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  • Study: Light Physical Activity Could Help to Lower Risk of Coronary and Cardiovascular Problems

    No one doubts the positive health effects of regular moderate-to-vigorous physical activity (MVPA), but now researchers are finding that even light physical activity can reduce the risk of coronary heart disease and cardiovascular disease. The latest findings, focused on women age 65 and older, echo revised US Department of Health and Human Services (HHS) activity guidelines strongly supported by APTA.

    The recent study, published in JAMA Network Open, asked 5,861 women with an average age of 78.5 years to wear a hip accelerometer for a week to establish PA rates, and then tracked rates of later coronary heart disease (CHD) and cardiovascular disease (CVD) for nearly 5 years. Researchers were particularly interested in the effect of light physical activity (PA)—between 1.6 and 2.9 metabolic equivalent tasks (METs)—on the risk of experiencing CVD and CHD.

    Researchers divided the participants into 4 groups based on the average amount of time spent per day in light PA: 36-236 minutes, 235-285 minutes, 286-333 minutes, and 334-617 minutes. They also tracked rates of MVPA, as well as demographic, educational, and health information including the presence of chronic conditions, alcohol consumption, smoker or nonsmoker status, and use of antihypertensive and antilipidemic medications. The population studied was a mix of white (48%), black (33.5%), and Hispanic (17.6%) women.

    They found that during the study period, participants in the highest light PA quartile (about 5-10 hours of light PA per day) reduced their risk of both CVD and CHD by significant percentages compared with the lowest light PA quartile (about 30 minutes to 4 hours per day)—by 42% for CVD and 22% for CHD, adjusted for demographic and health variables. The reduction was dose-dependent, with every additional hour of light PA correlating to a 20% reduction in CHD risk and a 10% reduction in risk for CVD.

    When researchers factored in rates of MVPA (METs of 3 and above), they found risk reductions beginning with the second-lowest quartile (27 minutes or more per day). Compared with women in the lowest MVPA quartile, women in the highest MVPA quartile (a difference of 42 minutes per day) reduced risk of CHD by 46% and lowered CVD risk by 31%. Those results, so similar to the light PA risk reductions, told researchers that light PA could play a more important role in long-term health than previously thought.

    Authors acknowledge that women with the highest levels of light PA tended to have healthier levels of HDL-C, triglycerides, and glucose, as well as on-average lower BMI to begin with—factors possibly tied to genetics—but they still believe light PA itself has an important role to play.

    HHS agrees. Its latest revision to national physical activity guidelines emphasizes that "some physical activity is better than none," even while promoting the familiar goals of at least 150 minutes of moderate intensity PA or 75 minutes or more of vigorous PA per week for adults. What's different is that the new guidelines no longer include statements saying that PA must occur for at least 10 minutes to be effective, stressing instead the anything-is-better-than-nothing approach.

    "This study is encouraging, as well as another confirmation of what the new HHS guidelines tell us—that any amount of physical activity can positively affect health," said Hadiya Green Guerrero, PT, DPT, a senior staff specialist in the APTA practice department and a certified sports physical therapy specialist. "What's encouraging here is the emphasis on light physical activity, something that's attainable by adults who are older. It's important to have evidence that further supports the idea that PTs are doing well by their patients when they promote movement through usual and enjoyable physical activities like walking, gardening, dancing, stretching exercises, or playing with grandchildren."

    In an editorial that accompanies the JAMA Network Open article, author Gregory W. Heath, DHSc, MPH, characterizes the study as a "clarion call" for physicians, other health care providers, and health care systems to promote the HHS guidelines. "To temporize such action is to jeopardize the future health and well-being of older women," Health writes.

    Green Guerrero, who represents APTA on the board of directors for the National Coalition for Promoting Physical Activity, and who led APTA's recent collaborative efforts with the National Institutes of Health's "Go4Life" exercise campaign, says that APTA couldn't agree more.

    "APTA supports efforts that look to keep America healthy and level the health disparities playing field rather than continuing to spiral down the exponentially expensive sick care from which only a select few benefit," Green-Guerrero said. "As movement experts PTs intimately understand that blood flowing through arteries, to the brain, and to and from the heart are crucial to function and movement. It only makes sense that movement—any movement—will help things keep churning and, in the case of the evidence presented in this study, significantly reduce risk of preventable cardiovascular disease processes."

    [Editor's note: Visit APTA's prevention and wellness webpage for resources on how physical therapists and physical therapist assistants can help individuals become more physically active, and share the latest PA information from APTA's consumer-focused MoveForwardPT.com with your patients, clients, and others interested in the benefits of exercise and movement. Want to connect with others interested in physical therapy's role in improving health? Join APTA's Council on Prevention, Health Promotion, and Wellness. The association is also an organizational partner in the National Physical Activity Plan Alliance and has a seat on its board of directors.]

    Authors of the JAMA study say that while more clinical trials could help to better define the relationship between light PA and risk reduction, there's no reason to wait on promoting this type of PA.

    "The magnitude of these associations for light PA and their consistency across strata of CVD risk, physical functioning, and MVPA suggest that light PA could have much to offer older women in the prevention of CVD whether or not they can or choose to engage in MVPA," authors write. "Given the low risks of light PA and the abundance of light movements that are part of everyday life, even in the absence of trial data it may be prudent to encourage older women to increase light PA to improve their CVD health and reduce the occurrence of CVD events."

    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.

    President's Budget Proposes Cuts to Public Health Programs, Health Research, Medicare, and Medicaid

    Although characterized by supporters as an approach that "embodies fiscal responsibility," the 2020 federal budget proposal from the Trump administration is facing criticism that the $4.1 trillion plan cuts too deeply into health care and education. Many of the proposed changes run counter to current APTA public policy priorities by reducing access to care and sacrificing important investments in research and education.

    The proposed budget, released by the White House last week, was touted by acting Office of Management and Budget Director Russ Vought as a plan that "takes aim at Washington's fraud, waste, and abuse," and will lead to a balanced budget in 15 years.

    Others see things differently. The approach is accompanied by significant cuts to a range of issues important to APTA, including funding decreases for the National Institutes of Health, the Centers for Disease Control and Prevention, the Administration for Community Living, the National Health Services Corps, and the Maternal and Child Health Block Grant program. The budget also includes policy recommendations that alter Medicaid and Medicare.

    The budget proposal is just that—a proposal. Congress must act on the plan in order for it to become law. APTA Executive Vice President of Public Affairs Katy Neas says that while the budget itself isn't likely to survive, there's a danger that some of the more damaging concepts could live on.

    "It's unlikely that Congress will embrace the changes to Medicare, Medicaid, and funding for important work at the National Institutes of Health," Neas said. "However, the challenge for APTA, the physical therapy profession, and patients will be to keep up the pressure against some of the budget's more damaging ideas that may resurface from time to time in policy debates."

    Among those more damaging ideas, according to APTA: the administration's proposal to move Medicaid away from its current funding system to a per-capita block grant program. The administration estimates the change could result in a $160 billion savings, but critics say the shift would reduce access to care, as would another provision in the plan that would mandate work or community volunteer requirements for "able-bodied, working-age individuals."

    The plan also calls for cuts to Medicare, primarily through a combination of payment decreases, more stringent oversight of individual provider reimbursement patterns, and more extensive prior authorization requirements for physicians.

    Among the provisions of particular interest to physical therapists (PTs) and their patients and clients:

    • Durable medical equipment, prosthetics, and orthotics (DMEPOs). Under the Trump budget, the US Centers for Medicare and Medicaid Services (CMS) competitive bidding program would be extended to apply to ventilators and orthotics, which could interfere with patient access to these devices as well as the ability for patient-specific adjustments to be made by providers. Additionally, the proposal would expand CMS prior authorization authority to additional DMEPOs—another provision that APTA believes could delay or prevent patient access.

    • Postacute care payment. The proposed budget steadily lowers annual Medicare payment updates for skilled nursing facilities, home health agencies, and inpatient rehabilitation facilities beginning in the 2020 fiscal year, leading up to the adoption of a unified postacute payment system for all settings in the 2025 fiscal year.

    • Prior authorization authority. The budget extends CMS authority to require prior authorization for all Medicare fee-for-service items and services, specifically those that CMS claims are at high risk for fraud and abuse.

    • Oversight of "excessive" physician orders for certain services—including therapy. The administration budget seeks to establish a prior authorization program for high-utilization practitioners of radiation therapy, therapy services, advanced imaging, and anatomic pathology services beginning in 2021. CMS would conduct annual reevaluations to identify the physicians who would be subject to prior authorization in the next calendar year.

    • National Institutes of Health (NIH) funding. The proposal would lower NIH funding by $4.5 billion to $6 billion compared with 2018, including a $900 million reduction in funding for the National Cancer Institute.

    • Education. In addition to reducing funding for college work-study programs and ending loan forgiveness for public-sector workers, the administration's plan would cancel a $1.4 billion surplus in the federal Pell grant program.

    "APTA's advocacy focus is on increasing patient access to effective care, eliminating inefficiencies and reducing administrative burden on providers, and supporting research and innovation," Neas said. "The administration's 2020 budget in many ways stands in contrast to those priorities, and we will continue to help legislators and policymakers understand the important differences."

    Researchers Find 'Only Positive Effects' From PTs in Primary Care Role

    Get thee to a physical therapist (PT): according to a new study from Sweden, patients seeking primary care for musculoskeletal disorders (MSDs) who are triaged to a PT fare just as well—and in some respects, better—than those who are seen by a physician general practitioner (GP). It's a finding consistent with APTA's own investigations into the PT's role in primary care settings.

    Authors of the study, published in Therapeutic Advances in Musculoskeletal Disease, concede that, at 55 participants, their study was small. But they assert that their findings indicate that directing patients to PTs for primary assessment in primary care results in slightly better patient-reported outcomes related to pain, disability, and health-related quality of life (HRQoL) at follow-up, from 2 weeks to a year after initial visit. "Only positive effects were notable, and no adverse events regarding the triaging process were reported," they write.

    Researchers worked with 3 primary care health centers (PHCCs) in Gothenberg, Sweden, each serving a slightly different socioeconomic population (one serving patients experiencing generally lower socioeconomic conditions; one in a more affluent area; and one serving a more mixed population). PHCCs are the usual route taken by patients in Sweden seeking primary care, where patients are first assessed by a nurse, who determines a treatment pathway—including which provider the patient sees next.

    [Editor's note: want to learn more about how PTs are deepening their footprint in primary care? This 2018 article from PT in Motion magazine explores how the landscape is changing and offers links to APTA resources on issues related to primary care.]

    For the study, it wasn't a question of whether PTs should be delivering primary care—they were already doing that at the 3 participating PHCCs—but of how PT primary care affected outcomes. To make this assessment, researchers worked with nurses to randomly assign patients who normally would be referred to a PT to a control group that received "treatment as usual" (TAU) from a GP. The researchers then compared patient-reported outcomes from the PT and TAU groups at various points.

    Patients participating in the study were "working age" (16-67 years old) individuals seeking help for a new musculoskeletal condition; patients were excluded from the study if they required home visits, were receiving ongoing treatment for the current MSD, were seeking help for a chronic condition unchanged for 3 months or more, or possessed insufficient English or Swedish language skills to complete patient questionnaires.

    Both groups were asked to complete patient questionnaires on pain (0-10 rating scale), disability (Disability Rating Index), HRQoL (EuroQol 5), and risk for developing chronic musculoskeletal pain (Orebro Musculoskeletal Pain Questionnaire). Researchers also sought to determine whether the PT patient group developed different attitudes about responsibility for their MSDs, shifting more of that sense of responsibility to the patient and away from employers and/or medical professionals. Researchers asked patients to complete the questionnaires at initial consultation and 2, 12, 26, and 52 weeks later.

    Analysis revealed that while all patients improved at roughly similar rates, the PT group reported consistently better—albeit just slightly better—outcomes. The exception to that trend was in HRQoL scores, which improved for the PT group over the TAU group by a statistically significant margin.

    As for patient attitudes about responsibility for MSDs, the PT group tended to reduce what authors call "externalization" of the condition to health care providers, but a slight drift to greater externalization focused on employers after 1 year. However, researchers found that the changes in attitudes were slight.

    "This study indicates that early contact with both GPs and [PTs] can reduce the risk for patients developing chronic conditions with subsequent need for more comprehensive treatment," authors write. "As the effects of [PT] treatment were at least as good as TAU, it is clearly feasible to impose management modifications which can free medical competence for other patient groups. It is important to take care of even the group of patients with short-term or low-intensive musculoskeletal conditions to prevent development of chronic disorders."

    The researchers acknowledge that besides the small study population, the project also experienced patient dropout over time—particularly among younger patients in the PT group. Still, they contend, the findings support the role of PTs in primary care.

    "While it cannot be irrevocably concluded that initiation treatment by a [PT] is better for all patients with [MSDs] than [is] medical advice and treatment by a GP, there is nothing to indicate that this triage model for managing patients with [MSDs] in primary care is, in any way, detrimental to the patient health or worse than standard care," they write. "Triaging to [PTs] for primary assessment in primary care seems to lead to at least as positive health effects as primary assessment by GPs and can be recommended as an alternative management pathway for patients with MSDs."

    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.

    The Good Stuff: Members and the Profession in the Media, March 2019

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

    Grab the popcorn: Lauren Snowdon, PT, DPT, professor in the Seton Hall physical therapy program, served as a clinical consultant for The Upside, the recently released movie starring Bryan Cranston and Kevin Hart. (New Jersey Stage)

    Now hear this: Lisa Muratori, PT, is working with a music professor to create audio software that helps patients with neurological conditions sense gait fluctuations. (Wired)

    Waddle it be? Cara Berg-Carramusa PT, MSPT, has advice for minimizing slips on the ice: "You've got to walk like a penguin." (WKBN27 News, Youngstown, Ohio)

    Post-flight physical therapy: Air Force Capt Anna Adkins PT, DPT, is part of a new program aimed at keeping pilots healthy between missions. (Stars and Stripes)

    Rolling with it: Karena Wu PT, DPT, explains some of the advantages of using a foam roller to address muscle soreness. (Better magazine)

    Let's dance: Michelle Ritter McGuire, PT, helps run an innovative program for the Cincinnati Ballet to bring adaptive dance to children with motor disabilities. (Falmouth, Kentucky, Outlook)

    The PT as DJ: Creighton University physical therapy students Danny McAndrew, SPT, and Kelsey Biaggi, SPT, are helping conduct research on the effect of customized playlists that use songs with specific beats-per-minute to help runners adjust their stride to lessen pain. Creighton professor Terry Grindstaff PT, ATC, PhD, is advising on the project. (KMTV3 News Now, Omaha, Nebraska)

    Making tummy time easier to stomach: Kristy Johnson, SPT, explains why it's important for parents to ensure that their infants spend time on their stomachs—even it's not their favorite thing to do. (KXNET News, Bismarck, North Dakota)

    Triathlete, PT, and mom of 3: Delaine Fowler PT, DPT, describes her approach to training during and after pregnancy. (Salisbury, North Carolina, Post)

    You don't know the calf of it: Nicole Haas PT, DPT, shares her perspective on the importance of calf strength. (Outside)

    Exercise and PD: Michael Braitsch, PT, DPT, outlines the importance of exercise for individuals with Parkinson disease. (Parkinson's News Today)

    Quotable: "If you have been smart enough to get PT after a problem, never second-guess the therapist. If he or she tells you to ice it twice a day, do it. If there is a rehab program assigned for ‘homework,’ follow it as scheduled." – Wina Sturgeon, editor of Adventure Sports Weekly (Bristol, Virginia, Herald Courier)

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

    North Carolina PTs Get Decisive Dry Needling Win

    After a nearly 4-year battle, physical therapists (PTs) in North Carolina can finally claim victory in their fight to protect dry needling: last week, the state's acupuncture licensing board relented on its attempt to restrict the intervention, signing off on a settlement agreement in federal district court that acknowledges dry needling as a part of the PT scope of practice in the state. The settlement is a decisive win for APTA’s state chapter, the North Carolina Physical Therapy Association (NCPTA), as well as for APTA, which provided support for the chapter's efforts.

    The agreement effectively ends a lawsuit brought by 4 PTs and 2 patients against the North Carolina Acupuncture Licensing Board (NCALB) in October 2015. That lawsuit asserted the NCALB's efforts to prevent PTs from engaging in dry needling—efforts that included issuing "cease and desist" letters to PTs who perform dry needling and threats that they would be charged with a Class 1 misdemeanor for violating federal antitrust laws.

    The lawsuit continued in court for the next 3 years, surviving the NCALB's attempts to get the case thrown out. Dry needling was also at issue in a September 2015 suit filed against the state's physical therapy licensing board by the NCALB, which sought to have a county superior court declare that dry needling is outside the scope of PT practice. That suit eventually wound up in the state's Supreme Court, which upheld the lower court's ruling that dry needling was part of PT practice in the state. The agreement reached in the federal case applies to current and future acupuncture boards, and includes a monetary settlement to the plaintiffs.

    "The Acupuncture Board finally yielded to the NCPTA's demands," said NCPTA President J. Kyle Covington, PT, DPT, PhD, in an online statement. "This tremendous victory—including the monetary settlement—sends a powerful message to those would seek to prevent our patients from receiving the treatment they need: no matter how tough the fight, no matter how long it takes, NCPTA will always stand up for our patients' access to care."

    At the national level, APTA assisted the North Carolina Chapter during the fight, as did other APTA components and individual members.

    APTA Director of State Affairs Angela Shuman says the decisive victory is a testament to both the validity of dry needling as a legitimate component of PT practice and the commitment of PTs, the North Carolina Chapter of APTA, and the association as a whole.

    "This is a major win for patients and physical therapists in North Carolina," Shuman said. "But it could not have been achieved without some amazingly hard word by the North Carolina Chapter and its members, and APTA is proud of what they have accomplished."

    New APTA Partnership Aimed at Improving Health Care Throughout the Americas

    APTA will be doing even more to support access to rehabilitative services beyond US borders, thanks to its newest partnership, with the Pan American Health Organization (PAHO), the world's oldest international public health agency.

    PAHO is now a participant in the APTA Partnerships Program, an initiative aimed at enhancing relationships between the association and other organizations that share common goals. APTA's collaboration with PAHO initially will focus on collecting data on what countries in the Americas are doing ensure and improve access to health and rehabilitation services. According to the World Health Organization (WHO), an estimated 150 million people in the western hemisphere live with a disability. Rehabilitation services are extremely limited in many countries across this region.

    Founded in 1902, PAHO works with other entities to promote equity in health and improve the lives of the peoples of the Americas. It serves as the Regional Office of WHO for the Americas and is the specialized health agency of the Inter-American System.

    "APTA has been working to build and strengthen relationships that can be leveraged strategically to benefit health care. We've also been exploring ways to expand our activities related to global health and international development, and to promote to our members the importance of these issues," said APTA CEO Justin Moore, PT, DPT, in an APTA news release. "Our vision to transform society by optimizing movement to improve the human experience is well aligned with PAHO's plan. They are an ideal partner for us."

    PAHO Director Carissa F. Etienne agrees that her organization and APTA are a good collaborative fit and thinks the partnership comes at an opportune time.

    "Rehabilitation is an increasingly important health service for the region, particularly for older populations and those who have experienced an injury or noncommunicable disease or for many with long- or short-term impairments," Etienne said. "This is an important partnership for PAHO as we look to strengthen rehabilitation services in the Americas."

    Other partners in the APTA Partnership Program include the American Academy of Manual Physical Therapy, the American College of Sports Medicine, the Federation of State Boards of Physical Therapy, Move Together, Special Olympics, and the US Department of Veterans Affairs.

    Researchers: Aquatic Exercise Offers Similar Results With Less Pain for Patients With Chronic LBP

    Aquatic exercise, a common physical therapist intervention for patients with chronic low back pain (CLBP), shouldn't be viewed as "less strenuous or less effective" than land-based exercise, according to authors of a recent study in PTJ (Physical Therapy). In fact, they write, water-based exercise can be beneficial for people whose movement is limited by pain.

    Researchers recruited 40 men aged 18 to 45 with a healthy body mass index. Half of participants had experienced CLBP for greater than 12 weeks; the control group experienced no back pain. Both groups performed 15 aquatic exercises and 15 land-based exercises with movement patterns similar to the aquatic exercises. Fourteen of the exercises included upper extremity dynamic movements, and 16 focused on the lower extremities.

    The authors measured heart rate, rate of perceived exertion, and pain. They also used video motion analysis and wireless, waterproof EMG sensors to measure bilateral activation of the erector spinae, multifidus, gluteus maximus, gluteus medius, rectus abdominis, external oblique, and internal oblique muscles.

    Among their findings:

    There were few significant differences between the CLBP and control groups. Heart rate (HR), rate of perceived exertion (RPE), pain, and muscle activation for both land and water-based exercises were similar for both groups. Patients with CLBP had greater mean left erector spinae activations in one exercise and higher RPE in another.

    Differences were seen when comparing results for exercises performed in water versus land. Muscle activation was greater on land in 29% of cases and in water in 5% of cases. Heart rate was higher on land with all exercises, but RPE was not consistently higher or lower in either environment.

    Pain was reported more than twice as frequently when subjects exercised on land. However, pain levels were generally low in both environments.

    While the study was small, and the researchers say it was the first to examine this data set for aquatic exercises, the fact that results were similar for both groups suggested to them that "exercising in the water can be beneficial for rehabilitation and strengthening by allowing people with CLBP to perform the exercises and activate muscles without their condition adversely affecting them."

    [Editor's note: interested in aquatic physical therapy? Check out the APTA Academy of Aquatic 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.

    Your Help Needed to Guide Movement System Integration

    APTA is leading the way in advancing the integration of the movement system as the core of physical therapist (PT) practice, education, and research. Now the association needs input from you to take an important next step: making the crucial leap from the conceptual to the practical through the development of a movement system diagnosis framework and movement screen.

    Draft diagnosis and screening templates have been created by the Movement System task force and work groups, and APTA would like you to take them for a test drive and provide your comments by the June 1, 2019, deadline.

    "We're at an exciting point in the evolution of the movement system concept and now need the widest possible stakeholder input," said Sue Whitney, PT, PhD, APTA Board of Directors member and chair of the Movement System Task Force. "Many PTs have been incorporating movement system concepts into their practice and teaching for some time now, but the development of these diagnosis and screening resources has the potential to accelerate the adoption of these concepts across the profession. That's why participation in the review and comment process is so critical—with the development of a repository of movement system diagnoses and the development of the screening templates, we hope to move the bar and create excitement about using the movement system in daily practice."

    Evaluation of each template involves a 2-step process. For the diagnosis template, reviewers are asked to submit an example of a movement system diagnosis using a specially developed online form, and then provide feedback about the template itself. The movement screen—a tool that helps PTs identify patient movement impairments observed during functional tasks and activities so that they can pinpoint which additional tests and measures should be brought into play—doesn't need to be filled out, just reviewed and evaluated through an accompanying survey. Click here to view the templates and provide your feedback.

    Work toward the development of the movement system concept in the physical therapy profession began in 2013, when APTA adopted a new vision statement with guiding principles that characterized the system as "the foundation of optimizing movement to improve the health of society." The association produced a white paper on the movement system in 2015 and held a Movement System Summit in 2016 that brought together 100 thought leaders to discuss how best to integrate the system throughout all facets of the profession. Since then, members of APTA’s Movement System Task Force have been developing resources to make widespread integration a reality.

    Want to learn more about the movement system? Visit APTA's Movement System webpage for a history of the association's work.

    Education Leadership Partnership Looks Back On a Productive Year

    When the purpose of a group is nothing less than "partnering to drive excellence in physical therapy education," you have every reason to expect that group to be doing, well…a lot of stuff. The 2018 annual report of the entities collectively known as the Education Leadership Partnership (ELP)—APTA, the American Council of Academic Physical Therapy (ACAPT), and the Academy of Physical Therapy Education (APTE)—shows how the group has been living up to that expectation while maintaining focus on important core values.

    The annual report recaps an important year for the collaborative group, documenting a year in which the partners took action on key initiatives around education research, including the approval of an educational research agenda, cosponsorship (with the Association of American Medical Colleges) of 2 medical education research certificate workshops (aka "MERCs"), the creation of an education research network, and the first-ever Grantsmanship and Mentorship in Education Research (aka "GAMER") workshop to help education researchers refine their abilities to secure grant funding.

    Education research wasn't the partnership's only area of focus, however. In 2018, the partners also held stakeholder meetings to develop action plans on clinical education, developed a framework to capture data related to physical therapist education, and provided a webinar and article, published in PTJ (Physical Therapy) on entrustable professional activities. Partnership members also formed a task force to address physical therapy program student debt.

    "It's been a busy year for the ELP," said Steven Chesbro, PT, DPT, EdD, APTA vice president of education, who helps to provide staff support to the partnership. "Progress in multiple areas is happening at a quick pace. The annual report provides a good snapshot of 2018, but we intend to keep stakeholders informed on an ongoing basis through the various partners' newsletters and other means—not only to maintain transparency, but to encourage as much participation as possible when ELP partners reach out for feedback."

    ELP comprises representatives from the 3 founding member organizations as well as ex-officio nonvoting members representing the American Board of Physical Therapy Residency and Fellowship Education, the American Board of Physical Therapy Specialties, the Commission on Accreditation in Physical Therapy Education, and the Federation of State Boards of Physical Therapy. Representatives from various areas of the clinical community—private practice, veterans, acute care, and health systems—also participate in the partnership.

    Want more information on the ELP, its history, and resources as they develop? Check out APTA's ELP webpage .

    CMS Promotes More Access to Nondrug Pain Management in Medicaid

    Could states be doing more to increase access to nonopioid and nonpharmacological approaches to management of chronic pain under Medicaid? The US Centers for Medicare and Medicaid Services (CMS) thinks so, and has issued guidance that outlines options and shares examples of some states' promising initiatives. The approaches are largely consistent with APTA's #ChoosePT opioid awareness campaign, which emphasizes the importance of patient access and choice in the treatment of pain.

    The CMS information bulletin released in late February is anchored in the US Centers for Disease Control and Prevention's (CDC) guidelines for prescribing opioids for chronic pain, published in 2016. Those guidelines, which recommend nonopioid approaches including physical therapy as the preferred first-line treatment for noncancer chronic pain, have been increasingly acknowledged and adopted by state health care entities, and early reports are positive, according to CMS. The new CMS document is designed to help states understand possible avenues for incorporating programs that help support the CDC guidelines.

    In outlining possibilities that could allow for the use of nonpharmacological approaches to chronic pain, CMS offers states a wide palette of mandatory and optional benefits, from more effective use of inpatient, outpatient, and health center services to expanded coverage for rehabilitative, physical therapy, and preventive services. The bulletin also offers home health benefits, special "demonstration" projects, and potential waivers as ways states could take creative steps to strengthen their nondrug offerings.

    CMS also offers examples of states that have changed or extended their Medicaid coverage options, including Oregon, which expanded its list of Medicaid-covered services for uncomplicated back and neck pain to include physical therapy, cognitive behavioral therapy, and other services; and California, where a 14-county Medicaid program implemented an intensive prescriber education program on nonopioid options for pain management.

    APTA has been engaged in the fight against opioid misuse in multiple ways. In addition to its flagship #ChoosePT opioid awareness campaign, the association has produced a white paper on reducing opioid use and contributed to the National Quality Partners Playbook on Opioid Stewardship. On the advocacy front, APTA continues to meet with legislators and agency representatives to address the opioid crisis, and comments on a range of topics, including a federal Pain Management Best Practices Inter-Agency Task Force draft report. Additionally, a recent formal partnership between APTA and the Department of Veterans Affairs includes collaboration to promote veterans' access to nopharmacologic approaches to pain management.

    "Providers and beneficiaries need access to effective therapy for chronic pain," CMS writes. "A multidisciplinary approach…that incorporates nonopioid pharmacologic and nonpharmacologic therapies, well-communicated treatment goals and expectations, and a careful consideration of the benefits and risks of available treatment options is the most appropriate approach for most patients and has the potential to lead to more appropriate prescribing of opioids."