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  • Study: Patients in Cardiac Rehab Are Older, Less Healthy, and Have More Diverse Needs Than Patients 20 Years Ago

    The use of cardiac rehabilitation (CR) has grown over time, but with that growth comes changes to patient demographics that present new challenges to providers, say researchers who studied the CR patient population in 1 health system over 2 decades. They describe today's CR patients as older, more overweight, and having a higher prevalence of coronary risk factors than CR patients in the past, with an expanded range of reasons for receiving CR that makes the population more diverse than ever.

    The study analyzed data from 5,396 patients who received CR at the University of Vermont Medical Center over a 20-year period between 1996 and 2015, taking in a host of variables, including the reason for participation in CR, the presence of comorbidities, BMI, age, sex, and medications taken. Results were published in the Journal of Cardiopulmonary Rehabilitation and Prevention (abstract only available for free).

    Among the findings:

    • The average age of CR patients changed from 60.8 to 64.2 over the study period—an average yearly increase of 0.23 years. The number of CR patients 65 and older grew at an average yearly rate of 0.6%, while the yearly growth rate for patients 75 and older grew by 0.4%.
    • Women, while still underrepresented, are a growing part of the CR population, and now make up 29.6% of patients, compared with 26.8% in 1996.
    • The percentage of patients considered obese (BMI of 30 or more) increased from 33.2% to 39.6%, reflecting an average yearly increase of 0.5%. While mean weight and waist circumference didn't change, researchers attribute the more steady rates to the growing number of women receiving CR, which tamped down the rise of overall averages. When waist circumference and weight were controlled for sex, both were shown to have increased significantly over time.
    • The prevalence of cardiac risk factors increased in several areas. The rate of diabetes rose from 17.3% to 21.7% of patients, while the percentage of patients with hypertension increased from 51% to 62.5%. The number of patients reporting current smoking also increased, from 6.6% to 8.4%. Both diabetes and smoking rates were about the same between men and women, but women had an 11% higher rate of hypertension.
    • The underlying reasons for receiving CR were among the most dramatic shifts noted by researchers, with the percentage of heart valve replacement patients rising from 0% to 10.6% of the overall CR population. Patients receiving CR as part of treatment for myocardial infarction also increased to 39.6% of the CR population, compared with 29.7% in 1996. At the same time, the percentage of coronary bypass patients decreased significantly, from 37.2% to 21.6%, as did angina patients (5.4% to 1.5%).
    • The use of cardiovascular medications has also increased, with the most dramatic change being in the use of statins by 98.7% of the CR population. Statin use was at 63.6% in 1996.
    • Despite its growth, authors describe CR as still "underutilized," with only 35.5% of people who survive a myocardial infarction participating.

    Authors say that the wider use of CR is fueling at least some of the changes in patient characteristics, with heart valve replacement patients having a seemingly significant impact. The valve replacement patients were, on average, 2.3 years older than other CR patient groups, with a higher percentage of women, lower obesity rates, and generally lower prevalence of cardiac risk factors. As an example of the way valve replacement patients may be shifting overall numbers, authors point out that when valve replacement patients are taken out of the total CR population, the obesity rate jumps from 39.2% to 41.2%.

    Authors acknowledge that their study is limited by its focus on a single health system with a "relatively homogeneous" population, and a less-than-comprehensive range of diagnostic categories included. They assert, however, that the changes observed over time need to continue to be monitored for future trends—and should inform current practice.

    "Given the increase in patient heterogeneity, programs could benefit from having staff with diverse skill sets and able to handle the unique needs of patients with different medical needs," they write. "The ability to individualize patient treatment plans will need to increase. Patient complexity will also differ, suggesting a potential need for increasing staffing ratios."

    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.

    30 Minutes of 'Acute' Exercise Temporarily Boosts Memory-Related Brain Activity, Strengthens Brain Over Time

    That name on the tip of your tongue might be easier to retrieve after 30 minutes of moderate-intensity exercise, according to new research that links "acute" bouts of exercise with increased activity in areas of the brain associated with a certain type of memory. Researchers believe that the postexercise spike in activity may function as a kind of workout for the brain that, over time, can increase neural efficiency and slow cognitive decline associated with aging.

    In the study, published in the Journal of the International Neuropsychological Society, researchers monitored brain activity of 26 adults between 55 and 85 years old as they were quizzed on their recognition of famous names (the "Famous Names Task," or FNT). Each adult was tested twice: once after sitting quietly for 30 minutes, and on another day after engaging in 30 minutes of moderate-level exercise on a stationary cycle.

    The computer-based FNT presents subjects with names of famous people and names of individuals randomly selected from a phone book. Test-takers press 1 key for a famous name, and a different key for a name they don't recognize as famous. For the study, participants' brain activity was monitored as well as their speed and accuracy on the FNT.

    Researchers were focused on areas of the brain associated with semantic memory, the type of memory used to access the store of knowledge humans accumulate over time. Difficulty with semantic memory—for instance, an inability to remember a name—is one of the most common complaints of older adults, and has been associated with early stages of more severe cognitive decline.

    Researchers already knew that regular physical activity can improve cognition in older adults by sparking as-yet understood neurological changes that make the brain work less hard, and that's what they expected to see happening in the brains of participants who had recently exercised. Indeed, participants did score better on the FNT after exercise; but instead of seeing a more efficiently operating brain post exercise, researchers recorded increased levels of brain activity, a kind of short-term supercharging of some of the areas they were studying.

    Authors of the study think that the increased activity is related to the use of "compensatory neural networks," the networks associated with the "cognitive reserve" observed in physically active older adults. In other words, that postexercise brain activity workout may be clearing the way for more efficient cognitive operations over time.

    "We speculate that performing a single bout of exercise elicits a short-term impact on the upregulation and expression of neurotransmitters and neural growth factors that promotes increased neural activation," authors write. "With regular participation in exercise, this process repeatedly occurs; a stress to the system followed by recovery and adaptation. This may promote a greater capacity within neural networks."

    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: Arthritis Affects 1 in 4 in US; More Emphasis on Physical Activity Needed

    The US Centers for Disease Control and Prevention's (CDC's) latest snapshot of arthritis prevalence, severity, and related physical inactivity reported in 2017 looks a lot like its previous one, based on 2015 data. As then, an estimated 1 in 4 US adults have the condition, almost 27% of whom experience severe joint pain. Making matters worse, says CDC, of those with arthritis, around a third report that they don't engage in any physical activity, the very thing that "can improve physical functioning in adults with joint conditions."

    The latest report is based on a nationwide survey conducted in 2017 in which 435,331 adults across the country responded to questions related to whether they have been diagnosed with arthritis, rheumatoid arthritis (RA), lupus, gout, or fibromyalgia; the severity of pain they experienced during the past 30 days; and their participation in any PA (other than PA associated with their jobs) over the past month. Researchers then compared these data with respondent demographics, including geographic areas, to get a picture of how arthritis is affecting the country.

    The findings point to a position long-supported by APTA: increased PA among individuals with arthritis can have a marked impact on reducing pain severity and increasing function. 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. 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.

    Among the findings of the CDC study:

    Overall rates of arthritis remain about the same as they were in 2015—and follow the same geographic trends.
    The latest study revealed an estimated 54.4 million US adults have diagnosed arthritis—about 1 in 4 Americans. Of those, about 27% report experiencing severe joint pain. From a geographic perspective, prevalence and pain severity varies by state but are worse in Appalachia and the Lower Mississippi Valley. Prevalence ranges from a low of 15.7% in Washington, DC, to 34.6% in West Virginia, with severe joint pain rates varying from a low of 30.3% in Colorado to 45.2% in Mississippi.

    The prevalence of arthritis increased with age and was higher for some demographic groups, including women.
    Among adults aged 18-44, 8.1% reported being told they had arthritis, RA, lupus, gout, or fibromyalgia. That rate climbed to 50.4% among adults 65 and older. More women than men reported having arthritis (25.4% vs 19.1%), as did adults with obesity compared with healthy weight or underweight adults (30.4% vs. 17.9%). Among ethnic groups, non-Hispanic American Indian/Alaska Natives reported a 29.7% prevalence, while other groups reported rates ranging from 12.8% to 25.5%. Hispanic and non-Hispanic Asians reported the lowest arthritis prevalence among ethnic groups.

    About 1 in 3 respondents with arthritis reported severe joint pain, but that rate declined with age.
    Overall, the rates of "no/mild," "moderate," and "severe" joint pain reported was 36.2%, 33%, and 30.8%, respectively. Among respondents who reported severe joint pain, the rates dropped from 33% of those 18-44 to 25.1% among adults 65 and older.

    Higher rates of severe joint pain were associated with education, socioeconomic status, and sexual orientation, among other characteristics.
    Age-standardized severe joint pain was reported at rates above 40% for respondents who had less than a high school diploma (54.1%) and respondents living at or below 125% of the poverty level (51.6%). Among other demographic groupings, severe joint pain prevalence above 40% was recorded for non-Hispanic blacks (50.9%), retired persons (45.8%), Hispanics (42%), non-Hispanic American Indians/Alaskan Natives (42%), and individuals identifying as lesbian/gay/bisexual/queer/questioning (40.7%, but reported in only 27 states). Two-thirds of those reporting arthritis and identified as unable to work or disabled reported severe pain.

    PA inactivity prevalence varied by socioeconomic factors, too, and included a geographic element.
    Overall, physical inactivity increased with reported pain levels, from an inactivity rate of 22% among those with no/mild pain to a 47% inactivity rate for those reporting severe pain. Groups whose rates of reporting little or no PA in the past month were above 40% included respondents with less than a high school diploma (46.4%) and those at or below 125% of the poverty level (42.6%). Overall inactivity rates also increased as rurality increased, ranging from a 30.7% rate in large metro centers to 38.7% in noncore rural areas.

    In its discussion of the findings, CDC focuses much of its attention on PA levels and engages in a kind of collective head-scratch as to why more Americans aren't pursuing "an inexpensive intervention that can reduce pain, prevent or delay disability and limitations, and improve mental health, physical functioning, and quality of life with few adverse effects."

    "Arthritis-appropriate, evidence-based, self-management programs and low-impact, group aerobic, or multicomponent physical activity programs are designed to safely increase physical activity in persons with arthritis," the CDC states in the report. "These programs are available nationwide and are especially important for those populations that might have limited access to health care, medications, and surgical interventions."

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

    Study of Health System Reveals Good Functional Outcomes for Patients in Bundled Care Model

    Bundled care models for total joint arthroplasty (TJA) may be popular with payers and policy makers, but do they work for patients? A new study says yes.

    Researchers arrived at their conclusion after tracking TJA episodes in the University of Utah health care system during its switch from a more traditional approach to Medicare's Bundled Payment Care Improvement (BCPI) model 2. Similar to other bundled care models, the BPCI reimburses providers a set amount for an entire episode of care, from admission to 90 days after the patient is discharged, rather than for specific services provided during care.

    The before-and-after pictures focus on functional recovery, based on data from 680 prebundle and 1,216 postbundle patients gathered between 2014 and 2016 (the health system launched the BCPI in July 2015). Researchers used the Activity Measure for Post Acute Care (AMPAC) mobility assessment and the PROMIS Physical Function Computer Adaptive Test (PF-CAT) to track function outcomes. The AMPAC was used at various points during the hospital stay, and the PF-CAT tracked function presurgery and then 2 weeks, 6 weeks, and 12 months afterwards. Results were published in Arthroplasty Today.

    APTA members Joshua Johnson, PT, DPT, ATC; Caitlin Miller, PT, DPT; Julie Fritz, PT, PhD, FAPTA; and Robin Marcus PT, PhD, were among the study’s authors. Johnson is a recipient of the 2015 Florence P. Kendall Doctoral Scholarship and a 2017 Promotion of Doctoral Studies I Scholarship from the Foundation for Physical Therapy Research, both of which were used to support the study in part. APTA also provided partial funding for the study.

    Limited to elective procedures only, the study included 1,666 patients associated with 1,896 TJA episodes. The majority of TJA procedures were for knee replacement (57.9%). Patients had an average age of 62, and most were women (57.3%). Here's what researchers found:

    • Postoperative mobility measured through the AMPAC was slightly better for the postbundle group, but not significantly so—and only at day 0. By days 1 and 2, there were no differences in average AMPAC scores.
    • The PF-CAT also uncovered no significant differences between the pre- and postbundle groups at 12 months or any earlier points.
    • The postbundle group averaged slightly shorter hospital stays than the prebundle group, with an average stay of 2.1 days compared with the prebundle group's average of 2.3 days.
    • Bundled care was associated with decreased odds of patients being discharged to a postacute care (PAC) facility: in the study, 10.9% of the postbundle patients were discharged to a PAC, compared with 26.9% of the prebundle group.

    "The big takeaway here is that, at least in the health system in this study, we see that joint replacement bundles achieve patient outcomes that are similar to nonbundled systems, and that's good news," said Heather Smith, PT, MPH, APTA director of quality. "The whole basis of the shift to bundled payment models is to control and decrease costs while still achieving good outcomes, and that's what seems to have happened here."

    Smith acknowledges that part of the study's positive results may be due to overall changes made to TJA care in the year prior to the system's switchover to a bundle model—changes that included adding a swing shift for inpatient physical therapy staff to ensure earlier ambulation postsurgery, as well as greater emphasis on patient education and increased crossdisciplinary work. But she sees this as more good news for bundled care models.

    "The changes the system made to its care pathways are part of the success of this study, but the important point is that the bundled model could absorb them," Smith said. "These kinds of redesigns applied to value-based models represent some real opportunities for physical therapy to become an even more important component of care."

    The results are encouraging for another reason: bundled care is probably here to stay. While voluntary Medicare models such as the BCPI have been around for years, a mandatory Medicare bundle program, known as the Comprehensive Care for Joint Replacement (CJR) was introduced in 2016 and affected some 800 hospitals in 67 geographic areas. The program has been scaled back since then and now applies to about 450 hospitals in 34 geographic areas, but the US Centers for Medicare and Medicaid Services (CMS) doesn't seem poised to dismantle the program—particularly if data show decreased costs and better patient outcomes.

    "CMS may have tapped the brakes on its move toward bundled care in 2017, but it's still moving and focused on shifting to value-based payment models," Smith said. "And if more studies emerge like this one showing that patient outcomes are unaffected by the change, that focus will likely increase."

    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.

    Time to Standardize Acute Care Rehab for Patients Poststroke, Say Researchers

    Not all rehabilitation is equal for acute care hospital patients with ischemic stroke, say researchers in an article published in the May issue of PTJ(Physical Therapy). Authors found “significant variation” in the use of hospital-based rehabilitation services that “suggest a timely opportunity to standardize rehabilitation service delivery in acute settings for patients with ischemic stroke.”

    While current guidelines recommend early mobilization during hospitalization for ischemic stroke, authors write, they do not “provide clear recommendations on the optimal dosage of therapy.” This, combined with no incentive for hospitals to report on functional status to the US Centers for Medicare and Medicaid Services (CMS), led researchers to examine Medicare claims data from 104,295 patients in 2010 to identify what factors were associated with the type and amount of rehabilitation services patients received while in acute care settings.

    Overall, authors found that only 85.2% received any rehabilitation services: 61.5% received both physical and occupational therapy; 22% received only physical therapy; and 1.7% received only occupational therapy.

    Patients were more likely to receive any type of rehabilitation services if they were older than 70 years of age, had longer lengths of stay, or had received tissue plasminogen activator (tPA).

    However, patients were 16% less likely to receive rehabilitation services if they were dual-eligible for both Medicare and Medicaid, and 11% less likely if they had a recent prior history of hospitalization. Men also were less likely to receive therapy, and patients with more severe stroke—who required an ICU stay or feeding tube—were significantly less likely to receive rehabilitation services.

    There also was variation in the number of minutes of therapy patients received. While patients received an average of 123 minutes of therapy over 4.8 days, authors write, “dual-eligible patients received 5 minutes less therapy compared with non–dual-eligible patients, and patients receiving tPA received 16 more minutes of therapy.” Patients with a feeding tube received 5 more minutes of therapy than those without, on average. [Editor's note: APTA's PTNow online resource offers a clinical summary on stroke as well as guidelines on interventions to address neuroplasticity.]

    In addition, certain hospital characteristics played a role: Rural hospitals, hospitals with a higher volume of patients with stroke, and hospitals with an inpatient rehabilitation unit were linked to a higher likelihood of receiving rehabilitation services. Patients who received rehabilitation services in a limited teaching hospital or nonteaching hospital received an average 19 and 20 more minutes of therapy, respectively.

    Authors found substantial variability in use of rehabilitation services across acute care hospitals, even after accounting for length of stay and other patient and hospital-level factors. Approximately 38% of hospitals provided significantly less (76.3 minutes during the whole length of stay) than the national average of rehabilitation services minutes (123 minutes), whereas 22.4% provided significantly more (180.7 minutes) than the national average. Authors suggest a number of factors contributing to this variation, including a “lack of clear guidance on rehabilitation timing and dosage in the acute care setting” and a hospital reimbursement structure that encourages cost savings by decreasing length of stay and rehabilitation services.

    However, hospitals with inpatient rehabilitation units were more likely to deliver rehabilitation services to these patients, possibly because they are specialized in providing comprehensive care, and therapists “can be proponents of providing upstream rehabilitation interventions to improve downstream 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.

    New Phys Ed Studies Say There's More Work to Do

    Despite concerns that US education policy over the past 2 decades may be squeezing out opportunities for physical activity in school, it turns out that average student attendance in physical education (PE) classes hasn't dropped since the mid-1990s—but then again, it hasn't increased either and remains below recommended levels. Those were among the conclusions in a pair of recently completed studies that also found public schools not fully embracing policies that could improve their PE programs.

    The 2 studies were conducted by the National Physical Activity Plan Alliance (NPAPA) at the request of the President's Council on Fitness, Sport, and Nutrition. APTA is an organizational partner of the NPAPA. [Editor's note: Want to learn more about the National Physical Activity Plan and the work of the NPAPA? Check out this video, and read the entire National Physical Activity Plan, a roadmap for community-level change.]

    To reach their conclusions, researchers looked at nationally representative survey responses. The attendance study focused on self-reported data from students, while the research on policy implementation was based on information primarily gathered from PE instructors. The study on PE attendance is an update on previous NPAPA research, while the policy study is a first-ever investigation into the degree to which schools have adopted best-practice recommendations from SHAPE America's Essential Components of Physical Education. The attendance study was published in Research Quarterly for Exercise and Sport (abstract only available for free); the PE policy study was published in the Journal of School Health (abstract only available for free).

    PE Attendance
    Researchers found that the percentage of students attending 1 or more PE classes per week continues to hover at around 50%--more or less the same rate reported since tracking began in 1991. The latest data, from 2015, puts the average number of days a high schooler attends PE classes at 4.11 per week; however, nearly half (48.4%) of students reported attending no PE classes on average. Only 29.8% of students reported attending the recommended 5 days of PE per week.

    While authors of the study say that their findings challenged a recent Institute of Medicine report that claimed "political and economic pressures" on school systems were reducing PE curricula, they also acknowledged that, though relatively stable, the attendance numbers aren't good enough.

    "The prevalence of PE attendance among US high school students is still well below the recommended national guidance of daily PE attendance and is far from reaching the [Healthy People 2020] national health objectives," authors write.

    PE Policies
    For the policy study, researchers analyzed the degree to which schools have adopted the 7 policy recommendations contained in the SHAPE resource: providing daily PE; prohibiting waivers, substitutions, and exemptions; limiting class size; not assigning or withholding PE as punishment; ensuring full inclusion of all students in PE; and having state-regulated teachers endorsed to teach PE.

    The results were mixed at best.

    The good news: about 75% of schools said they didn't allow substitution of other activities (such as sports teams or marching band) for PE, and nearly the same rate required certified or licensed PE teachers. More than half didn't allow PE to be assigned or withheld as punishment, and just over 40% enforced maximum student-to-teacher ratios in PE classes.

    The less-good news: Only a quarter of schools prohibited exemptions from PE, and just 4% of schools provided daily PE for the recommended amount of time. A mere 0.2% of schools reported implementing all 7 policy recommendations, and about half (49.3%) were implementing only 2-3 policies. The findings also uncovered regional variations.

    "The findings of this study suggest that many elementary, middle, and high schools across the United States are not implementing essential policies to ensure effective [PE] programs," authors write. They identified the provision of daily PE, class size limits, and prohibiting exemptions from PE as the policies most in need of wider adoption.

    APTA Senior Practice Specialist Hadiya Green Guerrero, PT, DPT, says that the studies shine a spotlight on the gap between widely accepted standards and day-to-day reality in schools.

    "This study is a reminder of the overall lack of progress in improving the well-being of our children by incorporating more movement in schools," Green Guerrero said. "There are progressive policies out there, but these reports show that what's needed is more advocacy in our own communities for their adoption. We can develop any number of great ideas, but without implementation we'll continue to see an increasingly unhealthy population of children of all backgrounds."

    APTA has long supported the promotion of physical activity and the value of physical fitness. In addition to representation on the NPAPA and other organizations, the association offers several resources on obesity, including a prevention and wellness webpage that links to podcasts on the harmful effects of inactivity. Interested members also are encouraged to join the APTA Council on Prevention, Health Promotion, and Wellness to engage with a community of shared interest. APTA is also a board member of the National Coalition for Promoting Physical Activity.

    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: Falls Are 'Critical Health Hazard' for Individuals With Upper Limb Loss

    Arm motion is critical to helping compensate for losing one's balance and avoiding a fall. For individuals with upper limb loss (ULL), the lower extremities take on the burden of reacting to avoid a fall, and the lack of upper arm movement may put them at greater risk for falls than older individuals, say authors of a new study in PTJ (Physical Therapy). This "critical health hazard," they write, requires falls screening and "targeted physical therapy to enhance postural control and minimize fall risk."

    Via an anonymous online survey, researchers asked 109 individuals with an average age of 43 with ULL about their body and health characteristics, upper and lower limb loss characteristics, physical activity level, fall history in the previous year and circumstances, and upper limb prosthesis use. Participants also completed the the Activities-specific Balance Confidence (ABC) Scale. 

    Authors found:

    Falls are prevalent in this population, surpassing fall rates for older individuals and stroke survivors. Including individuals with ULL and those with upper and lower limb loss, 45.7% fell at least once in the past 12 months, while 28.6% reported 2 or more falls. Those numbers were slightly lower for respondents with only ULL, with 40.7% reporting 1 fall and 22.0% reporting 2 or more falls. The percentage of respondents experiencing a single fall is higher than for older individuals (33%) and community dwelling stroke survivors (~40%).

    Of all those who reported falls, 31.7% were injured in the most recent fall and 14.6% required medical attention.

    Most falls were due to slips, trips, and loss of balance. Of the reported falls, 30% occurred while walking outdoors, and 30% occurred while walking up or down stairs. Only 11% of falls occurred during physical exercise or playing sports. Most fell because they lost their balance (27%), tripped (25%), or slipped (18%).

    Balance confidence and self-perception play a role. Respondents were significantly more likely to fall if they had lower balance confidence and low perceived physical capabilities. They also were 6 times more likely to fall if they reported using an upper limb prosthesis.

    These results, especially the high rate of injuries, have "considerable clinical importance because it suggests the presence of a critical health hazard for individuals with ULL," authors write. "Balance confidence, use of upper limb prostheses, and perceived physical capabilities could be useful screening metrics."

    While further research is necessary on which interventions are best to address these fall risks, authors suggest that balance-targeted therapies, as well as interventions developed for older adults to better recover from trips, could also help individuals with ULL "refine their motor response to perturbations and enhance overall stability."

    "Monitoring these patients during rehabilitation would help create awareness of this health concern, and identify individuals at risk of falling in the community who could benefit from intervention," they write.

    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 Announces 2019 Grant Opportunities

    The Foundation for Physical Therapy Research (Foundation) now is accepting applications for a host of 2019 Research Grants—including a new mechanism, made possible through a bequest from a lifetime APTA member, that will award up to $360,000 for a 3-year research project.

    The new Goergeny High Impact/High Priority Research Grant is the result of a $1.58 million bequest from the estate of Magdalen and Emil Goergeny. Originally from Hungary, the Goergenys immigrated to the United States in 1960, where Magdalen received physical therapist training and established a practice. The Goergenys' bequest, received after their deaths in 2013, is among the largest personal donations ever received by the Foundation.

    Application deadline for all grants is early August 2019, with 2 grants requiring letters of intent due May 31. Grant opportunities include:

    • Goergeny Research Grant (High Impact/High Priority): Up to $360,000 (2-year total of $240,000 with third year competitive renewal) for research focused on the role of physical therapy in the prevention of secondary health conditions, impairments of body structures and functions, activity limitations, and/or participation restrictions. Interested applicants must submit a letter of intent by May 31, 2019, at noon ET.
    • Magistro Family Foundation Research Grant: $100,000 for a research project investigating physical therapist interventions. Investigators at any level are welcome to apply regardless of funding history. A letter of intent is required; applicants will be invited to submit full applications based on content. Letter of intent is due May 31, 2019, at noon ET. This grant is made possible by the Magistro Family Endowment Fund.
    • Foundation Marquette Challenge Research Grant: $40,000 for an investigator-initiated research project by an emerging investigator. This grant is named in honor of the annual student fundraising effort, the Marquette Challenge.
    • Health Services Research Pipeline Grant: $40,000 awarded to support research that examines how patients obtain physical therapy-related health care, how much that care costs, and outcomes, with an emphasis on the most-effective ways to organize, manage, finance, and deliver high-quality physical therapy-related care while potentially reducing medical errors and improving safety for patients. Investigators at any level are welcome to apply regardless of funding history. This grant is made possible by APTA.
    • Pediatric Research Grant: $40,000 to an emerging investigator for research consistent with the current Academy of Pediatric Physical Therapy Research Agenda. This grant is made possible by the Academy of Pediatric Physical Therapy.
    • Women's Health Research Grant: $40,000 to an emerging investigator for research in abdominal and pelvic health physical therapy that aligns with the mission and vision of the APTA Section on Women’s Health. This grant is made possible by the APTA Section on Women's Health.

    Questions? Email the Foundation, or call 800/875-1378.

    Note: Before starting your funding application, be sure to carefully read all eligibility guidelines, instructions, and information on funding mechanism deadlines. Also, it's a good idea to start the submission process early to allow for potential questions to be answered.

    New Pilot Study Opportunities Available From CoHSTAR

    The Center on Health Services Training and Research (CoHSTAR) has opened a call for the development of multiple pilot studies that would help set the stage for larger efforts to advance a wide range of health services research. APTA was a major financial contributor to the development of CoHSTAR, having donated $1 million toward the center's startup in 2015.

    The selected pilot studies would address research questions in CoHSTAR's 4 areas of specialization—analysis of large data sets, rehabilitation outcome measurement, cost-effectiveness, and implementation of science and quality improvement research—and the CoHSTAR Pilot Study Program webpage lists examples of specific types of studies that would qualify for funding. Each pilot study will receive $25,000 in funding for direct costs.

    Priorities for funding will be given to applications that align with 1 of the 4 areas of CoHSTAR specialization, have a strong likelihood of leading to broader research with major external funding, and have good potential to result in future research with high societal or policy impact for physical therapy. Principal investigators must include at least 1 physical therapist (PT) who is a US citizen or a certified permanent resident of the United States.

    Letters of intent are due to CoHSTAR by June 1, 2019. Based on those letters, in early July CoHSTAR will invite applicants to submit a full application by August 26. Award winners will be notified on October 15. For more information, visit the CoHSTAR Pilot Study Program webpage.

    CoHSTAR was established with a Foundation for Physical Therapy Research grant of $2.5 million. In addition to APTA’s $1 million donation, funding for CoHSTAR also came from APTA components, individual PTs, foundations, and corporate supporters.

    JAMA Oncology: Telerehab Makes a Difference in Patients With Advanced-Stage Cancer

    "Collaborative telerehabilitation" isn't a regular part of care for patients with advanced-stage cancer, but maybe it should be, say authors of a study recently published in JAMA Oncology (abstract only available for free). They found that the approach, which combines remotely delivered rehabilitation instruction with outpatient physical therapy and regular communication, can reduce pain, improve function, shorten hospital says, and decrease the use of postacute care facilities.

    The findings are based on results from the Collaborative Care to Preserve Performance in Cancer (COPE) program, a randomized clinical trial designed to address what the JAMA authors describe as a "knowledge gap" in the application of collaborative care models (CCMs) focused on patient function. The COPE trial includes patients with stage III or IV solid or hematologic cancer with a life expectancy of more than 6 months, and who reported moderate functional impairment (a score of 53-60 on the Activity Measure for Postacute Care assessment, or AM-PAC).

    The 516 participants in the study were divided into 3 groups studied over 6 months: a control group that was encouraged to self-report on pain and function via telephone or web-based surveys (every other week for the first month and monthly thereafter), an "arm 2" group that received a collaborative telerehabilitation program led by 2 physical therapist (PT) fitness care managers (FCMs) with 15 years or more of specialization in cancer rehab, and an "arm 3" group that added pharmacological pain management to the collaborative telerehab model, overseen by a nurse pain care manager (PCM).

    The collaborative telerehabilitation model put patients in touch with FCMs who provided instruction on "an incremental pedometer-based walking program" as well as the Rapid Easy Strength Training (REST) resistance training program, individualized based on patients' physical impairments. Participants also reported to the FCMs on pain and function, where FCMs "encouraged the use of compensatory strategies and initiated rehabilitative analgesic modalities when indicated," authors write.

    The participants in the telerehab model also were referred to local outpatient PTs "to further adapt their conditioning and analgesic regimens," with the outpatient PTs and FCMs working together to advance step and REST goals. Participants in arm 2 reported on progress, pain, and function weekly for the first month of the study and were then allowed to drop back to every other week or even once a month. FCMs received an alert if participants reported loss of function or increased pain, or if they failed to achieve the recommended 4 REST sessions per week.

    The arm 3 participants received the same rehabilitation approach but at the direction of a PCM, with the only real difference being that during the monitoring phase participants could request a call from the PCM, who could recommend the prescription of pharmacological treatments to address pain and function.

    Among the findings:

    • Physical function, as measured by the AM-PAC, improved for the arm 2 and 3 groups versus control by about 1.3 points—a difference that exceeded the minimum clinically important difference (MCID) threshold of 1 point.
    • Both the arm 2 and arm 3 groups reported clinically significant, albeit similar, reductions in pain compared with control as measured by the Brief Pain Inventory—pain interference dropped by 0.4 for arms 2 and 3, while pain intensity dropped by 0.4 for arm 2 and 0.5 for arm 3.
    • When it came to quality-of-life measures, a slightly different picture emerged: arm 2 telerehab-only participants reported significant improvement over control via the 5-item EQ-5D-3L assessment, but arm 3 participants (telerehab plus pain management) did not.
    • Hospitalization days were on average 57% higher for the control group (7.4 days) than for arm 2 participants (4.2 days), and 18% higher than for arm 3 participants (7.2 days). Authors note that the differences had to do with shorter, not fewer, hospitalizations in arms 2 and 3.
    • Among patients who were hospitalized, arms 2 and 3 were 4.3 times more likely to be discharged home than was the control group.

    "Although modest, the COPE interventions' effect sizes of 0.23 for mobility and -0.24 for pain are nonetheless notable given the remote, low-touch delivery; the known positive effect of the control condition; and the trial's vulnerable, high-needs participants," authors write. "Furthermore, our findings agree with reports suggesting that surprisingly modest functional losses and gains among individuals with borderline dependency…can profoundly affect their requirement for inpatient care."

    The researchers were surprised by the data that showed the addition of pharmacological pain management to be less effective than telerehab alone when it came to improving function and about equally effective in decreasing pain. They believe more study is needed but speculate that the greater reliance on nonpharmacological approaches in both arms, as well as a "more seamless integration of pain- and function-directed treatments in arm 2, may have contributed to the outcomes.

    Authors also note that in addition to reduced pain and improved function, results of the COPE trial shed more light on possible avenues for reining in the costs of care for individuals with late-stage cancer.

    "Our findings of reduced hospital use among participants in the telerehabilitation arms add to growing evidence that proactively addressing functional impairment among vulnerable patients reduces hospital utilization," authors write "Reducing the requirement for institutional care among patients with late-stage cancer has the potential for high financial return given that hospitalizations account for a large proportion of health care spending in this population, drive regional variation in costs of care, and are not associated with survival or [quality of life]."

    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.