• News New Blog Banner

  • Researchers Say ‘Soft Robots’ Could Play a Role in Rehabilitation

    The idea of “soft robots”—robotic components that don’t comprise rigid parts—has been around for a while, but now researchers in Switzerland believe they may have come up with a combination of components that will allow soft robot technology to be more widely applied to a range of uses, including physical rehabilitation.

    The soft robots developed in the Reconfigurable Robotics Laboratory (RRL) look like a sausage hooked to pressurized air pump, and are basically akin to balloons whose expansion and contraction can be finely controlled—both in terms of direction and force. They’re known as soft pneumatic actuators (SPAs).

    And while that concept may seem simple enough, things quickly get complicated: the materials used for the SPAs have to be rigid enough to withstand significant air pressure without distorting their shape, yet pliant enough to bend and stretch in muscle-like fashion; they need to be light; and they need to be sensitive to both quick blasts of air for strong movement and weaker blasts for more delicate, slower motion. Perhaps most important of all for researchers, the SPAs need to be predictable, so that computer modeling can guide development.

    Writing in the journal Scientific Reports, the RRL researchers believe they may have hit on the right combination of materials, a 2-part arrangement of plastic materials consisting of a pliant actuator body and a rigid shell that guides the type of motion required—think along the lines of a caterpillar wearing a corset. The resulting SPAs are capable of bending up to 200 degrees or stretching to 6 times uninflated length, depending on the model. The materials also allow for reliable computer modeling—so much so that RRL has published open-source online software that allows anyone to investigate various configurations of bodies and shells.

    After developing a workable technology, the RRL team began collaborating with physical therapists in Switzerland to develop a prototype belt that could help individuals poststroke as part of gait rehabilitation. The prototype, included in a video from RRL, uses SPAs that lengthen and contract to help create stability in the lower torso and hips.

    Researchers admit that while their findings are moving soft robot technology forward, the concept has a long way to go—at least when it comes to physical rehabilitation. Right now, the SPAs are controlled by a series of bulky pneumatic pumps, and researchers are looking for ways to create miniaturized, wearable devices to power the SPAs.

    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.

    US News: Time for Chronic Pain Treatment Without Opioids – and Policies That Make it Possible

    Two researchers believe that when it comes to pain treatment, if the US truly wants to alter the future, it could do well to look to the preopioid past—and then make policy changes that would increase patient access to nondrug approaches to chronic pain.

    In a recent opinion piece published in US News and World Report, authors Jason Doctor, director of health informatics at the USC Leonard D. Schaeffer Center for Health Policy and Economics, and Joan Broderick, senior behavioral scientist at the University of Southern California Center for Economic and Social Research, write about the ways pain treatment should change in light of the Comprehensive Addiction and Recovery Act passed by Congress earlier this year. That act, aimed at battling the opioid abuse epidemic, includes the establishment of a Department of Health and Human Services task force that will review and modify best practices for pain management.

    Broderick and Doctor assert that simply reducing the amount of opioids prescribed won't by itself address the issue of what to do for the millions of Americans who will continue to suffer from chronic pain. That, they argue, will require the HHS task force to take a kind of back-to-the-future approach.

    "The task force needs to look back prior to the [opioid abuse] epidemic when the first-line treatment for chronic pain was not drugs," they write. "Teams of occupational and physical therapists, social workers, physicians, and psychologists—frequently operating in multidisciplinary centers—addressed the social, psychological, economic, and physical components of pain."

    When it comes to the treatments themselves, Broderick and Doctor don't mince words. "They worked," they write. "They made patients physically stronger and gave them the self-management skills that helped them lead more fulfilling and productive lives."

    The problem, they write, is that the current health care environment stacks the deck against nondrug approaches—something that must change.

    "That earlier era of chronic pain management can be revived with less expensive avenues of access, better incentives, and improved reimbursement," they write. "Medicare can lead the way in making pain coping skills widely available. Most important, it needs to create billing codes that make the services reimbursable." Broderick and Doctor also argue for quality performance standards "that would promote integrative solutions."

    The changes advocated by Broderick and Doctor echo the policy changes identified by APTA as crucial to improving patient access to PTs for treatment of pain. Those changes include the repeal of the Medicare therapy cap, more extensive direct access provisions, better private insurance coverage, and limits on physician self-referral.

    APTA's #ChoosePT campaign, which targets the opioid abuse epidemic, is at the center of the association's activities during National Physical Therapy Month. Housed at MoveForwardPT.com/ChoosePT, #ChoosePT resources now include a video public service announcement, as well as other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.

    From Move Forward Radio: Transforming Society's Understanding of Pain

    Andre Machado, MD, chairman of the Neurological Institute at Cleveland Clinic, thinks opioids are remarkable.

    "But 'remarkable' can have 2 meanings," he says. "It can be a positive remarkable, or a negative remarkable. And the long-term use of opioids, when we use it chronically, is often remarkable in the wrong direction."

    Now available from APTA's Move Forward Radio: a conversation with Machado, who is leading an innovative pain treatment research project that puts a combination of physical therapy and behavioral therapy at the front lines of pain treatment, and takes a cautious approach to the use of opioids. Machado shared his thoughts on opioids and the need for a cultural shift on attitudes about pain in a recent TIME magazine opinion piece. His Move Forward Radio interview delves even deeper into his beliefs on what constitutes truly effective pain treatment.

    "When pain becomes chronic it is no longer necessarily signaling an injury to the body," Machado tells Move Forward Radio. "It's just there. It's telling us that there is injury when there is really no injury, and this is really the difference between hurt and harm. It is on us to learn that sometimes there is hurt, but there is really no harm. By rehabilitating the body, which is the job of the physical therapist, while rehabilitating the mind and the perception of pain, we believe that we will be able to rehabilitate people in going back to their work, to their self-care, and care of their loved ones."

    Machado is joined in the interview by Ian Stephens, PT, DPT, a board-certified clinical specialist in orthopaedic physical therapy. Stephens is a faculty member for Cleveland Clinic’s orthopaedic physical therapy residency program, and is a provider in the study.

    Stephens believes that Machado's approach leverages what PTs do best: empowering their patients and clients.

    "When [patients] understand pain, and they understand triggers and how to reduce the sensitivity of their nervous system, I think they become empowered, and I think you can see that translate directly to their function," Stephens told Move Forward Radio.

    Move Forward Radio is featured and archived at MoveForwardPT.com, APTA's official consumer information website, and can be streamed online via Blog Talk Radio or downloaded as a podcast via iTunes.

    Other recent episodes include:

    Success Story: A Young Woman's Journey With Complex Regional Pain Disorder
    Margaret’s experience with pain started with an accident when she was stepped on by a horse.

    Success Story: An Art Teacher's Journey to a Pain-Free Life
    Joanne was enjoying her life as an art teacher when she started experiencing hip pain. The pain increasingly intensified, making it hard to stand or walk, and ultimately forcing her into retirement.

    Tips for Track and Field Athletes
    Shannon Singletary, PT, DPT, directs the health and sports performance team that cares for all of the University of Mississippi’s varsity athletes. In this episode of Move Forward Radio, Singletary advises youth athletes who want to excel in the various disciplines of track and field, or any sport.

    Success Story: Physical Therapist Treatment Gives Woman Active Life After Restricted by Pelvic Pain
    Erin Jackson endured intense chronic pelvic pain through college and law school, and would persevere to graduate both. But the pain would ultimately become severe enough to cause her to postpone her wedding and withdraw from a postgraduation job opportunity.

    APTA members are encouraged to alert their patients to the radio series and other MoveForwardPT.com resources to help educate the public about the benefits of treatment by a physical therapist. Ideas for future episodes and other feedback can be emailed to consumer@apta.org.

    DEA Reduces 2017 Opioid Production Quotas – Mostly by Eliminating 'Buffer'

    It's good news, just maybe not as good as it seems at first blush: yes, the US Drug Enforcement Administration (DEA) is reducing the amount of opioid controlled substances that can be manufactured in 2017, citing slowing sales and a drop in demand from physicians. But most of that reduction is related to the DEA's decision to eliminate a 25% "buffer" of excess production to offset potential shortages.

    Last week, the DEA announced that production quotas for "almost every" Schedule II opiate and opioid medication will be reduced by 25% for the coming year, with a few—including hydrocodone—being cut by a third. Details on quotas for individual drugs were released in a final order available for public inspection at the DEA website.

    According to a statement from the DEA, the reduction is intended to support the agency's responsibility to create quotas that "reduce or eliminate diversion from 'legitimate channels of trade.'" That non-legitimate use of opioids, often described as an epidemic, has received widespread media attention, and is the basis for APTA's #ChoosePT campaign to educate the public on physical therapy as a safe and effective alternative to opioids for the treatment of some types of pain.

    In its statement on the quotas, the DEA cites data from the National Survey on Drug Use and Health that the nonmedical use of controlled prescription medication was second only to marijuana in terms of the number of Americans 12 and older who reported drug use. At an estimated 6.5 million, that number is more than the number of cocaine, heroin, and hallucinogen users combined.

    In terms of the amount of opioids available for prescription, the reductions may not represent a big change. According to the DEA, "much of" the reduction is related to the elimination of an across-the-board 25% buffer to accommodate shortages that never occurred since the DEA started the buffer program in 2013. That year, the production of hydrocodone spiked at 150,000 kilograms, or about 163 tons; in 2017, that quota will drop to 108,000 kilograms.

    The #ChoosePT campaign targeted at the opioid abuse epidemic is also at the center of the APTA's activities during National Physical Therapy Month. Housed at MoveForwardPT.com/ChoosePT, resources now include a video public service announcement, as well as other targeted advertising and media outreach. APTA is also a member of the White House’s working group addressing the opioid epidemic.

    Many IRF Patients Experience Interruptions in Care – About 10% Due to Preventable Conditions

    New research into Medicare data has found that potentially costly interruptions in inpatient rehabilitation for neurological conditions may be occurring for as many as 1 in 3 patients, depending on the condition—and about 10% of all interruptions are related to complications that are considered preventable.

    In an article e-published ahead of print in The American Journal of Physical Medicine and Rehabilitation, researchers analyzed data from nearly 80,000 Medicare beneficiaries admitted to an inpatient rehabilitation facility (IRF) for services related to stroke (71,769), traumatic brain injury (TBI; 7,109), and spinal cord injury (SCI; 659) between 2012 and 2013. Their analysis was focused on the prevalence and causes of 2 types of interruptions in care: "program interruptions," wherein patients are transferred to another facility and returned to the IRF within 3 days; and "short-stay transfers," in which patients are transferred to a hospital, skilled nursing facility (SNF), or other facility before their expected IRF length-of-stay ends.

    Next, authors of the study looked at the reason for the interruption, paying special attention to interruptions caused by what the Agency for Health Care Research and Quality (AHRQ) defines as "preventable" conditions. Examples include urinary tract infection, dehydration, bacterial pneumonia, and heart failure.

    Here's what they found:

    Program Interruptions

    • About 1 in 100 patients experienced this type of interruption, with relatively minor variation among groups.
    • Virtually all program interruptions (100% for the TBI and SCI groups, 99% for the stroke group) were to acute care hospitals.
    • Just over 10% of all program interruptions were potentially preventable (12.3% in the stroke group, 11.7% in the TBI group, and 11.1% in the SCI group).
    • For individuals with stroke, the most frequent preventable conditions were dehydration (35.9%) and urinary tract infections (28.2%). In the TBI group, urinary tract infections were most frequent (42.9%), followed by heart failure (28.6%). Researchers had insufficient data to report on causes among the SCI group.

    Short-stay transfers

    • Short-stay transfers were more prevalent than program interruptions, with 22.3% of the stroke group, 21.8% of the TBI group, and 31.6% of the SCI group experiencing a transfer sooner than anticipated, given their case-mix and comorbidity tier.
    • Transfers to acute care settings accounted for 7.2% for the stroke group, 10.2% for individuals with TBI, and 12.3% for patients with SCI.
    • For individuals with stroke, 14.7% of the transfers were for preventable causes. That rate was 10.2% for the TBI group, and 3.8% for those with SCI.
    • As for types of preventable conditions, dehydration (30.6%) and heart failure (26.8%) were most common among individuals with stroke. Dehydration and bacterial pneumonia were equally prevalent among the TBI group (26.4% for both). The most prevalent preventable conditions for SCI patients were bacterial pneumonia (66.7%) and urinary tract infections (33.3%).
    • Rates of short-stay transfers to a nonacute care settings were 15.1% for the stroke group, 11.6% for individuals with TBI, and 19.3% for those with SCI.

    While authors of the study recognize that not all short-stay transfers represent an "undesirable" outcome, they assert that when combined with rates of program interruption, rates of short-stay transfers to acute care settings, and the fact that nearly all other nonacute short-stay transfers were to SNFs ("not the ideal or desired discharge setting for patients admitted to an [IRF]," they write), doing something about preventable interruptions could make a difference in patient experience and overall health care costs.

    Authors further point out that those potential cost reductions could in fact be an important element in emerging payment scenarios—particularly in bundled payment systems that are likely to be widely used in the future.

    "As bundled payments become a reality, providers (hospitals) will be incentivized to partner with other providers who deliver efficient quality care; for example, those with low program interruption and transfer rates," authors write. "Our findings indicate that program interruptions and short-stay transfers represent targets for care improvement efforts among Medicare fee-for-service beneficiaries receiving care for stroke, TBI and SCI."

    APTA member Addie Middleton, PT, PhD, was a co-author of the study.

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

    CDC: 2 in 10 Health Care Workers Didn't Get Flu Vaccines; 3 in 10 in Long-Term Care Settings

    About 20% of health care personnel didn't receive influenza vaccines during the 2015-2016 flu season, with employees in long-term care settings reporting an even higher—albeit improved—rate of non-vaccination, according to new data from the US Centers for Disease Control and Prevention (CDC).

    The report, based on an opt-in Internet panel survey of 2,258 health care personnel during March and April 2016, found that the overall rates didn't change much between the 2014-2015 and most recent flu season, with the most recent 79% rate more or less unchanged from the previous year's rate of 77.3%. Among settings, personnel working in hospital settings reported a higher rate of vaccination (91.2%) compared with those working in ambulatory care (79.8%) and long-term care (69.2%) settings.

    Not surprisingly, vaccination rates were highest among workers whose facility required vaccination (96.5%), but that rate fell to less than half (44.9%) for personnel whose employers didn't require, promote, or offer onsite vaccination programs. Coverage was highest among physicians (95.6%) and lowest among assistants and aides (64.1%). Physical therapists (PTs) and physical therapist assistants (PTAs) were not specifically listed in the data, but "other, clinical" was listed at a 94.4% overall rate.

    The only real gains from the 2014-2015 flu season and the most recent season were made in personnel working in long-term care settings, where vaccination rates rose from 63.9% to 69.2%. Authors of the CDC report described vaccinations in these settings as "especially important because influenza vaccination effectiveness is generally lowest in the elderly."

    CDC researchers link the lack of vaccination coverage to employers who don't require, promote, or offer onsite vaccination, writing that "health care personnel working in long-term care settings consistently are the least likely to report that their employer either required or promoted vaccination, or made vaccination available at no cost." In long-term care settings, 40.6% respondent reported that their employer offered no onsite vaccination or promotion.

    Infectious disease control should never be an afterthought. Check out APTA's resources at its Infectious Disease Control webpage.

    PTJ Poised to Move to 'Next Level' Through Publishing Partnership With Oxford University Press

    After several years of growth and increased impact in the research community, Physical Therapy (PTJ), APTA's scientific journal, is now ready to move to "the next level," thanks to a partnership with Oxford University Press (OUP), according to PTJ's Editor-in-Chief Alan Jette, PT, PhD, also a Catherine Worthingham Fellow of the American Physical Therapy Association. It's a partnership that could lead to some significant advances for the journal, including expanded international reach, wider exposure across disciplines and to the general public, and an online format that will allow PTJ readers to dive deeper into the content it offers each month.

    In an editorial published in the October issue of PTJ, Jette describes the PTJ-OUP copublishing partnership as a "great fit" for the journal that will allow PTJ to leverage OUP's status as the world's largest university press. OUP publishes more than 6,000 titles a year, including more than 350 journals. Of those journals, 22% are ranked in the top 10% of at least 1 subject category.

    According to Jette, OUP will publish PTJ through a platform that will offer "state-of-the-art dissemination and display of scholarly work," and will increase PTJ's exposure through, among other channels, promotion in the OUPblog. That blog, Jette writes, is "one of the most widely read academic blogs in the world, with a monthly average of about 70,000 visitors." The PTJ Editorial Board and staff team will maintain full control over the actual content of the journal.

    Also new for PTJ: the ability to offer open-access options for authors. The system will enable both "noncommercial" open access—which allows the sharing of an article for noncommercial purposes—as well as "unrestricted" open access, a system that allows authors and others to reproduce and share the article in any way, including for commercial purposes. According to Jette, these new capabilities will make PTJ an attractive venue for authors working with high-profile funding sources such as the Wellcome Trust and the Bill and Melinda Gates Foundation, which often require publication in journals that offer open-access options.

    One notable outcome of the OUP partnership is an eventual transition from PTJ’s current print and optional online format to an online-only platform. That shift will be made over the next few years.

    Jette believes that beyond its environmental friendliness, the electronic format offers readers "the best way to present and consume research because it allows podcasts, videos, access to archives, and advanced searching … to help readers get the most out of new information and find what they want whenever they want it." The online-only format also makes it easier for APTA and OUP to integrate the journal with social media efforts to promote its content, Jette adds.

    "I believe APTA's decision to co-publish with OUP puts PTJ in the very best position for future development," Jette writes. "[OUP] will work in partnership with our editorial team to continue PTJ's growth and leadership in an increasingly complex and challenging publishing landscape, and will be the publishing partner that can take PTJ to the next level by building on our strategic goals and vision."

    APTA Members: AMA Seeks Critical Input on Existing Physical Therapy CPT Code Values

    APTA members are being alerted to be on the lookout for an important survey from the American Medical Association (AMA) that will help to shape values for certain existing physical therapy current procedural terminology (CPT) codes.

    In the coming days, APTA will distribute an AMA survey to a random sampling of members about existing CPT codes related to physical therapist procedures, as part of the Centers for Medicare and Medicaid Services’ review of potentially “misvalued” codes. The survey is designed to determine the “professional work” value and time involved in the physical therapist’s provision of the services identified by each of these codes.

    "Professional work value" includes the mental effort and judgment, technical skill, and psychological stress involved in providing the service.

    APTA will submit the survey data to AMA’s Relative Value Scale Update Committee (RUC) Health Care Professions Advisory Committee (HCPAC), a multispecialty committee whose purpose is to develop values for CPT codes based in part on survey data such as this. The RUC HCPAC will make a recommendation to CMS for the professional work value of these selected procedure codes.

    If you receive an email requesting your participation in the survey: It is critically important to take the time to complete it. The online survey will take approximately 45-60 minutes. Your responses will be anonymous.

    To learn more about the survey process, check out this video (scroll to the bottom of the page).

    To read more about the review process for potentially misvalued codes, see APTA’s summaries and comments on the 2016 and proposed 2017 Medicare physician fee schedule.

    Dutch Study Finds Pelvic Floor Physical Therapy Useful in Countering Pediatric Constipation

    New research from the Netherlands has staked out another potential benefit of pelvic floor physical therapy (PPT): help with pediatric constipation. The randomized clinical trial found that children with functional constipation (FC) who received specific physical therapy interventions in addition to standard medical care (SMC) experienced a 92.3% rate of treatment effectiveness, compared with a 63% effectiveness rate among children who received SMC alone.

    The study involved 53 children, aged 5-16 years, who were diagnosed with FC according to Rome III criteria between 2009 and 2014. Of those, 26 were assigned to SMC that consisted of education, toilet training, and laxatives, with the remaining 27 receiving SMC plus no more than 6 physical therapy sessions provided by a physical therapist (PT) who specialized in PPT. Pediatricians from 5 hospitals and PTs from 5 PPT practices provided treatment. The study was e-published ahead of print in Gastroenterology (abstract only available for free).

    The PPT followed the Dutch Pelvic Physiotherapy Protocol, and consisted of exercises, practice in sitting on the toilet, the teaching of effective straining, increasing awareness of bodily sensations, and exercises to strengthen pelvic floor functions. In addition to exercises targeted at abdominal and pelvic floor muscles, interventions included balance and stability training, locomotor exercises to learn proper abdominal breathing, and sensory processing techniques.

    Researchers evaluated participants 6 months after they began treatment, and found a 29 percentage point difference in effectiveness between the children who received PPT and SMC (92.3%) compared with the SMC-only group (63%). The differences were also significant when it came to parent-reported secondary outcomes, which included the disappearance of FC complaints (88.5% of the PPT group versus 33.3% of the SMC group), and quality-of-life ratings on a 10-point numeric rating scale (for parents with children in the PPT group, an average 1.8 difference compared with SMC; for children, an average 2-point difference). The children in the PPT group also reported using laxatives at a lower rate than their SMC counterparts.

    While acknowledging that the study's numbers were relatively small, and that it can't be assumed all PPT would follow the Dutch standards, authors of the study assert that PTs offer a uniquely effective approach to pediatric CF, and that PPT may be a "valuable treatment option" that could prevent chronicity.

    "Physiotherapists are musculoskeletal experts, and there the approach in children with FC differs from SMC," they write. "Given the observed effects of this trial, this comprehensive musculoskeletal approach might explain the effectiveness of PPT."

    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.

    More than 1 in 10 Working-Age Americans Has 1 or More Disabilities; Rates Reveal Disparities

    In what it describes as a "conservative" estimate, the US Centers for Disease Control and Prevention (CDC) says that nearly 12% of the working-age population in the United States (18-64) has at least 1 disability, and that more than half of those disabilities are related to mobility. The numbers are based on a recent study that also found disparities in disability rates along income, education, and racial lines.

    The report, published this week, analyzed 128,014 results from the National Health Interview Survey from 2011 to 2014 to capture a picture of not only the prevalence of 1 or more disabilities among adults, but the characteristics of those adults—CDC's first attempt to look at disability in this way. The study tracked adults who reported "serious" disability related to hearing (deafness or near-deafness), blindness (blind or "serious difficulty seeing even when … wearing glasses"), cognitive function, mobility, self-care, and independent living. Respondents did not include adults aged 18-64 living in institutional settings or group homes.

    Researchers paired disability responses with various demographic, income, and employment status characteristics of the respondents to find out how disability prevalence plays out against those factors. Among their findings:

    • Overall, an estimated 22.6 million Americans aged 18-64 (11.9% of the working-age population) have 1 or more disability.
    • Mobility disability was the most common disability reported, cited by 51% of the respondents. Cognitive disability was the second most common disability (38.3%).
    • Of the estimated 12.8 million working-age Americans who report only 1 disability, mobility disability was most common, at 33.5%. Hearing disability was the second most-common single disability, at 24.4%, followed by cognition disability (23.1%).
    • An estimated total of 4.8 million working-age adults have 2 disabilities; 2.7 have 3 disabilities, and 2.4 million have 4 or more.
    • Compared with the national average, respondents with less than a high school education reported higher rates of disability (26.9% compared with the overall 11.9% rate). The same was true for respondents below the poverty line (29.2%), and non-Hispanic black Americans (16%).
    • Americans with 1 disability are twice as likely as Americans with no disability to have less than a high school education, live in poverty, and be looking for work.

    Those prevalence rates may be even higher than the reported estimate, according to the CDC. In their discussion of the study's limitations, authors of the report note that the surveys did not include those living in institutional settings or group homes, and that 4 of the survey questions asked only about "serious" difficulties, as reasons to believe that "the estimates reported here are likely to be conservative."

    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.

    Labels: None