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  • Study: High School Football Players Experience More Concussion Symptoms, Longer Return-to-Play Times Than Youth League or College Counterparts

    Researchers have found that high school and college football players report more concussion symptoms than youth league players, and that youth league players tend to return to play within 24 hours of injury at a higher rate than their older counterparts. What they haven't figured out is what accounts for the differences, although they have a few ideas.

    Authors of a study e-published ahead of print in JAMA Pediatrics tracked athletic trainer-reported diagnoses, symptoms, and return-to-play rates of 1,429 sports-related concussions among the 3 levels of football during the 2012-2014 seasons. The concussion data were drawn from 310 youth football team seasons, 184 high school team seasons, and 71 college team seasons.

    Researchers used a symptom cluster system to organize 17 concussion-related symptoms into 4 groups—cognitive, migraine, neuropsychiatric, and sleep—and tallied up all symptoms reported from initial injury to return to play, not just those reported at the time of the concussion.

    Here's what they found:

    • Across all concussions at all levels of play, an average of 5.48 symptoms were reported, with headache (94.3%), dizziness (75%), and difficulty concentrating (60.5%) being most common.
    • The average number of symptoms reported trended higher for high school players (5.6) and college players (5.56) than for youth sports players (4.76).
    • Within the symptom clusters, cognitive symptoms were experienced more frequently among high school and college players than among the youth league players. High school athletes reported higher rates of neurocognitive symptoms than the other groups, while college players reported a higher rate of sleep symptoms.
    • High school players were more likely to have a return-to-play wait of at least 30 days (19.5%), followed by youth (16.3%) and college players (7%).
    • Just over 10% of youth players returned to play within 24 hours of the injury, a rate more than twice that of college athletes (4.7% returned within 24 hours), and more than 10 times more than high school players (.8% returned within 24 hours).
    • Very few concussions resulted in loss of consciousness, a finding that authors believe "further [highlights] the limited utility of that symptom in diagnosing concussion."

    Researchers speculated on a number of possible reasons for the various differences among player groups. For example, the higher rate of cognitive symptoms experienced by high school players may be related to the fact that growth in brain gray matter peaks in adolescence, they write, and longer return to play times among this group could have something to do with "longer durations of class without breaks, which prolong symptom recovery."

    When it comes to the number of players who return to play within 24 hours, authors believe those rates might be partly accounted for by athletes presenting with delayed concussion symptoms, as well as "disagreement between athletic trainers and physicians" over a concussion assessment.

    The much higher rates of return to play within 24 hours for youth players may be explained by that age group's "struggle" to identify and describe their symptoms to athletic trainers, which authors believe presents a challenge of its own. "It is imperative to educate athletic trainers, parents, coaches, and officials on recognition and management of concussions in youth," they write. "This should include strategies on how to effectively elicit symptoms in this younger age group because they may be at greater risk for second impact syndrome."

    Physical therapists have a critical role in concussion prevention and management. APTA offers multiple resources on concussion, which include a Traumatic Brain Injury webpage, and a clinical summary on concussion available for free to members on PTNow. The association also offers a patient-focused Physical Therapist's Guide to Concussion on APTA's MoveForwardPT.com consumer website. Continuing education offerings from APTA include the prerecorded webinar "Managing Concussions With an Interprofessional Team" available through the APTA Learning Center.

    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.

    Even more information on concussion and youth sports injuries is available at the NEXT Conference and Exposition, June 8-11 in Nashville. Related sessions include "Concussion: Evidence-Informed Rehabilitation" and "The Young Athlete: Injury Prevention, Training, and Exercise Prescription for Performance Enhancement." Advance registration discounts end May 4.

    From PTJ: Electrodiagnostic Testing Sheds Light on 'Bioscaffolding' Procedure for VML

    Researchers believe electrodiagnostic testing may be a useful way to predict just what kind of improvement to expect from an experimental approach that uses material from pig bladders and intestines to grow new muscle in patients with severe muscle loss.

    According to an April 2016 article in Physical Therapy (PTJ), APTA's science journal, presurgical electrodiagnostic testing may help predict increase in muscle strength after a process known as extracellular matrix (ECM) implantation, a procedure that uses pig tissue cells to act as "scaffolding" that draws a patient's own stem cells to the site of volumetric muscle loss (VML). The procedure has been successful in regrowing tissue in preclinical testing, but research has been lacking on patient functional outcomes.

    In the longitudinal case series, authors wanted to find out how the surgery would change preoperative and postoperative electromyography (EMG) and nerve conduction study (NCS) results, as well as whether these tools could identify the best candidates for ECM implantation. They hypothesized that both electrophysiologic activity and muscle strength would improve.

    Researchers implanted 8 patients with severe muscle loss due to trauma. Three of the patients had VML in the anterior tibial compartment, 4 in the quadriceps compartment, and 1 in the biceps brachii. The average percentage of muscle loss was 66.1%.

    All participants completed a preoperative physical therapy program until they reached what authors describe as "a plateau in strength and function." One day prior to surgery, researchers performed needle EMG and NCS testing, and a physical therapist (PT) measured muscle strength using a handheld dynamometer. EMG testing measured muscle recruitment and abnormal spontaneous activity; the latter can indicate instability of muscle fibers.

    Within 48 hours after surgery, each patient began a 6-month physical therapy regimen, after which the same testing was performed. Four had significant improvement in strength (20% or more), 2 had minor improvement, and 2 experienced no increase in strength.

    Authors concluded that electrodiagnostic testing could be beneficial in predicting suboptimal outcomes. Five of the participants had improvements in either NCS or EMG results while also showing clinical improvements in muscle strength. Two participants showed no EMG activity or strength at baseline; they had no improvement in strength.

    "These findings suggest that muscles judged to have no electrical activity at baseline are unlikely to display improved strength following ECM implantation," authors note.

    The researchers attribute the wide variability in response to ECM implantation in part to degree and type of initial injury causing the muscle loss. For example, 1 participant showed increased compound muscle action potential (CMAP) amplitude of 80% but no increase in strength. Another had a 33.3% improvement in strength but no electrophysiologic improvement. Two others showed a "dramatic increase" in strength but decreased CMAP amplitude.

    Authors suggest the possibility "that the increased strength was a result of a restoration of mechanical integrity, rather than electrical conductance, of the muscle." However, the improvement in CMAP amplitude in 4 of the participants "is encouraging," they write, because it indicates an increased number of muscle fibers after implantation. These findings, the researchers contend, could not only inform surgical decisions in the future but also help PTs in designing regenerative rehabilitation protocols.

    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.

    Dutch Study Finds Positive Long-Term Outcomes for Multidisciplinary Treatment of Chronic Pain

    Authors of a new observational study from the Netherlands say that taking a multidisciplinary approach to chronic musculoskeletal pain (CMP) can not only result in short-term improvements, but seems to be beneficial even 2 years after a rehabilitation program has ended—particularly in terms of reducing health care provider usage and increasing patient working hours.

    For the study, published online in Musculoskeletal Care (abstract only available for free), researchers followed a group of 165 patients with CMP who participated in a 15-week multidisciplinary rehabilitation program that involved cognitive behavioral therapy (CBT), education, individual and group exercise, relaxation, and hydrotherapy. The program was provided by a team that included a rehab physician, an occupational therapist, a physical therapist, a social worker, and a psychologist.

    According to authors, an earlier study of the program had already established positive outcomes for pain and function at discharge; their study was focused on assessments of pain, function, fatigue, and other factors 12 and 24 months postdischarge. Participants were 87% female, with an average age of 44.1. The most-cited location of CMP was the back (71%), followed by shoulders (60%), neck (52%), and upper legs/knees (48%).

    Here's what researchers found:

    Mean ratings for pain were lowest at discharge; increased at 3 and 12 months, and then dropped slightly by 24 months but still showed moderate differences from baseline ratings. Ratings for fatigue followed the same pattern.
    At baseline, the mean participant rating for "pain in the previous week" was 6.6 on a 10-point scale. That number dropped to 5.2 at discharge and averaged 5.3 at 24 months. Ratings for the level of pain experienced on the worst days in the previous week averaged 8.2 at baseline, dropping to 7.1 at discharge and to 6.8 after 24 months. A 10-point fatigue scale (10 being "completely exhausted" over the previous 7 days) showed an average rating of 7.3 at baseline, 5.8 at discharge, and 6.3 at 24 months.

    Quality-of-life ratings rose at discharge, and by 24 months hadn't dropped off dramatically.
    Average scores on the Rand 36-Item Health Survey, which uses a 0-100 rating scale, showed the same general pattern of improvement that seemed to be maintained, for the most part, at 24 months. Increased average scores were recorded for Mental health (from 61 at baseline to 70 at 24 months postdischarge), physical functioning (from 46 at baseline to 53 at 24 months postdischarge), vitality (from 36 at baseline to 46 at 24 months postdischarge), and role-physical functioning (from 15 at baseline to 31 at 24 months postdischarge).

    Health care usage decreased, and hours worked increased.
    The number of health care providers participants reported seeing in the past year dropped from an average of 4 at baseline (range 1-13) to 2 at 24 months (range 0-9). The percentage of patients who reported working from 1 to 24 hours a week dropped from 62% to 53%, and the percentage of patients who reported working 25 or more hours a week increased, from 16% to 48%. The percentage of patients who reported no hours of work dropped to 0 at 24 months.

    One thing didn't change much: use of pain medications.
    The percentage of patients who reported using pain medication on at least a weekly basis was 75% at baseline and 69% at 24 months, a reduction that authors describe as not significantly different from rates at baseline.

    "The positive effect on pain in the present study was observed with the interventions [that targeted] the regain of activities and participation rather than on pain reduction," authors write. "The favorable effect on work status, as well as the significant reduction in health care usage seen in the present study suggests that the intervention may be cost-effective from the societal as well as health care perspective."

    The researchers acknowledge limitations to the study, including the lack of control group and the fact that the underlying causes of the CMP were not recorded—data that would have made it theoretically possible to make connections between specific conditions and the effectiveness of the multidisciplinary program.

    Still, authors write, the results show "promising" results for multidisciplinary approaches to treatment of CMP.

    "Multidisciplinary treatment is effective … especially taking into account that most of these patients were seeing many health professionals and were partly or totally out of work," authors write. "Furthermore, even 2 years later, the benefits were still present, with a sustained effect on health care usage and employment."

    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.

    Get more on the possibilities for physical therapy in the treatment of pain at the upcoming NEXT Conference and Exposition, June 8-11 in Nashville. Sessions related to pain include "The Physical Therapist as a Primary Care Provider for Patients With Low Back Pain," "A Sequential Cognitive and Physical Treatment Approach for Patients with Patellofemoral Pain Syndrome," "Pain Care Innovation in Rehabilitation," and "The Language of Pain: Define It, Speak It, Integrate It." Advance registration ends May 4.

    PTJ Podcast Roundup: Debility, Children's Mobility Needs, PTs in the ICU, and More

    The lead author of a recent study on debility and inpatient rehabilitation says that while physical therapists (PTs) are crucial to identifying deficits and making important protective changes in function, the improvements they help to establish may have a time-limited effect when it comes to reducing hospital readmissions.

    The comments were made during a recently posted podcast from Physical Therapy (PTJ), APTA's science journal. In the podcast, lead author Rebecca Galloway, PT, PhD, GCS, CEEAA, joins PTJ Editor-in-Chief Alan Jette, PT, PhD, FAPTA, to discuss findings of a study on debility and readmissions published in the February issue of the journal. That study found that while higher scores on the Functional Independence Measure (FIM) at discharge correlated to a decreased risk of readmission, the decreased risk essentially disappeared after 60 days.

    During the podcast, Galloway describes the importance of the PT's role in identifying variables in patients that can affect readmissions, and how the PT is in a special position to be able to pick up on the effects of comorbidities on function. "While we confirmed that that was important, we went a little bit further out than other studies have and identified for how long is that helpful information," she tells Jette.

    "While having higher motor function when a patient discharges is protective, that effect diminishes after 60 days," Galloway says in the podcast. "All that improvement and that effect of making a patient stronger and more functional during that inpatient rehab stay unfortunately is not going to have an everlasting effect on that patient's risk."

    Galloway's conversation with Jette is part of a podcast series produced by PTJ, all free-access for APTA members. Some of the other topics discussed in PTJ podcasts include:

    Community-based participatory research. Authors of a recent PTJ article discuss how PTs can build community-based partnerships to improve community health and help eliminate health care disparities.

    Unmet mobility and therapy needs among children. Jette and author Beth McManus, PT, ScD, discuss her research on caregivers' perceptions of how well needs are being met, and the ways those responses correlate to demographic variables.

    Why health services research matters. In one of her last podcasts as editor-in-chief of PTJ, Rebecca Craik, PT, PhD, FAPTA, interviews Linda Resnik, PT, PhD, FAPTA, and Janet Freburger, PT, PhD, the guest co-editors of the Health Services Research Special Series launched in the December 2015 issue.

    PT-led rehab intervention in the ICU. In this podcast Patricia Ohtake, PT, PhD, interviews Daniel Malone, PT, PhD, CCS, and Ellen Wruble Hakim, PT, DSc, CWS, who discuss the growing body of evidence showing how PTs improve outcomes in the ICU, and what that means for practice.

    Want to keep up with the free PTJ podcasts? Subscribe through itunes, sign up to receive new podcasts through an RSS feed, or simply visit the podcast webpage, click on a title to open the file in the media player associated with your browser, and listen on your computer's speakers.

    Can Care Meet the Need? Studies Show Arthritis Prevalence Is Growing, but Care System has 'Substantial Room for Improvement'

    By 2040, 1 in 4 Americans will have arthritis, 1 in 10 will experience a disability because of the condition, and—if things don't improve—many will receive treatment from community-based programs that, more often than not, fail to recommend exercise and education as a first-line approach. That's the picture created by 2 separate studies—one on predicted prevalence of arthritis, and another on the state of community-based osteoarthritis (OA) care.

    The prevalence study, which was e-published ahead of print in Arthritis & Rheumatology (abstract only available for free), uses National Health Interview Survey responses gathered over 3 years (2010-2012) to update earlier prevalence statistics based on 2003 data. Researchers then combined results with data from the US Census Bureau to make prevalence predictions, given demographic variables including the aging of the baby boomer population.

    Among their findings:

    • In 2010-2012, 22.7% of US adults were estimated to have doctor-diagnosed arthritis, based on "yes" responses to the question, "Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?"
    • Researchers estimate that during the same 2010-2012 time period, 9.8% of US adults reported arthritis-attributable activity limitations (AAAL), based on a "yes" response to the question, "Are you limited in any of your usual activities because of arthritis or joint symptoms?"
    • Arthritis prevalence is projected to increase by 49%, to 25.9% of all adults by 2040 (78.4 million).
    • The AAAL rate is projected to increase by 52%, to 11.4% of all adults by 2040 (34.6 million).

    "The implications of these projected increases in the prevalence of arthritis and AAAL are serious for a condition that is already the most common cause of disability," authors write. "The large and increasing burden of arthritis over the next 25 years, along with the important role that arthritis already plays in the millions of adults with multiple chronic conditions, suggests that it will remain an important factor for personal health and quality of life as well as public health."

    If an unrelated study's conclusions are correct, that "large and increasing burden" could be borne through community-based care that tends to come up short in terms of effectiveness as measured by quality indicators. That study, which focused only on OA, was e-published ahead of print in Arthritis Care & Research (abstract only available for free).

    Researchers conducted a systematic review and meta-analysis of "observational studies of actual clinical practice treating people with OA compared with quality indicators (QIs)" conducted between 2000 and 2015. A total of 15 studies including 16,103 patients were reviewed.

    To arrive at a sense of how well OA treatment was delivering care that met various QIs, researchers established "pass rates" in several areas, as well as an overall pass rate across studies. Quality indicators included "referral to orthopedic surgeon if no response to other therapy," "paracetamol or acetaminophen first drug used," "assessed for pain and/or function," and "referral or recommendation to exercise."

    The results, according to authors, show that there is "substantial room for improvement in the care of people with hip or knee OA." Among the findings:

    • The median overall pass rate across studies was 41%, and ranged from 22% to 65%.
    • The overall median pass rate for making an exercise recommendation was 34.1%, while referral to an orthopedic surgeon had a significantly higher pass rate, at 59.4%--something authors found "worth noticing," given the "general consensus that surgery should be considered only when the patient does not respond to conservative treatment."
    • Similar to exercise recommendations, the pass rate for "offering education and self-management" was also lower than referral to an orthopedic surgeon, at 35.4%.
    • The overall combined pass rate for first-line use of nonpharmacological approaches was under 40%.

    "Because no disease-modifying treatment is available, patient education and self-management interventions, exercises, and weight loss are the cornerstones of OA management," authors write. In their conclusion, though, they state that the lower pass rates for QIs related to those approaches "seems to be consistent, and indicates that there is substantial room for improvement in the care of individual patients and in cost containment for society."

    APTA offers a suite of resources on arthritis management through community-based programs, including an overview of evidence-based programs, and a decision aid to help physical therapists choose an appropriate program for the patient. Additionally, the US Bone and Joint Initiative (USBJI) offers a series of free public education programs aimed at helping providers increase community awareness of OA treatment. APTA is a founding member of USBJI.

    Don't miss the NEXT Conference and Exposition for even more on the subject. Be sure to attend "New Arthritis Foundation Resources for Individuals With Arthritis," presented by Cindy McDaniel, senior vice president of consumer health at the Arthritis Foundation, and Lori Schrodt, PT, PhD, chair of the Health Promotion and Wellness Special Interest Group of the APTA Academy of Geriatric Physical Therapy.

    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.

    Systematic Review: Telerehab-Based Assessments Do Well Compared With Face-to-Face Asessments—But Not Always

    Telerehabilitation (TR)-based physical therapy assessments for musculoskeletal disorders (MSDs)—some of them, anyway—fare quite well when stacked up against face-to-face (FTF) assessments, according to authors of a new systematic review. And while the news is mostly good for TR, authors say that more research is needed to see if this comparability holds up when applied to larger numbers of real patients, and in settings that are less than optimal.

    Researchers analyzed the results of 11 studies conducted between 2000 and 2010 to rate the validity and reliability of several TR-based assessments, compared with assessments conducted FTF. They also reviewed reliability within each TR assessment, looking at both consistency between physical therapists (PTs) who used the same TR-based assessment, and variance between repeated assessments conducted by the same PT. Results were published online in the Journal of Telemedicine and Telecare (abstract only available for free).

    What they found was that in several areas, TR-based assessments were not only reliably comparable with FTF assessments, but they also delivered reliable results between PTs and over repeated use by a PT.

    But it wasn't an across-the-board win for TR. Among the tests evaluated and researchers' findings:

    Range of motion (ROM). "No significant differences" were found between FTF documentation of knee ROM and a TR-based assessment (in which ROM was measured "by placing a universal goniometer directly on a computer screen"). Assessment of lateral flexion of the lumbar spine showed slightly more differences in a few studies; however, the "virtual goniometer" used in the assessments showed good-to-excellent results in 7 of the studies. Intra- and interrater reliabilities for TR-based ROM assessment were good-to-excellent, according to authors.

    Posture assessment. Authors found "conflicting evidence" here, with only 2 studies including the assessment and finding slight-to-substantial concurrent validity.

    Strength, endurance, and motor control. For assessments of lumbar spine endurance and motor control, TR-based assessments showed good validity (endurance) and excellent validity (motor control). Studies that evaluated TR-based assessments of static muscle strength ("by applying patients' self-resistance") found good-to-excellent agreement, as did studies that tracked TR-based muscle strength assessments among patients with total knee arthroplasty.

    Special orthopedic tests (SOTs). In studies that asked patients to watch a video and then perform SOTs under the supervision of a TR PT, agreement between TR and FTF assessments was less strong for elbow (75%) and shoulder (76%) conditions, but better for ankle (99.3%) and nonarticular lower limb musculoskeletal injuries (82.9%).

    Pain, swelling, and scarring. Agreement between TR-based and FTF pain assessments in ankle, shoulder, and elbow conditions was fair-to-moderate. Swelling assessment demonstrated a 90.3% rate of agreement, while scar measurement demonstrated low agreement.

    Gait and balance. Differences in the tools used for measurement among various studies seemed to affect the results, with 1 study that used the Tinetti tool demonstrating good concurrent validity, while other studies that used kinematic observational gait analysis showing excellent concurrent validity.

    Functional outcome measures. Excellent reliability was reported for the Oswestry Disability Index, the Short Form Health Survey, and the Tampa Kinesiophobia Scale; substantial-to-good levels of agreement were found for the Timed Up and Go test and the Berg test.

    Based on the findings, authors write that their review indicates that TR-based assessment is "technically feasible" to measure pain, swelling, ROM, muscle strength, balance, gait, and functional outcomes, but not as effective for lumbar spine posture assessments, neurodynamic tests, SOTs, and scar assessments.

    The words "technically feasible" shouldn't be overlooked; while authors believe that their review provides a good insight into what's known so far about TR-based assessments, they say that there's much more that needs to be found out.

    "The results of concurrent validity and reliability of TR-based physiotherapy assessments clearly demonstrate the feasibility of objective physiotherapy assessments for MSDs," authors write. "However, there is a scarcity of literature on TR-based musculoskeletal assessments."

    Authors explained that most of the studies they reviewed used simulated patients in laboratory settings, and "did not represent real populations who would include those unable to travel due to chronic disability or aging, or those who lived in rural areas with insufficient access to rehabilitative services." Other real-world issues that could affect the reliability of TR-based assessments, according to authors, include slow internet connections, low camera resolutions, poor lighting, inexperienced raters, "lack of video conference etiquette," and "poor rapport."

    "Attention should be given to the utilization of an optimal sample size, randomization procedure, data on real clinical populations, and real target environments," authors write. "Further studies are warranted to extend this TR-based physiotherapy assessment to other clinical populations of interest."

    In 2014, APTA's House of Delegates approved a resolution that supports the adoption of telehealth technologies in physical therapy as "an appropriate model of service delivery," when provided in ways that are "consistent with association positions, standards, guidelines, policies, procedures, Standards of Practice for Physical Therapy, Code of Ethics for the Physical Therapist, Standards of Ethical Conduct for the Physical Therapist Assistant, the Guide to Physical Therapist Practice, and APTA Telehealth Definitions and Guidelines; as well as federal, state, and local regulations." The association offers resources on telehealth in physical therapy—including a link to the Board of Directors’ definition and guidelines—on its telehealth webpage.

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

    Study: Episode-Based Payment Models Face Potential Overpayment, Underpayment Obstacles

    Paying for outpatient therapy by "episode"—the basic idea behind bundling models—could well reduce "wasteful variation" within episodes, but could bring with it the potential for "substantial" overpayment and underpayment, according to authors of a new study of community-dwelling individuals who received physical therapy, occupational therapy, and/or speech language pathology under Medicare.

    The study, e-published ahead of print in the Archives of Physical Medicine and Rehabilitation (abstract only available for free), analyzed Medicare part B data from 2010 related to outpatient therapy, limiting their episode analysis to only outpatient care (rather than an episode that begins with hospital admission) and excluding therapy users who resided in a nursing home or other institution for more than 90 days during the year. Researchers aimed to compare payment information based on "variable length episodes"—episodes of care that were defined by a 60-day "clean period" of no therapy before and after therapy, regardless of the length of therapy—with payment information based on fixed 30-, 60- and 90-day episode-of-care models.

    The idea behind the study? To get a better sense of how tying payment to a predetermined fixed-length episode of care would play out, and the effect variations in actual therapy lengths would have on overpayment or underpayment. Authors of the study include Pamela West, PT, DPT, MPH.

    In the variable-length analysis of 4.8 million episodes—3.8 million of which were physical therapy—researchers found that the average episode lasted 43 calendar days, with an average payment (for physical therapy) of $897. But that was the mean: the median for episode length was 29 days, a "considerably shorter" duration indicating that "most episodes are shorter than the average," authors write.

    When authors looked at the data through the lens of fixed episodes, they found that each window—30, 60, and 90 days—contained wide variations in actual treatment duration, and that setting payments based on the averages for each period could open up the possibility for overpayment and underpayment.

    For example, given that payments for therapy provided in the 30-day window ranged from $79 to nearly $1,000, researchers estimated that an averaged payment would open up the possibility that 10% of cases in the 30-day window could receive a $412 overpayment, and another 10% could be underpaid by at least $495. The pattern was similar in the 60- and 90-day episode categories.

    Authors write that while episode payments can reduce cost and potentially wasteful variation within episodes, "given the substantial variation in therapy episode expenditure, absent improvements in available data and in predictive information, pure lump sum payment would result in substantial revenue changes for many episodes."

    "The bundling or averaging inherent in episode payments means that some episodes are going to be paid less than current [fee-for-service] payments and some episodes will be paid more," they write. "Long-duration, higher-cost episodes will be paid less, and short, lower-cost episodes will be paid more under episode payment."

    Authors of the study point out that their research was confined to outpatient therapy only, and that some episode-based payment models—such as the recently enacted Centers for Medicare and Medicaid Services Comprehensive Care for Joint Replacement model—define their episodes around acute hospitalizations. In those cases, they write, "principal analysis of the larger bundle and therapy services must be considered as part of the larger episode, not as standalone, unrelated services."

    While acknowledging that it's hard to explain the "huge variation" in outlays under the fee-for-service model, authors believe that the challenge for bundled care models will be to decrease this variation while somehow dealing with the reality of the situation.

    "A desirable payment system will establish incentives to reduce any inefficiencies that may be reflected in this variation," they write, "but would also need to ensure access for beneficiaries in the extreme part of the distribution that need high levels of service."

    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: 'Cultural Competence' May Not Affect Health Disparities

    "Patchy" and "sparse"—those are the words used by authors of a US Department of Health and Human Services (HHS) report to describe the state of research into cultural competence and its effects on health disparities. And that patchy, sparse research could mean that the term "cultural competence" is outdated, at least when it comes to its usefulness as a way to address the equity of interventions among different populations, they say.

    The findings appear in a recently released "Comparative Effectiveness Review" from the HHS Agency for Healthcare Research and Quality (AHRQ). In the review, a multidisciplinary team describes its attempt to track down high-quality research into the kinds of cultural competence interventions used in health care, and whether those interventions actually affected health disparities. Bottom line: there isn't much research out there, much of it doesn't produce high-quality evidence, and almost none of it actually looks at the interventions' effects on disparities.

    After identifying more than 37,000 possible citations, 56 were ultimately identified as being appropriate for study. Of those, 39 were randomized controlled trials; the remaining studies were observational studies (15) or systematic reviews (2). The studies were clustered around interventions related to 3 groups: individuals with (physical and/or intellectual) disabilities; individuals in the LGBT population; and individuals who are members of racial and ethnic minorities.

    The 170-page report contains detailed information on the review process and findings for each group, but the researchers' conclusions in each area were virtually identical: "patchy" or "sparse" literature that fails to recognize intrapopulation differences, neglects the ways other cultures may intersect with the group at hand, or does not go into sufficient representative detail.

    Researchers found that the most prevalent type of cultural competence intervention was provider training, but they found "little evidence" that the trainings are effective at reducing disparities.

    "Long-term effects of such programs on provider behavior in the clinical setting and … patient health outcomes have not been evaluated," authors write. "Further, traditional provider cultural competence trainings based on attributions of a culture have the potential for unintended consequences, such as reinforcing stereotypes or increasing stigma."

    Also lacking, according to researchers, is "a better understanding of how cultural competence differs between and within groups."

    "For example, people with a physical disability experience more screening disparities because of limitations of the physical plant, whereas people with intellectual disabilities are more likely to not have secondary conditions diagnosed and treated," they write. "The interventions to address these disparities must also be different."

    Authors wonder whether the problems, and lack of good evidence, point to the need for a new approach that dispenses with the idea of "cultural competence" and focuses instead on outcomes for individuals who experience health disparities.

    "The 'cultural competency' label itself might be outdated, because it emphasizes the 'internal culture' of groups," they write. "A more useful term might be 'equity interventions,' which emphasizes equity as the desired outcome. More important than labels is that interventions address structural barriers faced by priority populations in order to attain health equity."

    APTA offers a webpage focused on racial and ethnic health disparities that includes a resource on addressing health care disparities with cultural competence in the clinic. In addition, the APTA learning center offers a professionalism module focused on cultural competence, as well as course titled "Developing Cultural Competence in a Multicultural World."

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

    Aquatic Exercise Good for Knee/Hip OA, Could Help With Transition to Land-Based Exercise

    Aquatic exercise can provide small, short-term benefits for people with mixed hip and knee osteoarthritis (OA), according to an updated Cochrane systematic review (partial review available; also accessible through PTNow ArticleSearch). But its real promise may be as a catalyst to move people with knee or hip OA toward effective land-based exercise.

    The update analyzed 13 randomized clinical trials (up from 6 in the previous version) to discern the effects of any aquatic exercise program on disability, pain, quality of life, and radiographic evaluation. Of the 1,190 participants, 75% were women, and the average age was 68. Most of the studies included individuals with hip, knee, or mixed knee and hip OA, though a handful examined knee or hip OA alone.

    Overall, the authors found moderate-quality evidence that active aquatic exercise caused a small, immediate improvement in disability, pain, and quality of life for mixed knee and hip OA. The jury is still out on whether it can be effective for people with arthritis in only the hip or knee—the trials focused on aquatic exercise for either knee or hip OA showed no statistically significant effect at any point after completing the program.

    Because of this difference, and because of the varied benefits of land-based loading for the 2 joints, the authors suggest that these active aquatic interventions may be useful for mixed OA only.

    While no studies have examined the long-term effects of aquatic exercise for knee and hip OA, absence of evidence is not evidence of absence, according to authors. The goal, they write, should be to "help inactive people with knee or hip OA to increase their daily physical activity" and begin physical training. Aquatic exercise may "diminish the deteriorating consequences of OA" and help improve "neuromuscular control in their lower extremities." "Lack of neuromuscular control," they write, "may lead to focal overload of the cartilage during land-based exercise."

    Future research, according to the authors, also should include radiographic imaging results to monitor changes in joint structure and identify the mechanism behind them.

    APTA features consumer-focused resources on aquatic therapy on a dedicated webpage at MoveForwardPT.com. In addition, APTA offers a Learning Center program on achieving a clinical competence certificate in aquatic physical therapy, and the association's Aquatic Physical Therapy Section provides opportunities for further involvement. Also available: an APTA webpage on arthritis management through community programs.

    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: As Youth Sports Intensity Grows, So Does Prevalence of Little League Shoulder

    Authors of new study say that Little League shoulder (LLS) is an underresearched condition—something that needs to change soon, because prevalence is up as more, and more intense, youth sports programs continue to proliferate.

    For the study, published in the American Journal of Sports Medicine (abstract only available for free), researchers looked at Boston Children's Hospital treatment records of 95 8- 16-year-olds diagnosed with LLS between 1999 and 2013. Although the numbers aren't large, authors claim that it's an improvement over what had been "the most instructive previous study to date," which only investigated 23 patients.

    To qualify for the study, patients had to have a diagnosis of LLS, also known as proximal humeral epiphysiolysis, with an open physis. Patients were further divided into groups with and without glenohumeral internal rotation deficits (GIRD). In addition to noting overall prevalence, researchers tracked demographics, treatment duration, recurrence rates, and possible risk factors associated with GIRD.

    The mean age of the patients in the study was 13.1 years, with 50% of all participants either 12 or 13 years old. The patient population was 98% male, and 97% of all patients were baseball players (3 patients were tennis players). Of the baseball players, 79 were pitchers, 7 were catchers, and the remaining 6 played other positions. The 2 females in the study—ages 10 and 11—were both baseball pitchers.

    Among the findings:

    • The incidence of LLS increased by an average of 8% per year, a rate of increase that was larger than growth in overall departmental and divisional patient volume.
    • Among all patients, 12 (13%) reported concurrent elbow pain, with 6 diagnosed with medial epicondyle apophysitis ("Little League elbow").
    • GIRD was diagnosed in 28 patients (30%), though authors feel prevalence may be underrepresented in their study. Ultimately they found that patients with previously-diagnosed GIRD were at higher risk for LLS, but the difference was deemed insignificant.
    • Cessation of throwing was part of the treatment recommendation for 94 of the 95 patients in the study, with an average 4.2-month resting period prescribed.
    • Physical therapy was provided to 75 patients (79%) at some point during treatment, with all GIRD patients receiving physical therapy.
    • Though 33% of patients were lost to follow-up, among the patients with adequate follow-up information, it took an average of 2.6 months to achieve resolution of symptoms, with an average return-to-play time of 4.2 months.
    • Authors believe that the clustering of LLS at ages 12 and 13 isn't surprising, as it's around that age that players move to a larger diamond that requires longer throwing distances.

    "The current study demonstrated increasing numbers of cases over the study period … which speaks to the pressing need for improved evidence in response to the evolving epidemiology of the condition," authors write.

    Authors also believe that the presence of concomitant elbow pain in 13% of the patients points to problems with how—or how often—children are throwing. "Impressively, this suggests that some young pitchers are throwing with such excessive force and/or frequency or with such poor throwing mechanics that 2 of their upper extremity joints are developing overuse injuries," they write.

    Moving forward, authors call for more research—and more care of youth sports participants.

    "As GIRD and symptom recurrence may occur in patients with LLS more than previously believed, consideration should be given toward close monitoring of patients for at least 1 year after initiation of treatment," authors write. "Current guidelines regarding pitch counts, rest, and activity modification in the setting of shoulder/arm pain should continue to be emphasized."

    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.