Intensive physical therapy and occupational therapy coupled with psychotherapy can significantly improve pain and function among youth with fibromyalgia, according to a study of teenagers who participated in a program designed to treat the condition without the use of drugs.
Between 2008 and 2011, researchers tracked the progress of 64 adolescents 13-18 with fibromyalgia as they progressed through a program that included 5 to 6 hours a day of physical therapy aimed at "quickly reestablishing normal function, along with maximizing aerobic conditioning." Participants also received up to 4 hours per week of psychosocial support that included individual and group cognitive-behavioral therapy, art therapy, music therapy, and "support for coping during [physical therapy and occupational therapy] sessions."
The length of the therapy varied by the participant, authors write, and was "individually determined by the treatment team based on physical functioning goals obtained, rate of improvement, and judgment regarding the child's ability to sustain and further improve on these functional goals in the home environment without formal physical therapy." The study was published online in the September issue of the Journal of Pediatrics.
Researchers evaluated outcomes at baseline, at the conclusion of the program, and 1 year afterwards using 6 measures but relying most heavily on scores from the Pain Stages of Change Questionnaire, adolescent version (PSOCQ-A), the Visual Analog Scale of pain (VAS), and the Pediatric Quality of Life Inventory (PedsQL).
They found that in all 3 measures, improvement was significant and sustained. At the 1-year mark, 81% of the participants recorded a score of 10 or less on the 1-100 VAS scale, with a third of all participants recording 0 on the VAS. Similarly, scores on the PSOCQ-A, which measures the degree to which an individual acknowledges and takes action over pain, showed a dramatic shift toward taking greater responsibility for addressing pain through behavioral change. Overall quality of life also improved significantly as reported in PedsQL scores, which recoded gain in physical and psychosocial health as well as school functioning.
Researchers acknowledge that "treatment goals were set high" for the physical therapy program, which included timed activities such as stepping in and out of a tub, running up and down stairs, stepping and squatting activity, scooter boards, treadmill, elliptical, stairs, long-distance community ambulation, strengthening and endurance activities, and video games that involve user motion.
"We focused on desensitization and prolonged aerobics, strengthening, and functional activities individualized to the subjects, and did not inquire about pain or let pain or the fear of pain stop them," authors write. "We believe that this focus on function rather than pain helps children break the pain cycle and overcome the long-standing functional and pain limitations with which they presented."
Researchers believe the program is effective not only because it achieves decrease in pain without the use of drugs, but because it provides children with the tools to address pain in the future.
"The children in the present study were significantly disabled and were able to achieve and maintain normal function by both self-report and objective measures over 1 year," authors write. "We speculate that most of these children will have the necessary mental and physical capability to stay well, and if relapses occur, will have the tools to self-reinstitute these measures and resolve any new symptoms."
Fibromyalgia is estimated to affect 2%-6% of the pediatric population, according to the study's authors, with girls reporting the condition 4 times more often than boys.
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 has spoken out in The New York Times (NYT) about recent reports that skilled nursing facilities (SNFs) are taking advantage of Medicare billing policies, stating that the allegations underscore the need to replace volume-based payment systems with systems tied to value.
In a letter to the editor published on October 8, APTA President Sharon L. Dunn, PT, PhD, OCS, responds to a September 30 NYT article titled "Nursing Homes Bill for More Therapy Than Patients Need, US Says." That article focused on a report from the Office of the Inspector General (OIG) of the US Department of Health and Human Services alleging that Medicare payments have "greatly exceeded SNF costs for therapy for a decade."
For APTA, the OIG report and related media coverage are directly related to the pressures being placed on physical therapists (PTs), physical therapist assistants (PTAs), and other providers to meet productivity demands that can sometimes run counter to actual treatment needed.
"The provision of physical therapy services should be driven by patient need and the clinical judgment of the licensed physical therapist," Dunn writes in the letter. "Productivity goals that drive services toward economic incentives continue to be an issue that policymakers and professional associations have a joint responsibility to meet."
Much of the criticism of SNFs is centered on the use of ultrahigh therapy hours in billing practices, which CMS estimates provides facilities with an average of $66 a day in payments over costs. A recent related analysis from the Wall Street Journal found that the use of ultrahigh therapy has increased from 7% of patient days in 2002 to 54% of patient days in 2013.
In the APTA letter to NYT, Dunn also describes APTA's collaborative efforts to address volume-based versus value-based care, and how the association's Integrity in Practice campaign aims to provide PTs and PTAs with resources to support care based on patient need and clinical judgment.
'We are committed to making sure that the correct incentives are invoked in care delivery, in a manner that maintains our patients' trust," the letter states.
The issue of productivity pressures is at the heart of an effort by APTA, the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASHA), which collaborated to produce a "Consensus Statement on Clinical Judgment in Health Care Settings (.pdf)." For more on productivity, check out "Measuring by Value, Not Volume," a recent feature article in PT in Motion magazine that takes a closer look at how some PTs are responding to the challenge.
A new podcast produced as part of APTA's #AgeWell campaign is shedding light on the fact that many of the health declines Americans believe are an "inevitable" part of getting older may not be so inevitable after all—and that physical therapists (PTs) and physical therapist assistants (PTAs) can help consumers take control.
MoveForwardPT.com is now offering a recorded interview with Alice Bell, PT, DPT, GCS, that focuses on the "9 Physical Therapist Tips to Help You #AgeWell" being promoted during National Physical Therapy Month. Bell addresses each of the 9 tips and describes how meaningful physical activity can make a difference—particularly when that activity is "reasonable" and "purposeful," 2 qualities that PTs and PTAs can help to ensure.
"The big message for any chronic disease [is] a healthy diet and engaging in meaningful physical activity," Bell says. "Physical therapists as the movement experts can really help to develop a plan and a strategy with an individual that is going to position them for success."
Beyond their ability to develop individual plans and strategies, Bell believes that PTs and PTAs are also positioned to create transformations in health care, moving it away from a system that tries to manage costly chronic conditions after the fact, and toward a system that encourages lifestyles that reduce the chances of these conditions ever taking hold in the first place.
"We have an opportunity to impact an individual in terms of their quality of life, functional performance, and life satisfaction, but we also have the opportunity and the ability to impact the entire population," Bell says in the podcast. "As a physical therapist, I view myself as an important member not just in an individual's health care team, but in an individual's wellness team, and we have the ability to change things dramatically."
The 9 #AgeWell tips are part of a wider effort to address—and debunk—assumptions about aging and what can be done to combat a range of problems, from diabetes to low back pain, and from osteoporosis to Alzheimer's disease. All of the #AgeWell information for consumers can be accessed at www.moveforwardpt.com/AgeWell. APTA also offers a range of online resources to help PTs and PTAs promote National Physical Therapy Month.
A new study of 5 years' worth of concussion data from NCAA sports reveals that men's wrestling is the sport with the highest rate of sports-related concussion (SRC), but men's football remains on top in terms of the sheer number of athletes who experience SRC while in practice or competition. And in men's and women's sports that can be directly compared—lacrosse, ice hockey, soccer, and others—female athletes tend to have higher rates of SRC than their male counterparts.
Researchers analyzed statistics from the NCAA Injury Surveillance Program (ISP) and found that between the 2009-2010 and 2013-2014 academic years, the overall SRC rate was 4.47 per 10,000 athlete exposures, or about 10,560 SRCs annually. Among reported SRCs, about 1 in 11 was recurrent. In almost every sport, the majority of SRCs occurred in practice, while the actual rates of SRCs were higher in competition settings.
Topping the list in terms of SRC rates was men's wrestling, which reported an overall rate of 10.92 per 10,000 athlete exposures. Next was men's ice hockey at 7.91, followed closely by women's ice hockey at 7.52. Men's football had a 6.71 rate of SRCs, but with an estimated 3,417 SRC incidents annually, it took the position as the sport that produced the most SRCs overall. Research results were published in the American Journal of Sports Medicine in September (abstract only available for free).
Rounding out the top 10 sports in terms of SRC rates were football in third position at the 6.71 rate, followed by women's soccer (6.31,), women's basketball (5.95), women's lacrosse (5.21), women's field hockey (4.02), men's basketball (3.89), and women's volleyball (3.57).
When it came to the overall estimated annual numbers of SRCs by sport, men's football was followed by women's soccer (1,113), women's basketball (998), men's basketball (773), and men's wrestling (617).
Researchers note differences in sex-comparable sports, with the women's sports reporting higher rates of SRCs in 4 of 5 activities (all except ice hockey, where men's and women's rates were nearly equal). Authors describe this finding as "consistent" with earlier NCAA findings and point to several factors that could contribute to these differences, including greater angular rotation and head-neck segment peak acceleration and displacement in women, weaker neck muscles, and the possibility that female athletes are more likely to report concussion.
In terms of the source of SRC, researchers found player-to-player contact as the leading cause, though this varied by sport, with some sports also reporting contact with the floor, balls, and equipment as not-infrequent causes of SRC. In men's wrestling, for example, "surface contact during takedown" accounted for 15.1% of all SRCs reported, while in women's volleyball, more SRCs occurred from ball contact or surface contact than from player contact.
Authors of the study write that overall rates of SRC seem to be increasing, but speculate that the increase may be related to increased reporting. The only sport that did not report an increase during the study period? Men's wresting, which while still highest in terms of incidence rates, actually dropped during the 5-year study period.
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 and the US Centers for Disease Control and Prevention (CDC) have partnered to offer physical therapists (PTs) and physical therapist assistants (PTAs) new resources to promote community-focused, evidence-based physical activity programs that help people manage arthritis outside a therapeutic setting.
Information on the offerings have been made available on the APTA website, through the association's consumer-focused MoveForwardPT.com, and via a CDC webpage. Taught by trained, certified instructors, the programs extend the benefits of physical therapy through activities including walking, aquatics, and low-impact aerobics.
The evidence-based programs are designed to be effective for patients with arthritis and related conditions that limit mobility, and generally cost less than $50 per participant.
Two physical therapists (PTs) have been named to a multidisciplinary work group that will focus on potential additions and changes to the American Medical Association's (AMA) current procedural terminology (CPT) codes as they relate to telehealth.
Alan Chong W. Lee, PT, PhD, DPT, CWS, GCS, and Helen Fearon, PT, FAPTA, will join the AMA Telehealth Services Workgroup, chaired by members of the CPT Editorial Panel. According to an AMA announcement, the group comprises "relevant medical specialties/organizations and industry stakeholders."
The work group will focus on recommending solutions for coding current nontelehealth services delivered using remote technology; addressing the accuracy of current code sets; exploring the possibility of creating new telehealth service codes; and developing or revising the introductory language that guides the coding of telehealth services. All work group recommendations will be presented for consideration by the CPT Editorial Panel.
Lee is an associate professor of physical therapy at Mount Saint Mary's University in Los Angeles. Fearon is executive vice president of Optimis Corp, a clinical service and software company, and partner in a private practice. Fearon also serves as APTA advisor to the AMA Current Procedural Terminology (CPT) Health Care Professionals Advisory Committee (HCPAC).
APTA continues to work toward an accurate payment system that recognizes and promotes the clinical judgment of the physical therapist as well as improving quality of care. Contact advocacy staff with questions.
Want to hear more about telehealth from newly-appointed work group member Alan Chong W. Lee, PT, PhD, DPT, CWS, GCS? Sign up for the live webinar, "Practical Application of Telehealth," presented by Lee and Clay A. Brown, PT, DPT, November 12 from 2:00 pm–3:30 pm, ET.
Physical therapy received some timely, high-profile exposure in a prominent Capitol Hill news source, when APTA joined 2 other organizations to pen an opinion piece that was published in The Hill. The subject: how eliminating the in-office ancillary services (IOAS) exception for physical therapy and other services could save Medicare money in what could be troubling times ahead.
Calling the elimination of the IOAS exceptions "an alternative without a hitch, without a downside, and where both the patient and taxpayer win," APTA President Sharon Dunn, PT, PhD, OCS, joined presidents of the American Clinical Laboratory Association (ACLA) and the Board of the American Society of Radiation Oncology (ASRO) in a letter that spelled out just how the exceptions process is encouraging overutilization at a time when the Medicare program is considering significant hikes to premiums.
While writing that "on the whole," the Ethics in Patient Referrals Act—also called the Stark law—helps to decrease overutilization that can happen when physicians can self-refer beneficiaries to entities in which they have a financial interest, APTA, ACLA, and ASRO stated that the exceptions carved out for some services, including physical therapy, are costing the program dearly.
"This loophole has paved the way, according to the Government Accountability Office (GAO), for spikes in utilization of certain ancillary services and a measurable jump in Medicare payments to physicians," the letter states. "Closing the physician self-referral loophole … would realign provider incentives, which is in the best interests of Medicare beneficiaries, taxpayers, and the American health care system."
Efforts to eliminate the IOAS exception have been going on for several years and are among APTA's public policy priorities for 2015-2016. Late last year, APTA and others advocating for an end to the loophole got a boost from the American Association of Retired Persons (AARP), which threw its support behind congressional efforts to stop the practice.
In the letter published in The Hill, APTA, ACLA, and ASRO make the case that ending the exemptions not only will strengthen the quality of health care practice, but can even help to blunt "the impending jolt" that could be imminent for beneficiaries.
"The reality is Congress can protect the integrity of medicine by eliminating services from the well-intentioned IOAS, enhance patient care by minimizing overutilization of services and unnecessary procedures, and soften the blow for the Medicare beneficiaries targeted for premium sticker shock in the New Year," the letter states.
According to a new study from New Zealand, a couple of things are clear: (1) exercise therapy for individuals with knee osteoarthritis (OA) tends to be more effective when some sessions are spread out over a year as "booster" sessions rather than held every few days over a shorter timeframe; and (2) manual therapy conducted in addition to exercise therapy increases overall treatment effectiveness—but only when it's part of sessions that are conducted in the compressed schedule. In fact, manual therapy actually seemed to decrease effectiveness when it was used in the booster program.
Weird, right? The authors of the study thought so, too. But they have some caveats about that particular result, which they describe as "perplexing."
The study, e-published ahead of print in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free), aimed to assess whether exercise therapy for knee OA was more effective when 12 45-minute exercise therapy sessions were provided over 9 weeks, or through a "booster" schedule that provided 8 consecutive sessions during the first 9 weeks, 2 booster sessions at 5 months, 1 booster session at 8 months, and a final booster session at 11 months. A second goal was to find out if the additional manual therapy improved outcomes. Reassessments took place 1 year after treatment began.
Researchers primarily relied on changes in Western Ontario and McMasters Universities Osteorarthritis (WOMAC) scores as the outcome measure for 66 participants with knee OA who were divided into 4 groups: a 9-week exercise therapy group (Ex), a 9-week Ex group that also received manual therapy (Ex+MT), a booster exercise therapy schedule group (ExB), and an ExB group that also received manual therapy (ExB+MT). Overall treatment success was also evaluated according to the Outcome Measures in Rheumatoid Arthritis Research Society International (OMERACT-OARSI) definitions, which rely on a combination of WOMAC scores, pain reduction ratings, functional improvements, and global rating of change.
At the 1-year mark researchers found that when it came to exercise therapy alone, individuals who participated in the booster program averaged scores on the 0-240 WOMAC scale that were 46 points lower than the average for individuals in the 9-week program (lower numbers are preferable). The effectiveness of the 9-week program improved when manual therapy was added, with the Ex+MT group averaging WOMAC scores 37.5 points below the Ex group.
But strangely enough, the addition of manual therapy to the booster group resulted in WOMAC scores that were, on average, almost the same as the scores registered by the group that received only exercise therapy in the 9-week timeframe—a result that seemed to show that adding manual therapy to a booster regimen actually decreased WOMAC scores for this group.
"The finding of an adverse interaction effect between manual therapy and booster sessions … was perplexing," authors write. Though they describe it as "conjecture," they speculate that "the simplest and therefore most likely explanation" is that small group sizes—18 or 19 participants per group—may have introduced instability to the study, which was intended to test main effects for the larger groups (Ex vs ExB, and manual therapy vs no manual therapy).
Authors acknowledge that although the study's findings are strong, the results do not concur with a similar study that found lower-than-expected treatment effects in the Ex group and contradictory interaction effects in the ExB+MT group. These variations underscore the need for more research on the incremental effectiveness of the various approaches, they write.
Authors of the study include J. Haxby Abbott, DPT, PhD, FNZP, G. Kelley Fitzgerald, PT, PhD, FAPTA, Julie Fritz, PT, PhD, FAPTA, and John Childs, PT, PhD, MBA, FAPTA, OCS.
Bipartisan legislation that will leave it to states to decide the cutoff number for what's defined as a "small employer" for purposes of health insurance coverage will likely be signed by President Obama, according to a recent story in the New York Times (NYT).
The NYT reports that although the administration "did not particularly like" the legislation that has moved out of the Senate, Obama is expected to approve a change aimed at saving businesses with between 51 and 100 employees from the "small employer" designation—and the designation's attendant "stringent insurance regulation" that would have started January 1 under the Affordable Care Act (ACA).
Instead, the Protecting Affordable Coverage for Employees Act will leave the issue to individual states to decide. The current cutoff for being designated a small employer is at 50 employees or fewer.
According to the NYT article, analysts predicted that employers with 51 to 100 employees would face premium increases averaging 18% next year if the numbers were changed as called for in the ACA.
A bill that would help physical therapists (PTs) in private practice improve continuity of care received supportive comments from several members of a House subcommittee during a hearing that featured the testimony of Sandra Norby, PT.
Norby's comments were provided during a House Energy and Commerce Subcommittee on Health hearing on the Prevent Interruptions in Physical Therapy Act (HR 556) and 2 other health care-related bills. The bill, which has companion legislation in the US Senate, would extend locum tenens provisions to PTs, allowing those therapists to bring in another licensed physical therapist to treat Medicare patients and bill Medicare through their Medicare national provider identifier (NPI) during temporary absences for illness, pregnancy, vacation, or continuing medical education.
APTA and the association's Private Practice Section collaborated on pressing for the legislation, which is one of the goals of the association's public policy priorities.
In her testimony, Norby described the legislation as a change that would provide "needed regulatory relief" through "a simple technical fix."
"Physical therapy is part of the comprehensive care model, therefore it is high time that the PT receives the same protections against unavoidable absences that are available to [other health care providers]," Norby said in her statement.
Norby outlined the safeguards that would prevent fraud and abuse of the provision, and provided her own personal example of the problems now faced by private practice PTs—a time when one of her staff PTs, the only one for that particular clinic, was off for maternity leave. As the only PT certified by Medicare to continue service at that particular clinic, Norby had to make the long trip to the rural Iowa clinic, often sleeping at the facility so that she could be on hand to see patients the next day—all in addition to her regular duties.
In questions that followed witness testimony Norby explained why the continuity opportunities provided by locum tenens were of particular value for physical therapy by using rehabilitation after a total knee replacement as an example. "Any interruption…is going to be very very detrimental to the progress of their care," she explained. "If continuity is interrupted, "[Patients] are literally going to have more visits to achieve that goal we set up in the first place."
Subcommittee members included Rep Gus Biliraikis (R-FL) and Ben Ray Lujan (D-NM), who introduced the bill and are leading the House efforts for passage. At the hearing, Billiraikis described the bill as "pro-patient and pro-physical therapists," while Lujan characterized the change as "common sense legislation."
Billirakis showed the real-world effects of the current system by sharing a letter from constituent Alicia Nixon, PT, DPT, BCA, PMDB, who wrote to Billirakis telling him that it was "almost impossible to take a vacation to attend seminars because of my need to be onsite at the clinic," and that "I was recommended to have surgery 6 years ago that I still have not had because it would require me to be away from my practice for over 6 weeks for recovery." Nixon also described an instance in which, in order to respond to a court summons, she had to close her clinic for the day, resulting in lost wages for her staff.
In later remarks, Lujan spoke out in more detail about his personal connection to physical therapy and his understanding of the importance of care continuity. Describing a head-on automobile accident that left him severely injured, he said that "it was physical therapists … that really put me back together to being able to move, and to be able to just walk."
If there had been an interruption in his care, he said, "I can't imagine what would've occurred."
APTA will monitor the progress of the bills and post updates to its locum tenens webpage. Resources on the website include a podcast on the importance of this legislation and information on how PTs can get involved in advocating for its passage.
Sandra Lee Norby, seated at far right, prepares to testify on locum tenens for physical therapists before the House Energy and Commerce Subcommittee on Health.
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