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  • CMS Announces Addition of Patient Opinions to Home Health Compare Website

    The US Centers for Medicare and Medicaid Services (CMS) has added patient perspectives to yet another of its star rating systems—this time, for home health agencies.

    The newly added ratings summarize patient responses to how often the home health team gave care "in a professional way"; how well the team communicated with patients; whether the team discussed medicines, pain, and home safety with patients; how patients rate "the overall care" from the agency; and whether patients would recommend the agency to friends and family. According to CMS, about 6,000 of the 11,000 agencies listed on the Home Health Compare site now include patient care experience ratings.

    According to a CMS news release, the home health addition continues a Department of Health and Human Services effort "to build a health care system that delivers better care, spends health care dollars wisely, and results in healthier people." In addition to the home health site, CMS offers consumer-focused comparison information for nursing homes, physicians, dialysis facilities, and hospitals.

    NYT Says Don't Stop Believin' (in Exercise for LBP)

    PT in Motion News recently covered a study and a Cochrane systematic review touting the positive effects of exercise for treating and preventing recurrence of low back pain (LBP). The New York Times (NYT) picked up on this message in its Well blog article, "To Prevent Back Pain, Orthotics Are Out, Exercise Is In."

    NYT columnist Gretchen Reynolds writes about the systematic review published in JAMA Internal Medicine (abstract only available for free) that analyzed effectiveness of interventions for preventing recurrence of low back pain. For those who experience LBP (described in the NYT article as "80% of those … in the Western world'), exercise is the key to preventing its return—not patient education, not back belts, not insoles.

    The article quotes APTA member Chris Maher, PT, PhD, FCAP, one of the authors of the review, as saying "of all the options currently available to prevent back pain, exercise is really the only one with any evidence that it works."

    Maher is a professor at The University of Sydney and research fellow at The George Institute for Global Health in Sydney, Australia, as well as an Editorial Board member of Physical Therapy, APTA's research journal.

    Some exercise programs examined in the review were standalone, and others combined exercise with education. Reynolds explains that, regardless of the type of exercise program, the participants were less likely to have experienced a subsequent episode of LBP after participating in the programs. The only caveat is that the effect tapers off after 1 year, according to existing high-quality research.

    Maher told NYT that the jury is still out on whether continuing exercise has the same effect in the long term, or which types of exercise program may be more beneficial than others.

    The results echo those of the recent Cochrane systematic review on knee osteoarthritis (OA) covered by PT in Motion News on January 14. Like the LBP review, OA reviewers also found that exercise relieved pain up to 2 months after completing an exercise program, after which point the effects were minimal.

    APTA offers a wealth of resources on low back pain. Offerings range from consumer-focused information including a PT's guide to low back pain, a podcast, and a video. The PTNow evidence-based practice resource includes a variety of guidelines on low back pain, including one published by the APTA Orthopaedic Section.

    Systematic Review: Physical Therapy in Hospice and Palliative Settings Supported by Limited Research

    A review of recent research on the role of physical therapy in hospice and palliative care supports the idea that physical therapy can go a long way toward improving patients' physical, social, and emotional well-being. The problem, according to authors, is that the research itself has a long way to go.

    In a systematic review published in the American Journal of Hospice & Palliative Medicine (abstract only available for free), authors reviewed 13 articles—mainly qualitative—that looked at the use of physical therapy among patients diagnosed with a critical or terminal illness. Authors focused on 5 major components addressed in the various studies—age of participants, types of physical therapy interventions used, assessment tools used, efficacy of treatment, and patient-reported satisfaction and quality of life. Authors of the study include Ahmed Radwan, PT, DPT, PhD.

    Age. Participants ranged in age from 17 to 95. Most subjects were 40-70 years old.

    Interventions. The most frequently discussed interventions were strengthening/therapeutic exercises, patient and family/caregiver education, balance and falls training, and transfer training.

    Assessment tools and outcome measures. Though a variety of outcome measures were used, the most common tools used in the studies were ones that rated patients' pain levels—mostly numeric scales; however, no single tool or measure was used in more than 1 study.

    Efficacy of treatment. "Throughout all of the 13 reviewed articles, it was reported that physical therapy resulted in improvements in a variety of aspects of patients' function and symptoms," authors write. Not surprisingly, most of the improvements were related to pain, although some studies noted improvements in mobility, activities of daily living, endurance, mood, fatigue, and lymphedema.

    Patient satisfaction. Among the studies reviewed, only 5 directly addressed satisfaction or quality of life. All found that these factors had improved.

    While the findings are encouraging, authors of the review also include a long list of limitations to their analysis, most having to do with the current dearth of information on the role of physical therapy in hospice and palliative care.

    Primary among the limitations is what authors believe is a general lack of quantitative research on the topic. When it comes to the reviewed studies themselves, authors cited limitations that include a lack of specificity around the types of treatment provided; multidisciplinary care approaches that, though "realistic," made it difficult to precisely identify the impact of physical therapy; a lack of discussion of treatment costs; high dropout rates; and the fact that every study used a different outcome measure.

    Despite those problems, authors believe that their review sheds some light on how physical therapy is used in hospice and palliative care, and the ways in which it can improve quality of life for patients and caregivers.

    "It is apparent that there is benefit in utilizing physical therapy in end-of-life and palliative care settings," authors write. "This study confirms that physical therapists serve a vital role in [these] settings and should be active members of the multidisciplinary team providing care for this critical patient population."

    APTA advocates for the use of physical therapy in hospice and palliative care, and offers a webpage devoted to the topic. Resources include guides, podcasts, and links to information from Medicare and Medicaid. In addition, PTNow's resources include a health care guideline on palliative care.

    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.

    Survey: 1 in 20 Children Have Problems with Balance or Dizziness

    In what they describe as the first-ever study among children in the US, authors of an epidemiology review estimate that 3.3 million children—about 1 in 20—suffer from some kind of dizziness or balance problem, with 600,000 experiencing symptoms that result in "moderate" or "very big" problems.

    The results are based on a probability sample of 10,954 children aged 3-17 years, by way of survey responses supplied by parents or caregivers. Respondents answered questions about whether, during the past 12 months, their children were bothered by vertigo, poor balance, poor coordination, frequent falls, light-headedness, or any other kind of dizziness or balance problems. Responses were then cross-referenced with other demographic and health information to create a picture of prevalence and potential risk factors. The full report is published in The Journal of Pediatrics (abstract only available for free).

    Among the findings:

    • Overall prevalence for dizziness and balance problems was 5.3% and increased with age, from 4.1% at 3-5 years to 7.5% for ages 15-17. Girls had a 5.7% prevalence, compared with boys' prevalence of 5.0%.
    • "Poor coordination" was the most often-reported symptom (46%), followed by light-headedness (35.1%), poor balance (30.9%), vertigo (29%), frequent falls (25%), and "other" (8.5%). Children were more likely to have 2 or more symptoms than a single symptom.
    • Among the children with balance and dizziness problems, 32.8% had received a diagnosis, a rate that increased to 59.6% for children with moderate to very big problems. Overall rates for being seen by a health care professional in the past year were 36%, and 71.6% among children who had moderate to very big problems.
    • Identified risk factors include being aged 12-17, household education less than high school, family income below the poverty level, low and very low birth weight, first steps without support at 15 months or later, and various developmental or illness conditions.
    • The most strongly associated risk factors, in order, were problems that limited a child's ability to crawl, walk, run, or play; frequent headaches/migraines; "other" developmental delays; seizures during the past 12 months; stuttering/stammering; hearing difficulty; and anemia during the past 12 months.
    • Low and very low birth weight was "significantly associated" with some, but not all, dizziness and balance symptoms—specifically, poor balance, poor coordination, and frequent falls, but not with vertigo or light-headedness. "This suggests that birth weight is more strongly associated with motor problems," authors write.
    • Prevalence of dizziness and balance problems among children with difficulty hearing was 20.9%. For children with vision problems (including those addressed by corrective lenses), prevalence was 14.4%.
    • The results are drawn from a survey funded by the National Institute on Deafness and Other Communication Disorders in 2012, and will be used as baseline data in the National Institutes of Health Healthy People 2020 initiative.

    Authors hope that the results will help with what they describe as a "poorly understood" health problem for a significant number of children in the US, and assert that the ways parents responded to the survey shed much light on the work that needs to be done.

    "Among the one-third of children in this study whose parents/caregivers reported they had been given a diagnosis, 49% replied that the dizziness and balance problems were due to 'other' unspecified causes," authors write. "This finding is not surprising. Almost 90% of children with balance disorders are categorized as 'unspecified dizziness,' indicating that the diagnostic accuracy and methods of physicians treating children with balance problems should be improved."

    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.

    Advocacy Forum, Upgraded App: Get This Year's Efforts Off to a Strong Start

    Ready for some physical therapy advocacy? Because advocacy's ready for you.

    APTA's 2016 advocacy efforts are up and running, with plenty of opportunities for members to participate in person or by way of their handheld device of choice.

    This year's Federal Advocacy Forum is scheduled for April 3-5 at the Grand Hyatt in Washington, DC. It's your opportunity to make the physical therapy profession's voice heard loud and clear on Capitol Hill, and to network with other professionals who share your commitment.

    With the sustainable growth rate gone from the Medicare physician fee schedule, APTA government affairs staff see opportunities to focus on other important issues that deserve attention and action.

    Registration and information on housing is available at the APTA Federal Advocacy Forum webpage. Special room rates are available until March 11, and CEUs are available for the event.

    Whether or not you can make it to DC this April, you can still participate in professional advocacy through the APTA Action App, the grassroots tool that makes it easy to stay on top of issues and influence state and federal decision-makers.

    The upgraded app is even more powerful than before, and now includes state government affairs information for a growing list of states—29 and counting. Available for free, the app includes an action center to contact lawmakers in Congress and in the state legislatures, Congressional and state directories, talking points, and more.

    If you don't have it, get it. If you downloaded the app earlier, be sure to get the update. The APTA Action App is available in the Apple and Google Play app stores.

    2016 - 01 - 27 - Advocacy App

    Physical Therapy 'Ineffective' for PD? Headlines Overstate Study's Conclusions

    A recent study from England involving physical therapy, occupational therapy, and individuals with Parkinson Disease (PD) has generated plenty of dramatic headlines about physical therapy's supposed "ineffectiveness." But as is often the case with dramatic headlines, there's more to the story.

    The study in question, published in JAMA Neurology (abstract only available for free), aimed to evaluate the clinical effectiveness of individualized physical and occupational therapy for individuals with PD by comparing outcomes at baseline and 3 months among 381 participants who received treatment with an equally sized control group that didn't.

    Researchers found little to no difference in outcomes primarily based on the Nottingham Extended Activities of Daily Living (NEADL) scale, and secondarily based on the Parkinson Disease Questionnaire-39 and the EruoQol-5D, writing that "physiotherapy and occupational therapy were not associated with immediate or medium-term clinical improvements in [activities of daily living] or quality of life in mild to moderate PD."

    Headlines ensued. "Parkinson's patients may not benefit from physical therapy," wrote United Press International. "Physical, Occupational Therapy Ineffective in Parkinson," was how Medscape framed the study. "Millions of pounds wasted providing physiotherapy for Parkinson's say researchers," was the headline at the UK newspaper The Telegraph. Several other news outlets took a similar approach.

    While dramatic, the headlines may be off the mark. According to researcher and physical therapy professor Theresa Ellis, PT, PhD, NCS, the study may have more to say about a particular intervention model used in England than it does about the effectiveness of physical therapy on individuals with PD.

    Ellis identifies several issues that may not make the study suitable for generalization. Among them: a low dosage of physical therapy (median number of physical therapy sessions received was 4, meaning that half of all treatment participants received fewer than 4 sessions); widely variable expertise among the physical therapists (PTs) delivering services; the use of 38 different sites for interventions; a wide range of severity among participants; the use of an outcome measure (NEADL) that has not been validated for use in PD; and little attention paid to participants' follow-through, particularly in relation to any homework assigned. "Essentially, most participants had 1 to 2 therapy sessions followed by nothing over 15 months," Ellis said.

    "The very low dose of therapy—below what is typically provided in the US—and the absence of an ongoing home exercise program contribute substantially to the lack of improvement observed," Ellis said. "Other studies in Parkinson, in which larger doses of physical therapy were provided, reveal improvements in walking, functional mobility, and balance."

    Authors of the study admit that the number of sessions was relatively low, but argue that the dosage reflects common practice in England, and that other studies that incorporated more sessions yielded results similar to theirs. Still, they were careful to limit their conclusions only to the effectiveness of low-dose physical and occupational therapy that uses "an individual goal-setting approach" on patients with mild-to-moderate PD, and then only to short and medium-term benefits in activities of daily living or quality of life.

    According to Ellis, even those more narrow conclusions may be questioned. For Ellis, 1 potential problem is the fact that about a third of the patients in the study were in the more severe stages of PD. Another issue: among the mild-to-moderate group, "a substantial number scored at the upper limits of their measure [at baseline], making it impossible to show any progress in these participants," Ellis said.

    While authors of the study hold to their conclusions about the effectiveness of low-dose physical and occupational therapy for individuals with mild-to-moderate PD, they acknowledge that more research is needed—particularly around "the development and testing of more structured … therapy programs in patients with all stages of PD"—the kind of nuance that apparently isn't the stuff of headlines.

    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 Opens 2016 Call for Committee Members

    Ready to step up to APTA committee service? Now’s your chance.

    The call for volunteers to serve on APTA committees is open now through February 23. Members interested in serving on the Ethics and Judicial, Finance and Audit, Leadership Development, Public Policy and Advocacy, or Reference committee, or an Awards subcommittee, are encouraged to let APTA know of their willingness to participate.

    APTA relies heavily on its volunteers. We need the best skills, passion, and varied perspectives to build an energetic, inclusive, and innovative corps of volunteer leaders. Detailed descriptions of the committees, charter, and origins can be found through links on the APTA Volunteer Groups webpage.

    Apply through the Volunteer Interest Pool by updating your profile, then click "Apply for Current Vacancies" to answer questions specific to the committee. Your profile and thoughtful responses to the application question will be read carefully and will help us select the best teams possible. For more information, contact the Appointed Group Pool.

    'Pathways' Program Takes Center Stage as Premier Advanced Proficiency Program for PTAs

    Physical Therapist Assistants (PTAs) now have a single program to help them demonstrate advanced proficiency in several different areas of care.

    APTA announced that the PTA Advanced Proficiency Pathways (APP) program has been elevated to the association's sole postgraduation proficiency recognition program, and that the PTA Recognition of Advanced Proficiency program will be discontinued.

    The APP program uses multiple approaches to help applicants gain and demonstrate proficiency in areas of interest that include acute care, cardiovascular and pulmonary, geriatrics, oncology, orthopedics, pediatrics, and wound management. Participants take online core courses common to all of the APPs as well as content-specific courses for the selected area of work, followed by experiences with a qualified mentor of the participant's choosing. A dedicated program mentor at APTA makes sure that participants stay on the pathway and arrive at advanced proficiency as efficiently as possible.

    The next APP program application cycle will open on May 1, 2016, with a submission deadline of August 1, 2016.

    The soon-to-be discontinued Recognition of Advanced Proficiency program will issue its last call for applications on February 1, 2016 with the recognition remaining valid through 2021. Recipients in this final cycle will be recognized during the 2016 NEXT Conference and Exposition. Questions about PTA Recognition of Advanced Proficiency can be directed to Lisa McLaughlin at lisamclaughlin@apta.org.

    For more information on APP, contact Derek Stepp at derekstepp@apta.org.

    NIH-Funded Project Looks at Using a Robot to Help Children Improve Mobility

    Could a 22-inch robot help children with disabilities improve mobility—and, in turn, overall development? A team of researchers that includes a physical therapist (PT) is hoping to find out.

    An interdisciplinary team from the University of Delaware that includes Cole Galloway, PT, PhD, recently received a grant from the National Institutes of Health to pursue a project they're calling GEAR—Grounded Early Adaptive Rehabilitation. The Delaware team that includes Galloway, robotics experts, computational linguists, and engineers, will collaborate with researchers from the Johns Hopkins University Center for Imaging Science, according to an article in Delaware Online.

    The idea behind GEAR is to program a commercially available robot to serve as a kind of cheerleader, monitor, and coach for children with motor disabilities. The researchers hope to develop a robot that not only can encourage these children to engage in certain activities, but can learn and adapt to each child's movement patterns, and provide customized lessons that fit individual needs.

    The team is using NAO, a 22-inch, programmable, bipedal robot developed by Aldebaran Inc, a company that describes its products as "kindly robots in humanoid form." And the robot is pretty cute—right down to its button-like eyes and tiny fingers.

    But looks aren't everything. According to Galloway, the team faces a significant challenge: namely, getting the thing to keep up with a toddler—even one with a mobility disability. He says the project is "Mars Rover-level" in terms of complexity.

    First, NAO needs to observe and learn how children without disabilities move, which in turn means it will need to have a high degree of mobility itself. Then the robot will have to compare that data with the observed movements of children with a disability and target its encouragement and instruction to deficit areas—all under the watchful programming eye of a real human being, that is.

    Galloway is excited about the project and about the opportunity for the physical therapy profession to be represented in a major interdisciplinary research project. "As physical therapists, we're concerned with social mobility," Galloway said. "This project is interesting because we can apply this concern to a research setting to hopefully see some very practical results. I think it will help to put us on the map in terms interdisciplinary research."

    Naturally, Galloway is concerned about what happens with the robot project after—and outside of—the lab. As the founder of GoBabyGo!, an initiative that invites people to adapt kids' ride-on toys into mobility devices using easily available materials, Galloway is particularly interested in how lessons from the GEAR project can be applied widely, and cheaply, to the broadest possible range of users.

    "This is a great $10,000 robot," Galloway said. "But if, when it's all over, if we've only figured out how to make a $10,000 robot work in a lab, what have we done? It's important that we find out the possibilities, and then see what we can do to create something that costs $100, or even less." To that end, he hopes to get funding to sponsor a separate-but-related project that will allow a postdoctoral researcher to translate the lessons of the GEAR project into more affordable applications.

    This isn't the first time the NAO robot was used as a potential aid in physical therapy: in April, PT in Motion News reported on researchers in Spain who were hoping to use NAO as a "social therapist" designed to "enliven rehabilitation processes."

    Want to read more of Cole Galloway's thoughts research vs the real world in physical therapy? Check out his insights on turning inspiration into action in "Taking the Leap," part of APTA's online series, "Physical Therapy: A Profession in Transformation."

    Could 'Bioresorbable' Sensors Help Individuals Recover From Brain Injury, Surgery?

    They melt in your brain, not in your hand.

    Scientists at the University of Illinois at Urbana-Champagne have created a sensor they hope can one day be implanted in the brains of patients to monitor and wirelessly transmit data on pressure and temperature within the skull for a time, and then simply resorb into the body. Researchers believe the new approach could help make physical therapy less complicated for individuals recovering from brain injury or surgery (no more external wires in the way) and reduce the incidence of infection, allergic reaction, or other complications associated with implanted sensors that require external wiring and eventual surgical removal.

    Described in a report in Science Daily as "smaller than a grain of rice," the sensors are made of thin sheets of naturally biodegradable silicon that send data to a transmitter "roughly the size of a postage stamp" implanted under the skin of the skull. This transmitter in turn feeds temperature and pressure data to monitoring equipment, all without the use of external wires.

    So far, the new technology has only been tested on rats, but researchers tell Science Daily that the measurement precision of the dissolvable sensors "was just as good as that of the conventional devices." Results of the animal testing were published in the January 18 issue of Nature.

    Rory Murphy, a neurosurgeon at Washington University and part of the research team, told Science Daily that "the ultimate strategy is to have a device that you can place in the brain—or in other organs in the body—that is entirely implanted, intimately connected with the organ you want to monitor and can transmit signals wirelessly to provide information on the health of that organ, allowing doctors to intervene if necessary to prevent bigger problems. After the critical period that you actually want to monitor, it will dissolve away and disappear."

    According to Science Daily, researchers are "moving toward" human trials of the technology, and looking at other possible areas of the body that would be well-suited for this type of monitoring system. They also hope to investigate ways the technology could be used to deliver electrical stimulation or drugs.

    CDC Says Nondrug Approaches 'Preferred' to Treat Chronic Pain; APTA Adds its Support

    The US Centers for Disease Control and Prevention's (CDC's) draft clinical guidelines on the use of opioids for chronic pain make it clear: nondrug approaches such as physical therapy are the "preferred" treatment path for chronic pain.

    APTA couldn't agree more.

    This week, APTA submitted comments to a new CDC document aimed at primary providers who may prescribe opioids to treat chronic pain. The guidelines attempt to rein in growing rates of opioid use disorder and opioid overdose, and to help reduce the prevalence of opioid prescriptions, which topped 259 million in 2012—"enough for every adult in the United States to have a bottle of pills," according to the CDC.

    The guidelines were developed after expert review of evidence around not only the effectiveness of opioids (and their dangers), but also the ways in which nondrug approaches can be used in treatment. After evaluating the evidence, the CDC drafted recommendations around determining when to initiate or continue opioids for chronic pain, as well as guidelines for drug selection and dosage, and risk assessment.

    Its first recommendation: "Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain."

    "Based on contextual evidence, many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, complementary and alternative therapies (e.g., manipulation, massage, and acupuncture), psychological therapies such as CBT, and certain interventional procedures can ameliorate chronic pain," the draft states. "In particular, there is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip … or knee … osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2–6 months."

    In its comments to the draft, APTA applauds the recommendations, stating that approaches such as physical therapy "have been underutilized, and, therefore, can serve as a primary strategy to reducing prescription pain medication abuse and improving the lives of individuals with chronic pain."

    APTA's comments also note that referral to exercised-based interventions "is essential prior to the initiation of opioid-based therapy," and that exercise interventions "have the potential to improve health outcomes, reduce costs, and decrease the risks associated with opioid prescriptions."

    The association goes on to recommend that the CDC provide clear guidance on the patient populations that would benefit from nondrug approaches, and that more extensive patient education resources should be developed on the benefits of exercise-based interventions over opioid prescriptions. This education needs to be aimed at both the public and primary care providers, ATPA writes.

    APTA also added its support to CDC recommendations around the use of multidisciplinary approaches to management of chronic pain, such as a combination of physical therapy and cognitive-based interventions. The problem, the association points out, is that although supported by evidence, the approaches "have been challenged by reimbursement policies." APTA recommends that the use of multimodal approaches to treat chronic pain be part of a broader effort to change payment policies in ways that make them more amenable to nondrug approaches to chronic pain.

    The CDC guidelines—and APTA's comments—come at a time when the fight against opioid abuse and heroin use has gained attention at a national level. The issue was a part of President Barack Obama's final State of the Union address on January 12, and the epidemic is the subject of a White House initiative that includes APTA and other health care and corporate partners. At the state level, West Virginia—one of the states hardest hit by the opioid abuse problem—has announced the formation of a new House committee on substance abuse. That committee includes Rep Mick Bates, PT.

    Quick Quiz: When Medicare Says You've Been Overpaid

    There you are, hard at work. Your patients are making progress, you're feeling good, things seem to be going along just fine, and then—boom—you get a letter from the Centers for Medicare and Medicaid Services (CMS) saying they think they've overpaid you on a claim. It's enough to ruin anyone's day.

    Think you know your way around the overpayment process? Take this quick quiz, and then check out this CMS fact sheet for more details on the options available to you if CMS says you’ve been overpaid on a claim. (Quick tip: When it comes to the overpayment process, deadlines matter and are taken seriously. The CMS fact sheet also lays out timelines clearly—you may want to keep a copy handy.)

    Ready? Here we go.

    1. Overpayments above which amount will trigger the Medicare Administrative Contractor (MAC) recovery process?

    A. $5
    B. $10
    C. $25
    D. $50

    2. If you don't repay the alleged overpayment (or submit a rebuttal to the MAC), when does interest begin accruing?

    A. On the initial notification
    B. 30 days after notification
    C. The next quarter of the year
    D. Upon submission of a subsequent claim for reimbursement

    3. Which of the following is NOT an option if you receive an overpayment demand letter?

    A. Make an immediate payment
    B. Request that the overpayment be immediately recouped through reductions in current due or future claims you've submitted or will submit ("immediate recoupment")
    C. Request that the MAC reduce your payments on claims beginning 16 days after the demand letter was issued ("standard recoupment")
    D. Request an extended repayment schedule (ERS)
    E. Submit a rebuttal explaining why Medicare shouldn't begin recoupment
    F. Request a redetermination to appeal the overpayment determination
    G. Ignore the whole thing and binge-watch "American Gladiators"

    4. True or false: It's possible for an appeal to an overpayment determination to be decided in Federal District Court.

    5. How many days after a demand letter is sent do you have to request an appeal of the determination and stop recoupment?

    A. 7
    B. 15
    C. 30
    D. 60



    Answers: 1-C; 2-B; 3-G; 4-True; 5-C.

    Supervised Exercise (Still) Beneficial for Knee OA

    Most clinical practice guidelines recommend exercise as a first-line treatment for stiffness and pain in knee osteoarthritis (OA), and an updated Cochrane systematic review published in the British Journal of Sports Medicineindicates there's even more reason to do so.

    The authors examined 54 randomized clinical trials (RCTs) involving over 5,000 participants to determine the effectiveness of land-based exercise in improving pain, physical function, and quality of life in individuals with knee OA. Participants who completed exercise programs experienced moderate improvement in pain and physical function immediately after treatment, about the same as that of analgesics and nonsteroidal anti-inflammatory drugs.

    While pain relief from exercise was still significant at 2 to 6 months after treatment, the effect was smaller, and benefits were minimal after 6 months. Physical function improvement was "better sustained," according to authors, producing small yet significant results even at 6 months.

    New to this review was an analysis of data related to quality of life, where pooled results of 13 studies showed a statistically significant benefit of exercise immediately post treatment—"equivalent to an improvement of four points … on a 0–100-point scale," authors write.

    The review included studies that compared “any land-based non-perioperative therapeutic exercise regimen” with a non-exercise control group. This wide variation in exercise type, duration, frequency, and intensity didn't allow the authors to evaluate the benefits of one program over another. Also, these findings only pertain to strengthening or weight-bearing exercises—the authors found no studies that examined high-impact exercise as an intervention for knee OA.

    Researchers did find that supervised individual exercise programs were more effective than group exercise or home-based programs, with the authors writing that “the magnitude of immediate treatment effects of exercise on pain and physical function increases with the number of face-to-face contact occasions with the healthcare professional.”

    The new review updated an earlier Cochrane study on the topic completed in 2008. That study pointed to the positive effects of exercise for pain and physical function in individuals with knee OA.

    Eight years and 22 studies later, the evidence still supports that idea.

    "Health care professionals and people with OA can be reassured that any type of exercise program that is performed regularly and is closely monitored by healthcare professionals can improve pain, physical function and quality of life related to knee OA in the short term," they write.

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

    Top SNF Therapy Provider Settles DOJ Lawsuit for $125 Million

    The US Department of Justice (DOJ) announced that the nation's largest nursing home therapy provider has agreed to pay $125 million to settle a DOJ lawsuit that alleged the company engaged in a "systematic and broad-ranging scheme" to increase Medicare reimbursements by submitting false claims for rehabilitation therapy.

    RehabCare Group Inc, RehabCare Group East Inc, and parent company Kindred Healthcare will pay out the money in response to allegations that they violated the False Claims Act by "providing unreasonable and unnecessary services to Medicare patients," and that they "led … SNF [skilled nursing facility] customers to submit artificially and improperly inflated bills to Medicare that included those services," according to a DOJ press release. RehabCare contracts with more than 1,000 SNFs in 44 states to provide rehabilitation therapy.

    The alleged violations include:

    • Placing patients in the highest-possible reimbursement levels, regardless of determinations made through patient evaluation
    • "Boosting" the amount of reported therapy during "assessment reference periods" and then providing less therapy to those patients outside of those reference periods
    • Scheduling and reporting the provision of therapy, even after the patients' therapist had recommended discharge
    • Shifting minutes of planned therapy among disciplines "to ensure targeted therapy reimbursement levels were achieved, regardless of the clinical need for therapy"
    • Providing higher amounts of therapy near the end of a therapy measurement period to maximize payment
    • Reporting time spent on initial evaluation as therapy time rather than evaluation time
    • Reporting that skilled therapy had been provided "when in fact the patients were asleep or otherwise unable to undergo or benefit from skilled therapy"
    • Reporting estimated or rounded minutes of therapy rather than actual minutes provided


     According to DOJ, the settlement is also linked to 4 other settlements with individual SNFs for their roles in submitting false claims of therapy provided by RehabCare. Those payments range from $3.9 million to $750,000.

    The $125 million RehabCare settlement is the result of a whistleblower lawsuit brought to the DOJ by APTA member Janet Mahoney, PT, DPT, and Shawn Fahey, an occupational therapist. Both worked for RehabCare.

    SNF billing practices began making headlines late last summer, when the Wall Street Journal published a report outlining the findings of its study of the use of "ultrahigh" therapy hours, and resurfaced in October when the Office of the Inspector General of the US Department of Health and Human Services (HHS) issued a report highly critical of SNFs. That report was in turn the subject of a New York Times article on the issue, an article that prompted a letter to the editor from APTA President Sharon L. Dunn, PT, PhD, OCS, published in the Times.

    In the DOJ press release, Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the DOJ's Civil Division, says that the scrutiny will continue.

    "Medicare beneficiaries are entitled to receive care that is dictated by their clinical needs rather than the fiscal interests of health care providers," Mizer said. "All providers, whether contractors or direct billers of taxpayer-funded federal health care programs, will be held accountable when their actions cause false claims for unnecessary services."

    Helping physical therapists and physical therapist assistants understand their obligation to eliminate fraud, abuse, and waste is the central idea behind APTA's online Center for Integrity in Practice—a suite of resources to support care based on patient need and clinical judgment.

    The Good Stuff: Members and the Profession in Local News, January 2016

    "The Good Stuff," is an occasional series that highlights recent, mostly local 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!

    Laurent Ziaks, PT, DPT, ATC, the "queen of concussions," describes her work with concussion recovery, and how her own injuries inform her approach. (Deseret, Utah, News)

    Darrin Taullie, PT, DPT, offers advice to seniors on becoming more physically active (La Junta, Colorado, Tribune-Democrat)

    "The prosthetic guy came to my hospital room, and he said, 'You can get 120 Percocets a month and watch TV all day, or you can put a leg on and go to work.' I want to put a leg on and go to work." --Plumber Ryan Pater, on his path of rehabilitation after amputation. (Middletown, Ohio, Journal-News)

    Amber Devers, PT, DPT, NCS, explains her clinic's participation in an exoskeleton research program: "We are interested in seeing how the Indego exoskeleton helps people after stroke compared to other devices." (Richmond Times-Dispatch)

    Sandra Terrazas, PT, comments on her clinic's efforts to increase physical fitness among older adults: "Our [physical therapy] training was about restoring function, but it's also about quality of life." (El Paso Plus)

    Brad Cooper, PT, MSPT, MBA, MTC, ATC, CWC, (and author of PT in Motion's "Well To Do" column),"The world's fittest CEO" – Video profile of Cooper and his completion of the "endurance trifecta." (Colorado Business Journal)

    "Physical therapy hurts so good" (Opinion in Fort Wayne, Indiana Journal Gazette)

    Christopher Mulvey, PT, DPT, describes the similarities between learning to ride a hoverboard and regaining balance after an injury, in a story about southwest Florida's "first-ever hoverboard training center." (Fox 4 News, Cape Coral, Florida)

    Adele Levine, PT, DPT, OCS, writes about how combat amputees and their therapists "find roads to happiness." (New York Times)

    "It's difficult being injured, but you learn some different techniques and a lot of little details when you're in physical therapy every day. Things like your hip and back alignment that you might not think about very much, but there are a lot of things to do (to prevent injuries) in those areas." --Julia Krass, the youngest athlete selected for the US slopestyle ski team, on her road to recovery. (West Lebanon, New Hampshire Valley News, free login required)

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

    Separate Studies Support Exercise to Treat, Prevent LBP

    Research continues to support the effectiveness of exercise when it comes to low back pain (LBP)—not only as a way to treat existing LBP, but as a way to prevent it.

    A new systematic review and meta-analysis in JAMA Internal Medicine (abstract only available for free) assessed research into the value of exercise as a way to prevent episodes of LBP. It found that exercise alone was linked to a 35% reduction in risk, while a combination of exercise and education was associated with a 45% risk reduction for up to 1 year. The use of exercise was also found to result in a 78% reduction in sick leave for LBP.

    The review was based on 23 published studies involving 30,850 participants, and looked at the preventive qualities not only of exercise and education (both combined and separately), but also of back belts and orthotic shoe insoles. In the end, only exercise was linked to a reduced risk of LBP: authors of the study found that while education helped to further reduce that risk when combined with exercise, education alone didn't seem to have much effect.

    The problem: the risk reduction benefits of exercise "disappeared" after 1 year. Authors attribute the dropoff to some individuals discontinuing the exercise program.

    "The finding raises the important issue that, for exercise to remain protective against future LBP, it is likely that ongoing exercise is required," authors write. "Prevention programs focusing on long-term behavior change in exercise habits seem to be important."

    Also Works for Treatment of Chronic LBP
    While the JAMA authors focused on prevention, researchers whose findings were included in a recently updated Cochrane review ( currently, abstract only available for free; complete article will be made available via APTA's ArticleSearch in the coming weeks) aimed at evaluating the evidence supporting exercise—specifically motor control exercise (MCE) to coordinate and stabilize deep trunk muscles—as a treatment for chronic LBP.

    Their conclusion was that MCE "probably provides better improvements in pain, function, and global impression of recovery" than minimal intervention at all follow-up periods (these varied by study), and that it "may" provide better improvements than exercise and electrophysical agents. Authors found results to be about the same when it came to MCE versus manual therapy, and MCE versus "other forms of exercise." The analysis was based on 29 trials involving 2,431 participants.

    "Given the minimal evidence that MCE is superior to other forms of exercise, the choice of exercise for chronic LBP would probably depend on patient or therapist preferences, therapist training, costs, and safety," authors write.

    'Uncommonly Prescribed'
    In an invited commentary on the JAMA article, authors Timothy Carey, MD, and Janet Freburger, PT, PhD, focus on the LBP prevention study, but the main point they raise—the need for more widespread use of exercise prescriptions—could apply to the MCE study as well.

    "If a medication or injection were available that reduced LBP recurrence by [the amounts cited in the JAMA article], we would be reading the marketing materials in our journals and viewing them on television," commentary authors write. "However, formal exercise instruction after an episode of LBP is uncommonly prescribed by physicians." They describe the gap as part of a pattern in the treatment of musculoskeletal problems "in which effective but lower-technology and often lower-reimbursed activities are underused."

    Carey and Freburger describe several barriers to more common use of exercise instruction that include a lack of consensus around "standard, efficient, and acceptable bundled intervention" for LBP, unclear understandings of the role of patient education, questions about how best to motivate patients, a paucity of cost-effectiveness studies, hesitancy among payers to support exercise programs, and a shortage of clinicians "able to describe, with confidence, the benefits of easily accessible exercise programs to diverse patient populations."

    "To address these barriers, payers, professional societies, consumers, and members of health care delivery systems will need to work together," write Carey and Freburger, adding that if they do, "the potential benefits to the health system, patients, and employers are substantial."

    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.

    Survey: Most Older Americans Have 2 or More Chronic Health Conditions

    If you're an American adult 65 or older, it's more likely than not that you're being treated for at least 1 chronic health condition, and there's a good chance you have 4 or more, according to the Medical Expenditure Panel Survey (MEPS).

    The new data, presented in a MEPS statistical brief, targets the prevalence and costs of treated chronic conditions among US adults in 2012. It shows that in the 65 and older demographic, it's less a matter of if an individual in this group has a chronic condition as it is a matter of how many he or she has: nearly 66% of adults 65 and up reported being treated for at least 2 chronic conditions. Just under 1 in 4—23.2%—report receiving treatment for 4 or more.

    Overall, 25.9% of all Americans have reported being treated for 2 or more chronic conditions, accounting for 57% of all health care expenditures. When you add in the 18.6% of Americans who have 1 treated chronic condition, the combined group accounts for 77.7% of US health care expenditures. In the report, "expenditures" is defined as "payments from all sources for hospital inpatient care, ambulatory care provided in offices and hospital outpatient departments, care provided in emergency departments, home health care, dental care, prescribed medicine purchases reported by respondents," and other services such as prescription glasses and medical supplies.

    Prevalence was linked to age—in the 18- 44-year-old group, 5.6% reported 2 or more chronic conditions. That rate rose to 31.7% in adults aged 45-64, and then more than doubled for the 65-and-older group.

    The chronic conditions targeted in the survey were hypertension, congestive heart failure, coronary artery disease, cardiac arrhythmias, hyperlipidemia, stroke, arthritis, asthma, autism spectrum disorder, cancer, chronic kidney disease, chronic obstructive pulmonary disease, dementia (including Alzheimer's and other senile dementias), depression, diabetes, hepatitis, human immunodeficiency virus (HIV), osteoporosis, schizophrenia, and substance abuse disorders.

    APTA highlights the role of the physical therapist and physical therapist assistant in the treatment of chronic conditions through its prevention, wellness, and disease management webpage. In addition, the 2015 House of Delegates adopted the position Health Priorities for Populations and Individuals (RC 11-15) "to guide [APTA's] work in the areas of prevention, wellness, fitness, health promotion, and management of disease and disability." The priorities include active living, injury prevention, and secondary prevention in chronic disease and disability management. The topic was also the subject of a popular presentation at the 2015 NEXT Conference and Exposition.

    Want to learn more? Attend "Exercise Prescription Principles for the Older Adult With Multiple Chronic Conditions," one of the presentations scheduled for the 2016 APTA Combined Sections Meeting, February 17-20 in Anaheim. Also available from the APTA Learning Center: Disease Management Models for Physical Therapists: Focus on Diabetes and Cardiovascular Disease.

    Ahhh…Paris in April: Another Adventure to Raise Awareness for PT Research

    Physical therapy research advocate, Foundation for Physical Therapy (Foundation) trustee, and general ball of energy Stanley Paris, PT, PhD, FAPTA, FAAOMPT, is at it again—ready to set out on another adventure to raise money for physical therapy research.

    And this time, everyone's invited to join him.

    Paris announced that beginning Friday, April 1, he will begin his "Ride for PT Research," a 3,000-mile bicycle journey across the United States. And he says he's going to do it with only 3 days' rest.

    Similar to adventures he took on in 2014 and 2015—attempts to circumnavigate the globe solo in his sailboat—Paris is hoping to raise money for the Foundation through donations to his project.

    This time, however, in addition to making donations, supporters can actually take part in the journey: Paris is inviting riders to join him on any segment of the trip—or for the entire ride. Think of it as a chance to visit Paris by bike.

    Paris will be using the Adventure Cycling Association's southern tier route, beginning in San Diego and ending in St Augustine, Florida.

    "We have appreciated Stanley’s multiple efforts in the past to advocate on behalf of the Foundation," said Foundation Board of Trustees President Barbara Connolly, PT, DPT, EdD, FAPTA, in a Foundation press release. "There is a huge need to continue to raise awareness and publicize physical therapy research. We are truly excited to have him take on this challenge with the Foundation in mind."

    2016 - 01 - 08 - Stan Paris Bike Ride

    CMS Announces 14-Day Hold on 2016 Claims; Predicts 'Minimal Impact'

    The Centers for Medicare and Medicaid Services (CMS) announced that it will hold claims on services provided in 2016 until possibly as long as January 15 in order to fix "technical errors" it discovered after publication of the 2016 Medicare physician fee schedule.

    According to a CMS announcement, the hold will not affect claims for services provided in 2015, and should have "minimal impact on provider cash flow," as current law prevents payment on clean electronic claims any sooner than 14 days after receipt.

    TKA, THA Certification Program Unveiled

    The focus on total knee arthroplasty (TKA) and total hip arthroplasty (THA) as a major health care issue continues with the official debut of a Joint Commission-sponsored TKA and THA certification program for facilities.

    According to the commission, the certification program was created to "address challenges that exist in current practice," and pays close attention to quality, consistency, and safety—particularly in relation to how transitions between the preoperative, intraoperative, and postoperative phases of care are managed. Accredited hospitals, critical access hospitals, and ambulatory surgery centers are eligible for the certification.

    Physical therapists (PTs) and physical therapist assistants (PTAs) were invited to comment on a draft of the program in April of 2015. APTA member Jerry Cain, PT, MPT, was part of the task force that created the new resource.

    As TKA and THA rates continue to rise, the procedures have taken center stage at the Centers for Medicare and Medicaid Services (CMS), which will launch a mandatory bundled payment system—called the Comprehensive Care Joint Replacement (CJR) model—for Medicare beneficiaries receiving TKA or THA in 67 metropolitan statistical areas beginning April 1. APTA offers a webpage on the CJR, and will add resources and educational components in the coming months.

    'First Fruits' of APTA Program Provides Clinical Guidelines on VTE

    An APTA clinical practice guideline (CPG) development process that began in 2012 is now paying off, with the upcoming publication of a new CPG on the role of the PT in management of patients with venous thromboembolism (VTE). The guidelines were jointly produced by the APTA Cardiovascular and Pulmonary Section and the association's Acute Care Section, with funding and support provided by APTA.

    The 32-page document (.pdf) includes algorithms for screening for risk of VTE, determining the likelihood of a lower extremity deep vein thrombosis (LE DVT), and mobilizing patients with LE DVT, as well as 14 "action statements" that outline best practices. First e-published ahead of print in October in Physical Therapy (PTJ), APTA's research journal, a draft of the CPG was shared during the 2015 APTA Combined Sections Meeting. The final version, set for publication in the February issue of PTJ, will be used to develop pocket guides, patient brochures, podcasts, and "checklists and sample evaluation forms incorporating the recommendations of the CPG,” according to guideline authors.

    The CPG was developed through a program, started in 2012, in which APTA facilitates (and provides funding for) the creation of guidelines in partnership with sections. The assistance includes workshops and other training, and helps to shepherd the CPG all the way to final publication. The importance of CPGs—and APTA's role in their development—was featured as part of APTA's series "Physical Therapy: A Profession in Transformation" published in 2015. Also produced through the APTA program: a clinical guidance statement on the management of falls in community-dwelling older adults, developed by the Academy of Geriatric Physical Therapy.

    "This CPG and the falls guidance statement are the first fruits in what we believe will be a series of high-quality resource documents that are focused specifically on connecting PTs and PTAs with the best available research, and making it easy for them to put that research into practice," said APTA's Anita Bemis-Dougherty, PT, DPT, MAS, vice president in the Department of Practice. "We're looking forward to much more in the months and years to come."

    The CPG was written by Ellen Hillegass, PT, PhD, FAPTA, CCS, Michael Puthoff, PT, PhD, GCS, Ethel Frese, PT, DPT, CCS, Mary Thigpen, PT, PhD, Dennis Sobush, PT, MA, DPT, CCS, and Beth Auten, MLIS, MA, AHIP.

    Opioid Prescription Study Sparks Talk of Nondrug Approaches to Chronic Pain

    A new study on access to prescription opioids has garnered media attention—and triggered more discussion about the need for physicians to more carefully consider other treatments for chronic pain, including physical therapy.

    The study, covered by Reuters, The Boston Globe, and other media outlets, found that more than 90% of individuals who survived a prescription drug overdose were able to get another prescription for the same drug after the overdose. And it would seem that for the most part, it wasn't that hard to do—70% of the people who obtained the postoverdose prescription got it from the same physician who prescribed it earlier.

    Quoted in the Reuters article, lead study author Marc Larochelle, MD, said that a possible explanation for the "surprising and concerning" results is that "providers are not aware that their patients experienced an overdose when making the decision to continue prescribing opioids."

    The Boston Globe characterized the study as one that suggests "major gaps in communication, education, and oversight."

    Closing those gaps will require physicians to pay careful attention to signs of opioid abuse among their patients and to consider treatments other than opioids for chronic pain, according to Larochelle.

    "In addition to any potential opioid use disorder, we need to communicate alternative options for treatment of chronic pain, and all modalities should be considered, including nonopioid medications, physical therapy, and complementary and alternative treatments," Larochelle told Reuters.

    Jessica Gregg, MD, who wrote an editorial that accompanies the study, echoed Larochelle's points, telling Reuters that "in a perfect world, a physician would be able to work with a team that might include physical therapists and/or occupational therapists, alcohol and drug counselors," and others with related expertise.

    In the Globe article, Gregg says that while effective, treatments that rely less heavily on opioids are "slow fixes" that the current health care system isn't "particularly well set up" to accommodate. She characterizes physical therapy and emotional health treatment as "things that will help, but not quickly."

    The study, published in the Annals of Internal Medicine (abstract only available for free), surfaced in the media not long after the US Centers for Disease Control and Prevention (CDC) issued a report stating that drug and opioid overdose deaths in the US rose dramatically in 2014, to 14.7 per 100,000 persons. That's an increase of 6.5% over the 2013 rate, part of a trend that has amounted to 137% increase in overdose death rates from all drugs since 2000. Death rates from opioid pain relievers and heroin increased by 200% during that same time.

    APTA has taken an active role in bringing the physical therapy perspective to the fight against prescription drug abuse and heroin use, and is currently participating in a public-private White House initiative to combat the problem. In addition to APTA, initiative participants include the American Medical Association, the American Academy of Family Physicians, the American Nurses Association, the American Public Health Association, the American Academy of Hospice and Palliative Medicine, and the American College of Osteopathic Surgeons.