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  • Large-Scale Investigation: Falls-Prevention Exercise Interventions Work

    An extensive review of more than 100 randomized controlled trials (RCTs) strongly supports exercise interventions as a way to reduce both the risk of falls among adults 65 and older and the actual number of those who experience a fall. What's less clear are some of the nuances of that finding—such as the effectiveness of resistance training or walking programs, and the differences between interventions provided by "health professionals" versus "trained providers who were not health professionals."

    The recently published Cochrane systematic review (abstract only available for free) focused on 108 RCTs involving 23,407 community-dwelling adults in 25 countries. Participants were an average age of 76, and 77% were women. The majority of participants lived in the community, and RCTs that focused on participants with conditions that increased the risk of falls—Parkinson disease, stroke, multiple sclerosis, dementia, hip fracture, and severe visual impairment—were excluded.

    The Cochrane reviewers analyzed various categories of exercise interventions versus control, which consisted of either no change in usual activities or an intervention not anticipated to reduce falls, such as health education, social visits, "gentle" exercises, or sham exercises. The exercise interventions were categorized as balance and functional; resistance; flexibility training; "3D" exercise including Tai Chi and Qigong; "3D" dance-based exercise; walking programs; endurance; "other"; and exercise interventions that included more than 1 of the studied categories.

    Among the findings:

    • Overall, exercise reduces the rate of falls by 23% compared with control—but this difference doesn't seem to apply to individuals 75 or older.
    • In terms of risk, authors found that, overall, individuals who received an exercise intervention from a trained health care professional had a 31% lower risk of falls compared with controls, while participants who received the intervention from providers who weren’t trained health care professionals had an 18% lower risk compared with control. Interestingly the differences between the trained and not-trained provider rates weren't present when researchers looked at individual programs that combined 2 or more exercise interventions.
    • Overall, risk reduction was about the same for exercise interventions that were provided individually (21% risk reduction) versus in a group setting (24% risk reduction).
    • In terms of specific types of exercise, the interventions researchers defined as focusing primarily on gait, balance, coordination, or functional task training were found to reduce falls by 24%. Tai Chi/Qigong was estimated to reduce falls by 19%, and a combination of 2 or more interventions was estimated to reduce falls by 34%. Studies on resistance training, danced-based exercise, and walking programs alone versus control didn't yield strong enough evidence to support a definitive conclusion.
    • While a combination of interventions produced an overall reduction of 34%, authors found that when the most common combination—balance/functional exercises and resistance training—was looked at separately, the reduction rate remained nearly the same (31%).
    • Balance and functional exercise interventions reported the best results in terms of reducing the long-term risk of falls (18 months or more post-intervention), with a reported 18% reduction versus control.
    • Overall, exercise interventions were found to reduce the risk of later fall-related fractures by 27% and lower the risk of falls that require medical attention by 39%.

    While they acknowledge that there wasn't enough evidence for reviewers to look at the differences in exercise modality or doses, authors note that "there may also be longer-term benefits of introducing fall prevention exercise habits in people in the general community." They point out that most of the studies reviewed focused on programs that lasted 12 weeks or more, with nearly a third lasting a year or more. "These findings highlight the importance of primary prevention," they write.

    Even with the definitive conclusion on the overall effectiveness of exercise in falls prevention, authors of the review believe more work should be done to tease out the impact of various exercise programs, though they advise that the studies will need to be "very large." They also recommend further research into fall prevention programs in emerging economies "where the burden of falls is increasing more rapidly than in high-income countries," and the need to investigate how best to integrate falls prevention interventions into routine care of individuals 65 and older.

    Even with those gaps in evidence, "there is high-certainty evidence that falls can be prevented by exercise programs," authors write. "Exercise reduces both the rate of falls…and the number of people experiencing falls."

    APTA provides extensive resources on falls prevention at its Balance and Falls webpage. Offerings include consumer-focused information, online courses, and links to other sources of information, including the CDC and the National Council on Aging. In addition, APTA's PTNow evidence-based practice resource offers a unilateral vestibular hypofunction clinical summary, a summary on falls risk in community-dwelling elders, an osteoporosis clinical summary, and tests and measures such as a fracture risk assessment, a clinical test of sensory interaction and balance, and a self-paced walk test. The association's scientific journal, PTJ (Physical Therapy) has published a clinical guidance statement from the APTA Academy of Geriatric Physical Therapy on management of falls in community-dwelling older adults.

    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.

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    APTA Working for You: Practice-Related Updates, February 2019

    APTA brings the profession's insights and expertise to bear in a variety of settings. Here's a quick rundown of some of the latest news and APTA activities.

    Professional Issues

    • APTA helps the National Institutes of Health's (NIH’s) "Go4Life" exercise campaign spread the word about the benefits of exercise: APTA was featured on the Go4Life website for the strong ties between APTA and NIH's National Institute on Aging (NIOA). APTA Senior Staff Specialist Hadiya Green Guerrero, PT, DPT, a certified sports physical therapy specialist, is working with NIOA on consumer fact sheets about physical activity for people with musculoskeletal conditions.
    • Understanding of the APTA Physical Therapy Outcomes Registry continues to grow: APTA is working with US Department of Health and Human Services Office of the National Coordinator for Health Information (ONC) and professional societies toward standardization of elements of practice, a key concept for the Registry. APTA staff also are collaborating with professional organizations on getting electronic health records to understand certain standard data elements.
    • APTA is helping staff at the Medstar National Rehabilitation Hospital (NRH) better understand the elements of culturally competent practice: APTA Practice Department staff will emphasize APTA’s mission, vision, and strategic plan at an upcoming NRH event, and explain how being a culturally competent practitioner can improve outcomes and patient satisfaction.
    • A list of consumer questions on pain management is now part of the #ChoosePT online toolkit: APTA practice staff helped to create a set of questions on pain and pain management for patients to ask their providers. Those questions are now featured within the #ChoosePT toolkit.
    • Could primary care become the next APTA board-certified specialty? An APTA House of Delegates charge to explore the role of physical therapists on the primary care team is being pursued. Led by member John Heick, PT, DPT, PhD, board-certified clinical specialist in 3 different areas--orthopaedics, neurology, and sports—APTA is petitioning for primary care to be recognized as a board-certified clinical specialty area of practice by the American Board of Physical Therapy Specialties (ABPTS). Signatures are being collected now for the ABPTS petition.

    APTA at the Table

    • National Coalition for Promoting Physical Activity
      APTA representatives attended the National Coalition for Promoting Physical Activity’s congressional briefing promoting the release of the latest edition of the Physical Activity Guidelines for Americans. Hadiya Green Guerrero has been named to the coalition's board of directors.
    • National Institutes of Health
      Staff from APTA took part in a strategic planning session for NIH's National Institute of Arthritis and Musculoskeletal and Skin Diseases.
    • Movement is Life National Caucus
      APTA Director of Minority Affairs Johnette Meadows, PT MS, who serves on the Movement is Life national caucus steering committee, provided leadership on understanding health disparities at the group's most recent gathering.
    • Osteoarthritis Action Alliance (OAAA)
      APTA continues its participation in OAAA and is helping the alliance to promote the Arthritis Foundation's evidence-based self-directed "Walk With Ease" program guidebook on creating a community-based walking program for individuals with OA.

    Clinical Practice Guidelines: Updates

    • Adults With Neurologic Conditions
      The APTA Academy of Neurologic Physical Therapy (ANPT) has published an APTA-funded clinical practice guideline titled "A Core Set of Outcome Measures for Adults With Neurologic Conditions Undergoing Rehabilitation." APTA is working with the ANPT now on implementing the CPG and sharing resources that have been developed by the section.
    • Total Knee Replacement
      The American Academy of Orthopedic Surgeons (AAOS) is working with APTA practice staff to finalize action steps related to a clinical practice guideline on total knee replacement.The CPG will appear in an upcoming issue of PTJ (Physical Therapy) in 2019.

    Clinical Practice Guidelines: Resources

    APTA offers a wide range of resources for learning more about practice-related topics and staying connected. PTNow is a central source for evidence-based practice information including CPGs; other online resources include APTA's Annual Checkup by a Physical Therapist and Cultural Competence webpages. Members can stay connected by joining 1 or more APTA practice-related councils—the Council of Health Systems Physical Therapy, the Council on Prevention, Health Promotion, and Wellness, and Frontiers in Rehabilitation, Science, and Technology (FiRST) Council—and keep up with the latest practice-related news by subscribing to the Professional Issues and Evidence and Care editions of APTA's Friday Focus newsletter series to receive monthly compilations of practice-related news and resources. Questions? Email Practice-Dept@apta.org.

    Can Cognitive and Physical Activity in Midlife Reduce the Risk of Dementia in Later Years? Researchers Say Yes

    Staying intellectually engaged and physically active is an important part of a healthy lifestyle at any age, but now authors of a new study from Sweden say that cognitive and physical activity in midlife can pay off years later by reducing the risk of some forms of dementia. The results of the study showed that individuals who were cognitively active in midlife reduced their risk for Alzheimer's disease (AD) by as much as 46%, while those who were physically active reduced the risk of later dementia and stroke by 53%.

    The study, e-published ahead of print in Neurology, followed 800 women from 1968 to 2012, noting levels of cognitive and physical activity at baseline, and analyzing rates of various types of dementia as the women aged. Baseline activity ratings were taken when the women were 38-54 years old (average age, 47) as part of the Prospective Population Study of Women.

    Cognitive activity was assessed on 0-2 point scale based on each woman's level of involvement in 5 areas of activity: intellectual, artistic, manual, club, and religious. Activity in each category could range from no/low (0) to high (2). Information was obtained via "semi-structured psychiatric interviews."

    Physical activity (PA) was assessed using the Saltin-Grimb Physical Activity Level Scale, which assigns PA levels on a 4-point scale: 1 - completely inactive; 2 - light PA for at least 4 hours a week; 3 - regular physical training such as running or swimming for at least 2-3 hours a week; and 4 - regular intense physical training such as running or swimming several times a week or participating in competitive sports.

    After the initial assessments in 1968-69, participants were reexamined for cognitive and neurophysiologic function in 1974-75, 1980-81, 1992-93, 2000-03, 2005-06, and 2009-10. The last 4 follow-ups included "close informant interviews" that provided additional, third-party information on behavioral changes, activities of daily living, and, if it had occurred, the participant's age at onset of dementia. Information on potential confounders—education, socioeconomic status, hypertension, smoking, diabetes, angina, psychological stress, and depression—was also gathered.

    Between 1998 and 2012, 194 women—nearly 25%--developed dementia over an average 31.5-year timespan. Average age of dementia onset in the group was 79.8 years, and the overall average age at death was 80 years. In addition to total dementia rates, researchers looked at rates of AD, vascular dementia (VaD), "mixed dementia" (both AD and cerebrovascular disease [CVD]), and "dementia with CVD,” which encompassed individuals with any type of dementia and stroke.

    When researchers began analyzing rates of dementia in terms of baseline levels of cognitive and physical activity, they discovered a connection between that activity and lower risk of dementia, albeit in different areas: cognitive activity was associated with a 46% risk reduction for Alzheimer's disease, while PA was associated with a 37% risk reduction for mixed dementia and a 53% drop in risk for dementia with CVD. Both types of activity reduced overall dementia risk by about 33%. The reduced risk rates remained even when researchers factored in the potential confounders. Neither type of activity seemed to reduce the risk for VaD alone.

    Authors write that a possible explanation for the reduced risk has to do with the ways in which cognitive and physical activity increase "cognitive reserve," or "how flexible and efficiently one can make use of available brain reserve," even when measurable factors such as brain size and neuronal count are lower. It's a concept echoed in a study that appeared in Neurology earlier this year, in which researchers reported that higher levels of PA and motor skills not only lowered the odds of dementia, but seemed to buffer its severity if it did occur.

    Authors of the Swedish study acknowledge some significant limitations in their study, including its focus on a fairly demographically homogenous group, and the lack of any data on whether the women active in midlife remained so as they aged. Also "impossible to rule out," according to the researchers: the possibility that the lower cognitive and physical activity levels reported by some of the women were "manifestations of very early pathologic processes in dementia disorders."

    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.

    New Medicare SNF Payment System Explained in Upcoming Q-and-A Sessions

    PTs and other providers in skilled nursing facilities (SNFs) will face an entirely new payment methodology beginning in October. APTA can help you get up to speed.

    Similar to an earlier-announced educational series on the upcoming home health payment system change, APTA will host 2 live Q-and-A sessions with staff and member experts on the new SNF payment system, known as the Patient-Driven Payment Model (PDPM). Presenters for the hour-long sessions—offered on March 12, 1:00 pm-2:00 pm ET, and March 14, 7:00 pm-8:00 pm ET—will answer questions from registered participants who've reviewed a prerecorded webinar that will be available after February 22. The recorded webinar and live sessions are free to APTA members

    Interested? Start by registering now for 1 of the Q-and-A sessions, then check back in on the SNF Patient-Driven Payment Model Webinars page on or after February 22 to download and review the recorded webinar. Have your questions ready for the hosts, including APTA Director of Regulatory Affairs Kara Gainer, JD; APTA Senior Payment Specialist Alice Bell, PT, DPT, board-certified geriatric clinical specialist; Jon Anderson, PT; Robert Latz, PT, DPT; and Ellen Strunk, PT, MS, board-certified geriatric clinical specialist.

    Clinicians in home health care will face a similar change in payment methodology beginning January 1, 2020, with implementation of the Patient-Driven Groupings Model (PDGM). APTA will host 2 Q-and-A sessions on the PDGM March 5 and 6.

    [Editor's note: Even more information on both the new SNF and new home health payment models is available on a specially created APTA webpage that includes resources from APTA and the US Centers for Medicare and Medicaid Services.]

    CPG: Avoid Surgery for Atraumatic Shoulder Pain

    Authors of a new clinical practice guideline (CPG) on treatment of shoulder pain took a hard look at the advisability of surgery and came to a conclusion that can be boiled down to 3 words: don't do it.

    Published in BMJ, the CPG focuses on adults with atraumatic shoulder pain lasting for 3 months or more (diagnosed as subacromial pain syndrome, or SAPS), and zeroes in on the effectiveness of arthroscopic decompression surgery versus nonsurgical approaches including exercise therapy, analgesics, and injections. The CPG development group, which included patients who had experienced SAPS, analyzed results of 2 systematic reviews—one on what constitutes a "minimally critically important difference" (MCID) in patient-reported outcomes, and another on the benefits and harms of decompression surgery. The systematic reviews included 7 trials involving 1, 014 patients.

    In reviewing the systematic review of MCIDs for SAPS, the CPG group identified, with confidence, 2 changes that patients value: a difference in pain of at least 1.5 points on a visual 1-10 scale, and a difference in function of at least 8.3 units on a 100-point scale. In both areas, decompression surgery resulted in no significant differences from other approaches—including placebo surgery. The lack of difference remained at 6-month, 2-year, and 5-year follow ups.

    Authors of the CPG also looked at 6 trials that compared surgery with exercise therapy, and although all were at high risk of bias due to lack of blinding, the results indicated that surgery demonstrated no advantages over exercise therapy in terms of pain, function, quality of life, perceived effect, and return to work.

    Armed with the conclusion that decompression surgery isn't any more effective than sham surgery or other treatment approaches, the CPG authors next analyzed the benefits and harms of the procedure. Again, surgery didn't fare well.

    After the guideline panel found that "potential harms from surgery were incompletely reported in the trials," the group requested that the systematic review be expanded to include observational studies that evaluated harm after the procedure. They found 4 sets of results from a large US study that found a roughly 0.55% risk of complications after 30 days. The harms included bleeding, infections, peripheral nerve injury, anesthetic complications, and venous thromboembolism.

    Given the procedure's risks and apparent lack of superiority in terms of effectiveness, "the panel concluded that almost all well informed patients would decline surgery and therefore made a strong recommendation against subacromial decompression surgery," authors write. "Clinicians should not offer patients subacromial decompression surgery unprompted, and others should make efforts to educate the public regarding the ineffectiveness of surgery."

    As for the alternatives to surgery, authors state that "the whole area of best management of SAPS is uncertain," including exercise therapy, manual therapy, and electrotherapies. Current evidence on these approaches show "uncertain benefit to patients compared with watchful waiting, and guidelines vary in their recommendations," 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.

    Crazy Little Thing Called (APTA) Love

    APTA members are sharing the APTA love—and their stories are all about finding community in the association, no matter the paths they took to get there.

    In the spirit of Valentine's Day, APTA asked members to share their "APTA love stories" by recounting how they first came to join the association, and what made them feel a true connection to the organization and fellow members. The results are being posted to social media and have been collected on a special "APTA Love Stories" webpage.

    The stories reflect the diversity of the APTA membership. From a then-DPT student who questioned a program's membership requirement only to come to see the value in the connections she made, to an aspiring physical therapist (PT) who asked to join APTA before she'd even entered school, to longtime PTs who've spent their careers involved in the association, the details are varied. The common thread: each member discovered the ways APTA builds connections, strengthens the profession, and provides opportunities for professional growth.

    But that's not where the stories end. APTA will continue to collect member reflections and periodically publish what members share, so watch your social media feeds and check back with the Love Stories page from time to time.

    How about you? We'd love to hear your "APTA love story"—visit the APTA Engage website to find out how to get started.

    The Good Stuff: Members and the Profession in the Media, February 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!

    The power of Darfur United: Alexandra Nuttall-Smith, PT, MPT, ATC, shares her experiences as athletic trainer for the world's first soccer team of former refugees. (NATA News)

    Quotable: “Physical therapy students get more intensive anatomy training than our medical students because their profession is very anatomy dependent. They are so knowledgeable and great with the med students that it’s just like having another faculty member. It was an experiment that I think is going really well.” –Daniel Topping, MD, director of the University of Central Florida (UCF) College of Medicine's anatomy lab, explaining why the lab has adopted a program that brings in DPT students to help instruct medical students. Kayla Combs, SPT; Akash Bali, SPT; and Kelly LaMaster, SPT, were recent student-instructors; Patrick Pabian, PT, DPT, is UCF DPT program director. (University of Central Florida News)

    The private details: Karen Litzy, PT, DPT, offers tips on growing a private practice. (Authority Magazine)

    Battle of the bands: Brian Gurney, PT, DPT, provides suggestions on ways to properly stretch the iliotibial band to lessen hip and knee pain. (Prevention)

    Quotable: "No one ever died of an overdose of physical therapy." –Caleb Alexander, codirector of the Johns Hopkins University Center for Drug Safety and Effectiveness, on the need for insurers to increase access and lower patient costs for nonpharmacological approaches to pain management. (Politico)

    A lesson in advocacy: Ashley Wallace, SPT, is among the University of Southern California DPT students learning about advocacy from professors Cheryl Resnik, PT, DPT, FAPTA, and Yogi Matharu, PT, DPT, MBA, while Scott McAfee PT, DPT, a recent graduate of the USC program, says he's still benefitting from the lessons learned. (USC News)

    Exercising the options: Amy Stein PT, and Heather Jeffcoat, PT, DPT, rate the top Kegel exercisers. (New York magazine)

    Post-resolution solutions: Stephen Rapposelli, PT, lays out 8 tips for improving health even after the New Year's resolutions have been abandoned. (Delaware online)

    Dealing with bladder leaks: Carrie Pagliano PT, DPT, explains how physical therapy can help women overcome stress incontinence. (Consumer Reports)

    Quotable: "The important thing to remember is we aren't treating ALS. We’re treating Kelli." -Greg Bachman, PT, on his work with Kelli Johnson, who is now in her 10th year of living with ALS. (Emporia, Kansas, Gazette)

    No slouch at posture instruction: Julie Moon, PT, provides pointers and exercises to improve posture. (KHON2 News, Honolulu)

    Home is where the gym is: Brian Jones, PT, discusses simple ways to create usable exercise space at home. (C&G Newspapers)

    Massager messenger: David Reavy, PT, MBA, lists the best back massage devices to help ease pain. (Prevention)

    Quotable: "That’s when I learned what a difference there is between doing some exercises on my own versus having a physical therapist guide my rehabilitation. And those professionals have tools and techniques to help manage pain and inflammation that would not be available to me otherwise, unless I become a professional athlete. " – Donna Kallner, describing the importance of rehabilitation even when living in a rural area makes access challenging. (The Daily Yonder)

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

    From PTJ: PT, PTA Injuries Related to Patient Handling Still Common in LTC Settings

    Despite efforts by APTA and others to emphasize safety and the use of lifting devices, physical therapists (PTs) and physical therapist assistants (PTAs) working in long-term care (LTC) facilities continue to experience musculoskeletal disorders (MSDs) linked to patient handling incidents, say authors of a new study. Areas of injury most frequently cited by PTs, PTAs, and other "therapy personnel"—occupational therapists (OTs) and occupational therapy assistants (OTAs)—were the lower back, shoulder, and neck.

    For the study, published in the February issue of PTJ (Physical Therapy), researchers looked at a year's worth of workers compensation claims (WCCs) from a long-term care company with 202 skilled nursing facilities and 20 assisted living facilities, and compared those data with the results of confidential surveys completed by 2,642 employees of the company. While the primary aim of the study was to get a sense of the magnitude of musculoskeletal injuries experienced by employees, authors also were interested in how those injuries correlate to workers' perceptions of their job demands and whether they routinely used resident-lifting equipment.

    For the analysis, the authors divided the WCC claims into 4 categories related to the cause of injury: ergonomic (manual or patient handling, bodily reaction, repetition), workplace violence, acute incident (fall, slips, trips, being struck by an object), and other. The nature of the injury—acute, subacute, nonspecific, nonmusculoskeletal—and body region affected also were grouped into major areas. Employees were grouped into larger categories: therapy personnel, nursing aide, licensed practical nurse (LPN), registered nurse (RN), social/speech/respiratory service, technician, housekeeping/dietary maintenance, and office/administrative service.

    Among the findings:

    • According to WCC data, the most commonly injured body regions among all employees were upper extremities (37%), lower back/back and trunk (20%), and lower extremities (17%).
    • Therapy personnel had the lowest rate of claims for acute injury, at 2 claims per 1,000, but their average per-claim cost were the highest.
    • In terms of ergonomic injury among clinical staff, nursing aides reported the highest rate of injury, at 36 claims per 1,000. Therapy personnel were next, at 16 per 1,000—a rate similar to those of LPNs and RNs.
    • About 43% of subacute injuries (defined by the authors as "sprains, spasms, muscle contusions, carpal tunnel, tendinitis, disc hernias, and similar injuries") were related to patient handling incidents across all jobs, with nursing aides once again reporting the highest claims rate, at 58 per 1,000. Therapy personnel were next highest at 15 per 1,000.
    • Therapy personnel, RNs, and nursing aides reported low back pain at a similar rate—48.1%, 44%, and 47.5%, respectively. Therapy personnel registered higher rates of neck pain (24.4%) and shoulder pain (34.6%) than nursing personnel (14%-22% for neck pain and 25%-30% for shoulder pain).
    • In analyzing survey results among employee categories, researchers found that therapy personnel recorded the third highest "psychological demand score" (5.87 on a 2- to 8-point scale, behind RNs and LPNs), and the highest "physical demand score"(14.6 on a 5- to 20-point scale), followed by nursing aides (12.6).
    • Just over half of therapy personnel—53%—reported that they "never" or "rarely" use resident-lifting equipment. When asked to explain the use rates, "a majority of therapy personnel stated that treatment did not involve lifting because the goal was to make residents independent," authors write.

    "It is concerning that MSD symptoms and costs…for therapy personnel were higher than for nurses," the authors write. "Our finding on the low use of resident-handling equipment by therapy staff, and the rationale that equipment use interferes with therapy goals, are consistent with prior studies." This use pattern is common despite evidence of similar patient outcomes with and without the use of patient-handling equipment and safe patient-handling protocols, they add.

    APTA's Safe Patient Handling webpage offers resources for avoiding injury, including links to online courses, US Food and Drug Administration guidelines on proper use of patient lifts, and a bibliography of journal articles from multiple disciplines.

    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.

    Proposed Rules on Electronic Health Information Seek Better Patient Access, More Interoperability

    With the release of proposed rules aimed at increasing the interoperability of electronic health information (EHI) among insurers and eliminating EHI "information blocking" practices, the US Department of Health and Human Services (HHS) is sending a clear signal: it intends to move ahead with a push toward making it as easy as possible for patients to access their health care records from just about any device, for free. And it won't hesitate to name the names of facilities and insurers that aren't cooperating.

    In 2 separate but related proposed rules, the US Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC)—both agencies under HHS—laid out new requirements that, if adopted unchanged, would force improvements to patient EHI access by as early as 2020.

    The proposed rules, released February 11, are complex, and APTA regulatory affairs staff are reviewing the contents to prepare comments by the anticipated early-April deadlines. At the big-picture level, a few basic ideas are emerging.

    The CMS-generated rule would require Medicare Advantage, Medicaid, Children's Health Insurance Program, and Affordable Care Act plans to provide enrollees with immediate access to their medical claims and other information by 2020, and would allow CMS to publicize the names of facilities that make it difficult or impossible for patients to access these data, according to a CMS fact sheet. The proposed rule would also require health care providers and plans to use open data-sharing technologies to make it easier for people to move between different payers.

    The proposed rule from the ONC (fact sheet) would require that health care payers and providers move to standardized application programming interfaces—techspeak for systems that make it easier for individuals to access a variety of EHI on phones and other mobile devices. Additionally, the rule would target information-blocking practices that prevent patients from accessing their own records or apply a charge for providing them. The ONC proposal would ensure that access is unrestricted and free to patients.

    The proposed ONC rule also asks for comments on pricing information that could accompany EHI to help the public get a better idea of the cost of care. The CMS proposed rule includes a request for comments on how the agency can "leverage its authority to improve patient identification and safety to encourage better coordination of care across different healthcare settings while advancing interoperability." Those settings include long-term and postacute care.

    "In a general sense, the move toward greater EHI interoperability is a concept strongly supported by APTA, but with the proposed rules coming in at more than 1,000 pages combined, it will require some time to fully understand the impact these proposals may have on physical therapists," said APTA Director of Regulatory Affairs Kara Gainer. "Once we better understand the details of the CMS and ONC proposals, we will be able to provide a more complete perspective through APTA comments and other resources and updates."

    [Editor's note: Want to add your voice to the profession's take on interoperability? During the coming weeks, be sure to check APTA's "Regulatory Issues: Take Action" webpage for template letters that make it easy to share your perspective.]

    New APTA Policy Priorities Push for a More Wellness-Oriented, Value-Based, and Accessible Health Care System

    APTA's newest advocacy roadmap puts the current state of health care in the United States in stark terms—and commits the association to working for change.

    Describing the United States as being "at a crossroads," the association's 2019-2020 Public Policy Priorities document characterizes the country's health care system as one that favors treating illness over investing in prevention and wellness. It's an approach that APTA believes leaves too many Americans underserved, including people with disabilities, chronic conditions, and opioid addiction.

    The association's response? "This must change."

    The need for systemic change throughout the health care system is the common thread running throughout APTA's new resource, a high-level exploration of the areas that will be the focus of the association's advocacy efforts for the next 2 years. Much like the association's recently adopted strategic plan, the priorities point to an association that will fuel change at the societal level.

    The guide lays out 4 broad areas of emphasis for 2019 and 2020: population health; patient choice and access; value-based care and practice; and research and innovation. Within each area, the association lists multiple advocacy opportunities. Some, such as working for increased funding for the Individuals with Disabilities Education Act, are targeted at specific existing programs. Many others, however, such as a continued press for increased direct access to physical therapists (PTs) and decreased administrative burden, are more open-ended.

    The mix of general and specific was purposeful, according to Katy Neas, APTA's executive vice president of public affairs.

    "Over the course of 2018, the APTA Public Policy and Advocacy Committee [PPAC] developed policy recommendations that enhance the role of the profession as integral to an effective and efficient health care system that ensures better health outcomes for our patients," Neas said. "This guide advances the APTA Board of Directors' approval of the PPAC recommendations in ways that clearly reflect our commitment to true change in the health care system, and position APTA to partner with other stakeholders in innovative ways."

    Part of the reason the priorities take a more expansive approach is that an earlier advocacy goal—ending a hard stop on therapy services under Medicare part B, known as the "therapy cap"—was achieved in early 2018. With the nearly 2-decade battle over, the association found itself with an opportunity to survey an even wider advocacy landscape.

    Next: turning that plan into action, something that's already happening in many advocacy areas, according to Justin Elliott, APTA's vice president of government affairs.

    "Advocacy never stops for APTA and its members," Elliott said. "The new policy agenda includes many APTA existing priorities, such as our work to finalize the coverage of physical therapist assistants in the Department of Defense TRICARE program, but also creates opportunities to act as new legislation and policy possibilities arise."

    The new advocacy opportunities available to the profession will be a major focus of the upcoming APTA Federal Advocacy Forum in Washington, DC, a 3-day conference that provides the latest on regulatory and legislative issues affecting the profession, and ends with a chance for attendees to apply what they've learned by making in-person visits to Senate and House offices. The event is set for March 31 – April 1; registrations are open until March 18.

    Check Your QPP Status (Again)

    Beginning this year, Medicare's Quality Payment Program (QPP) applies to qualifying physical therapists (PTs). Does that mean you?

    The US Centers for Medicare and Medicaid Services (CMS) has recently updated its QPP participation lookup resource to reflect the rules for 2019. APTA recommends that even if you've checked on your participation status before, you should revisit the site to see if anything has changed.

    The QPP and its Merit-based Incentive Payment System (MIPS) represent some of the most sweeping changes to PT reporting and payment in years—and all indications are that the models will likely include more PTs in the future. Get up to speed with this major shift through resources available at APTA's QPP webpage.

    Researchers: Physical Therapy-Related Cochrane Reviews Largely Inconclusive

    The Cochrane Database of Systematic Reviews is widely considered the “gold standard” for health care professionals who want to know what current, high-quality research says about the efficacy of various interventions. But when it comes to physical therapy, a “researcher or clinician would not necessarily be able to turn to [Cochrane reviews] for a definitive answer” on a treatment strategy, write authors of an article in the International Journal of Rehabilitation Research (abstract only available for free).

    Reviewers for the Cochrane Collaboration—an international network of subject-matter groups that produces evidence-based resources—are known for their systematic analysis of evidence obtained from randomized clinical trials and provide recommendations for specific interventions. Like any systematic review, Cochrane reviews (CRs) are based on the existing research, and randomized controlled trials vary in quality.

    For the Rehabilitation Research study, a multidisciplinary group of researchers in Japan turned to physical therapy to find out what CRs had to say about various interventions. They examined 283 CRs to evaluate just how conclusive the evidence is with regard to physical therapy, as well as what factors influence the degree of conclusiveness.

    Authors classified a CR as “conclusive” if it identified a particular intervention as “superior to another” or found that interventions are “equivalent.” Inconclusive reviews concluded that “no decision can be made.”

    While the authors acknowledge that CRs “often show a lack of strong evidence for the efficacy of a particular treatment or strategy,” they found that an overwhelming majority of reviews related to physical therapy—94.3%—were inconclusive and recommended further study, a rate higher than in many other areas of study. Reviews that evaluated a larger number of trials or included greater total numbers of patients were more likely to list conclusive results; still, even among CRs with conclusive results, 68.8% recommended further study.

    According to the authors, many factors were associated with recommendations for further research, including low-quality study design, small sample sizes, too few available studies, and not enough data on participant subgroups or on adverse effects.

    “The low proportion of conclusive studies may be attributable to the poor quality of evidence” in physical therapy, the authors write, noting, however, that, unlike other areas of study, blinded randomized controlled trials are “often hard to achieve” in physical therapy research.

    Authors emphasized that although inconclusive reviews cannot assist in clinical decision making, “high-quality inconclusive reviews…are of great value” to identify gaps in the literature and areas for further study.

    And while there's much work to be done to increase the number of physical therapy-related CRs with conclusive recommendations, authors think the effort is worthwhile—and timely.

    “Trials in physiotherapy are worth conducting, as the field is positioned as a new frontier and is receiving much attention," they write. "Future research in physiotherapy and further development of the [Cochrane Collaboration] are eagerly awaited.”

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

    Study: More Evidence for Early Post-TKR Exercise Interventions 'Urgently Needed'

    With the number of total knee replacements (TKRs) on the rise and average hospital lengths-of-stay (LOS) for the procedure dropping, you might naturally assume that the most effective early postoperative exercise interventions for TKR have been pretty well established by now.

    You'd be wrong, say authors of a new systematic review.

    They write that their review, which scoured more than 1,200 potentially useful studies, reveals a "paucity" of research that "makes it challenging for clinicians to deliver high-quality evidence-based exercise programs in the early postoperative period." They add that the prevalence of TKR and ever-decreasing hospital stays underscore the fact that more high-quality randomized clinical trials are "urgently needed."

    Authors of the review, published in BMC Musculoskeletal Disorders, had an inkling of what they were up against: they were aware that there were "limited studies" that demonstrated the effectiveness or best approach to early postoperative interventions, and they recognized that "large variations between institutions and individual clinicians exist as to what active inpatient therapy is prescribed." Still, they wanted to evaluate existing research to see if some of those gaps could be filled in.

    Focusing on studies that investigated supervised exercise therapy after TKR in the acute hospital setting, the researchers were able to find 1,296 possibly useful articles, of which 77 were reviewed in full text. Of those, only 4 articles were considered eligible for systematic review, and just 3 of the 4 met the criteria for meta-analysis. Reviewers excluded studies that used electrical stimulation, acupuncture, cryotherapy, and "electrical modalities" such as continuous passive motion, "as these were considered...an adjunct to physiotherapist-led exercise-based interventions."

    In the end, the 4 studies included in the review involved 323 participants and 373 individual knees (1 study with 50 participants studied both knees of each individual). Total study-versus-control group sizes were roughly equal, and, overall, most participants (78.5%) were female. The review focused on outcomes from 4 interventions: modified quadriceps setting, flexion splinting, passive flexion ranging, and a drop-and-dangle flexion protocol. As for assessment of outcomes, those varied depending on the study—not only did baselines differ, but follow-up times ranged from 4 weeks postsurgery to as much as 1 year afterward.

    Though not conclusive, researchers noted a few characteristics related to the various interventions: patients receiving the drop-and-dangle protocol had better flexion in the first 2 days after TKR and at discharge; flexion splint patients tended to be discharged earlier and had greater flexion at 6 weeks after TKR; and the modified quadriceps-setting patients tended to have greater hamstring and gluteal muscle strength. However, a meta-analysis of 3 of the 4 studies found no differences in flexion or knee society scores at 6 weeks' post-TKR.

    The real bottom line to be gleaned from the analysis, according to authors, is that the lack of solid evidence "precludes the formulation of clinical guidelines as to the optimum type, frequency, or duration of early exercise therapy after TKR."

    "Given the cost of providing these inpatient services, it is surprising that such a large deficit exists in the literature," authors write. "There is a need for further studies of high-quality design into supervised exercise therapy programs to provide greater functional outcomes and patient-reported satisfaction following TKR surgery, particularly in the early post-operative period."

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

    APTA Volunteer Opportunities Now Available

    There are new volunteer opportunities available with APTA—and a new way of letting the association know you're interested.

    Calls are now open for several APTA Board of Directors-appointed groups, including the Reference, Ethics and Judicial, Finance and Audit, Public Policy and Advocacy, and Scientific and Practice Affairs committees; as well as APTA awards subcommittees on advocacy, education, lectures, practice and service, publications, research, scholarships, and Catherine Worthingham Fellows. Deadline for making your interest known is February 28, 2019, for all groups except the Reference Committee, which has a March 1 deadline. More information on the opportunities can be found on APTA's volunteer groups webpage.

    But that's not all of what's new when it comes to volunteering with APTA. The most recent call for volunteers coincides with the debut of APTA Engage, a new volunteer portal designed to make it easier to serve the association and its components. The new system allows users to build a volunteer profile that can help identify the right volunteer fit, and features a dynamic list of opportunities ranging from 1-time, low time-commitment, locally based options to long-term volunteer positions at the national level.

    Members interested in volunteer positions currently open should use APTA Engage to notify the association of their willingness to serve, but even those who aren't hoping to participate in 1 of the currently available roles should consider creating an APTA Engage profile soon to make the process that much easier when other opportunities present themselves. Questions? Contact denakilgore@apta.org.

    APTA, ACSM Partnership Agreement Formalizes Long-Time Collaboration

    A longstanding collaborative relationship is now official: APTA and the American College of Sports Medicine (ACSM) have entered into a formal partnership that the organizations believe will strengthen their work toward improving health through movement.

    ACSM 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. ACSM joins Special Olympics, Move Together, the American Academy of Orthopaedic Manual Physical Therapists, the Federation of State Boards of Physical Therapy, and the US Department of Veterans Affairs in the program.

    ACSM and APTA aren't strangers to each other. The organizations have worked together before, and they hope to build on their relationship to bolster advocacy efforts as well as expand participation in each group's events and initiatives.

    "I am so pleased we were able to formalize our already productive and positive relationship with ACSM," said APTA CEO Justin Moore, PT, DPT, in an APTA news release. "Both organizations are founded in helping individuals live their best lives, and this partnership will help better achieve our goals."

    ACSM EVP and CEO Jim Whitehead also sees promise in the new partnership.

    "The American Physical Therapy Association is a recognized leader in promoting recovery, health, and wellness," said Whitehead. "Our 2 organization have a shared vision to improve lives through exercise and healthy lifestyles, so this partnership will open the door to tremendous opportunities that wouldn't be possible otherwise. We can't wait to get moving."

    ACSM's members number more than 50,000 and include physicians, scientists, researchers, educators, exercise professionals, and others in the field of sports medicine and exercise science. The mission of the college is to advance and integrate scientific research to provide educational and practical applications of exercise science and sports medicine.

    From PT in Motion Magazine: Recognizing—and Beating—Burnout

    Being a physical therapist (PT) or physical therapist assistant (PTA) can be fulfilling, but it also can be demanding and challenging—so demanding and challenging that those feelings of fulfillment seem out of reach at times. The result: burnout, a condition being experienced by an increasing number of PTs and PTAs, sometimes before they even know it's happening to them.

    In its February issue, PT in Motion magazine takes an in-depth look at clinician burnout through the eyes of PTs and PTAs who experienced burnout firsthand, PTs who've been looking at ways to stop burnout before it starts, and PT researchers looking into the topic. The article is part of a PT in Motion special theme issue on trauma and stress in the physical therapy profession. (Other articles in the series are “It Can Happen Anywhere: Protecting Your Workplace From Public Safety Threats” and “Combatting Sexual Harassment and Inappropriate Patient Sexual Behavior.”)

    "Beating Burnout" is anchored in the stories of APTA members Meredith Castin, PT, DPT, and Sean Hagey, PTA, who found themselves feeling increasingly unable to find a sense of satisfaction in roles that demanded too much and seemed to put patient-centered care in the backseat.

    Both found a healthier, happier career path, albeit in different ways: Hagey sought counseling and convinced his employer to decrease productivity demands (and in the process, move to a more user-friendly electronic health records system); Castin left clinical practice entirely and started up a website that explores nonclinical roles for PTs and PTAs.

    According to the article, some of the major contributors to PT and PTA burnout are the usual suspects, including some employers' unreasonable productivity demands and the cloud of student debt that puts additional pressures on many in the profession. But there are other, less-obvious factors that can lead to burnout, too, including a lack of mentorship, feelings of being undervalued, and the letdown that inevitably results when unrealistic career expectations as a student aren't met upon joining the workforce.

    But the topic isn't left there. The PTs and PTAs interviewed for "Beating Burnout" also offer strategies for making positive changes to defeat burnout, or stop it before it starts. Those ideas include seeking out strong mentors, having "hard conversations" with employers about productivity demands, and getting involved with APTA and the surrounding community to maintain a sense of connection to peers and the world beyond the clinic.

    "Beating Burnout" is featured in the February issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them one of the benefits of belonging to APTA.