient socio demographic factors, and comorbidities at baseline all had strong effects on PRO changes over episodes of care," the report states. "Differences in these baseline patient factors must be accounted for to ensure fair performance comparisons of physical therapists."

    Despite baseline patient factors, physical therapists are making an overall difference in patients' lives.
    Researchers found that clinically important improvements in PROs were achieved in all 3 body regions over 12-14 visits.

    When it comes to risk adjustment, the data are there...
    The project also explored just how much patient baseline data are needed to establish risk-adjustment algorithms, labeled "minimal," "practical," and "optimal." In the end, researchers found that the "practical" dataset—commonly available EMR data that include payer source, weight, BMI, sex, patient zip code, and the presence of comorbidities and history of smoking—were sufficient to provide insight on variation in PROs.

    …The data can be put to use right now…
    The report includes risk-adjusted regression models for neck, shoulder, and spine patients that estimate levels of PRO change for every baseline variable in all 3 dataset models: "minimal," "practical," and "optimal."

    …And more is always better.
    "The completeness of data necessary for risk adjustment was a limitation of this project with only 8.8% of the patient episodes received [having] appropriate baseline and discharge PROs and only 6.3% [having] measures of the appropriate set of risk-adjustment factors," the report states. "Physical therapy organizations must be committed to institutional strategies that promote the collection of PROs at baseline and baseline patient factors into existing EMRs."

    Heather Smith, PT, MPH, APTA's director of quality, believes the report sheds light on 2 important issues: the value of physical therapy no matter the patient baseline characteristics, and the crucial need for consistent and thorough data that can help drive that point home.

    "The findings in this report add more depth to what we already know—that physical therapy improves patients' lives in ways patients can see and feel, even when other factors affect outcomes," Smith said. "But just as important, it points to the absolute necessity of widespread, standardized data collection and outcomes reporting throughout the profession. The more data we compile, the more we can help our patients and make the case for the effectiveness of our interventions."

    [Editor's note: APTA's Physical Therapy Outcomes Registry is a key player in the collection of data to improve patient care and strengthen the profession, and actively collects PROs as well as risk variables. Find out how you can participate in the Registry.]

    Survey of PTs Reveals 'Significantly Inadequate' Rates of BP and HR Measurement

    Despite the frequency with which physical therapists (PTs) in outpatient settings encounter patients who have or are at risk for cardiovascular disease (CVD), rates of blood pressure (BP) and heart rate (HR) screening remain "significantly inadequate," say authors of a new study based on a nationwide survey of PTs. The survey reveals that only 14.8% of respondents reported measuring BP and HR on initial examination of new patients, and sheds some light on factors that influence the tendency to perform the screens—or forgo them.

    The analysis, published in the July issue of PTJ (Physical Therapy), is based on survey responses from 1,812 PTs who worked in outpatient settings and were members of the APTA Academy of Orthopaedic Physical Therapy at the time of the survey. The survey was administered online and consisted of 30 multiple-choice questions that delved into CVD-risk screening behaviors and related rationales as well as demographics and education background of the respondents, and patient characteristics.

    The results showed that although 51% of PTs reported that at least half of their current caseload included patients with or at moderate-to-severe risk of developing CVD—and 28% reported that more than 50% of their patients were in this category—only 14.8% said that BP and HR screenings were a regular part of their initial examination of a new patient. When researchers dug deeper into the results, they uncovered other interesting details, including:

    • Nearly 7 in 10 PTs (68.9%) said they encountered a new patient with or at risk for CVD at least twice a week, and 29% said they encountered this kind of new patient daily.
    • In terms of how frequently BP and HR were measured at the initial visit, 63.74% of the respondents reported doing the measurements less than 50% of the time; 39.8% said they conducted the screenings less than 25% of the time; and 13% responded by saying that they never measured BP or HR.
    • The most commonly reported barriers to BP and HR screening were lack of time (37.44%) and "lack of perceived importance" (35.62%). Most respondents reported that they were adequately equipped to perform routine screening and felt confident in their ability to do so.
    • When it came to factors that were linked to more frequent BP and HR measurements, respondents with higher percentages of patients with or at risk for CVD tended to perform the screenings more often, as did PTs who had completed a residency or fellowship training program, and clinicians with more than 20 years of practice experience. Possessing a board-certified specialization credential of any kind was not linked with increased likelihood of conducting the screenings.

    Authors of the PTJ article describe the results as "surprising," particularly given the typical respondent caseload and the PTs' apparent confidence in their ability to perform BP and HR screenings. They write that current rates, while better than in the past, are still "significantly inadequate in relation to the high rates of CVD risk factors present in the patient population."

    As for what might be done to improve the rates, the researchers point to the link between postprofessional education (specifically, residencies and fellowships) and increased screening as one promising possibility, but they also stress other avenues for increasing clinician knowledge, such as wider use of social media to "improve clinician knowledge and practice patterns." Clinics could make a difference as well, they add, by changing policy to emphasize the importance of initial BP and HR measurements.

    APTA members Richard Severin, PT, DPT, PhD(c); Adam Wielechowski, PT, DPT; and Shane Phillips, PT, PhD, were among the authors of the study. Severin is a board-certified cardiopulmonary clinical specialist; Wielechowski is a board-certified specialist in orthopaedic physical therapy.

    [Editor's note: for an exploration of the importance of blood pressure screening and the role of PTs, check out this #PTTransforms blog post that discusses the impact of changes made to blood pressure guidelines in 2018.]

    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.

    JAMA Neurology: Telerehab Program Works as Well as Clinic-Based Program for Improved Arm Function Poststroke

    It's probably not news to physical therapists (PTs) when research backs up the idea that patients who experience arm impairments poststroke will tend to make greater functional improvements with larger and longer doses of rehabilitation. Unfortunately, PTs are also familiar with the fact that what's optimal isn't necessarily what's typical, with challenges such as payment systems, logistics, and clinic access making it difficult to achieve the best possible results. That's where telerehabilitation could make a big difference, say authors of a new study that found an entirely remotely delivered rehab program to be as effective as an equal amount of clinic-based sessions.

    The findings lend further support to the ideas behind APTA's efforts to increase telehealth opportunities for PTs and their patients—a significant component of the association's current public policy priorities. In addition, APTA provides multiple telehealth resources on a webpage devoted to the topic, and has created the Frontiers in Research, Science, and Technology Council that provides interested members and other stakeholders with an online community to discuss technology's role in physical therapy.

    The study, published in JAMA Neurology (abstract only available for free), involved 124 participants who experienced arm motor deficits poststroke. All participants were enrolled in a rehabilitation therapy program that included 36 70-minute treatment sessions, half of which were supervised, over a 6- to 8-week period. The only major difference: one group's supervised sessions were face-to-face with a physical therapist (PT) or occupational therapist (OT), while the other group received telerehab from a PT or OT via a computer with video capabilities, accompanied by the use of a gaming system.

    Researchers were interested in finding out how patients fared in each approach, using scores from the Fugl Meyer (FM) assessment of motor recovery poststroke as their primary measure. Authors of the study also measured patient adherence with therapy as well as levels of patient motivation related to how well they liked the therapy they were receiving and their degree of dedication to treatment goals.

    Using a treatment approach "based on an upper-extremity task-specific training manual and Accelerated Skill Acquisition Program," researchers set up matched programs that included at least 15 minutes per session of arm exercises from a common set of 88 possible exercises, at least 15 minutes of functional training, and 5 minutes of stroke education. The clinic-based participants received in-person instruction on the exercises and used "standard exercise hardware"; the telerehab patients received instructions via video link and engaged in functional exercise via a videogame interface. Here's what the researchers found:

    • Both groups improved at about the same rate, with the telerehab participants averaging a 7.86 FM gain, compared with an average gain of 8.36 points for the clinic-based group.
    • Improvements were also about the same for the subgroup of participants who entered rehabilitation more than 90 days poststroke, with these "late" participants averaging a 6.6-point gain for the telerehab group and a 7.4-point increase for the clinic-based group.
    • While both groups reported high levels of dedication to treatment goals, the clinic-based group tended to report better levels of motivation and satisfaction. Adherence was also high for both groups, with a 93.4% adherence rate for the clinic-based group and a rate of 98.3% for the telerehab group.
    • Both groups increased their knowledge of stroke at similar rates.

    As for the technical details of the telerehab sessions, the system included a computer linked to the internet, a table, a chair, and 12 "gaming input devices." Keyboards were not necessary. The supervised sessions began with a 30-minute videoconference between the patient and therapist, and the functional training games used were designed to match the functional task work being done with the clinic-based participants. Unsupervised sessions adhered to the same content but didn't include contact with the therapist.

    "In an era when prescribed doses of poststroke rehabilitation therapy are declining, adversely affecting patient outcomes, these and prior findings suggest that outcomes could be improved for many patients…if larger doses of rehabilitation therapy were prescribed," authors write. "Our study found that a 6-week course of daily home-based [telerehab] is safe, is rated favorably by patients, is associated with excellent treatment adherence, and produces substantial gains in arm function that were not inferior to dose-matched interventions delivered in the clinic."

    Authors acknowledged that patient satisfaction with telerehab might be improved by increasing the amount of time spent with the therapist—providing that therapist is properly trained. "Current results underscore the importance of maintaining a licensed therapist's involvement during [telerehab]," they write.

    Ultimately, it's still too early to determine just how generalizable the findings are to other populations and conditions, the researchers say, but all indicators seem to point to the need for increasing the availability of telerehab and its inclusion in health plans.

    "The US Bipartisan Budget Act of 2018 expanded telehealth benefits," authors write. "Eventually, home-based [telerehab] may plan an ascendant role for improving patient outcomes."

    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.