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  • Experts: It's Time to Act on the Evidence for Low Back Pain

    Recent features on Good Morning America and WebMD aside, the idea that low back pain (LBP) is best managed through nondrug, nonsurgical approaches isn't exactly news to physical therapists (PTs) and physical therapist assistant (PTAs). What would be news is if health care systems and providers widely accepted that reality and began taking steps to apply evidence to practice and payment.

    The latest rise in media attention on LBP was sparked by a recent series of articles published in The Lancet (free registration required) that highlighted the lack of adherence to clinical practice guidelines advocating "self-management, physical and psychological therapies" as first-line treatment for LBP. It's a disconnect that authors believe deserves immediate attention, given that LBP is the leading cause of disability worldwide, and is a condition that is increasing more rapidly in low-income and middle-income countries, according to the Lancet articles.

    The problem, according to the authors, is that despite the evidence, many providers—including some PTs—still recommend rest and time off work, and the use of drugs and surgery is more prevalent than it should be.

    "The message here is the critical need to close the evidence-practice gap across all aspects of spine care," said Julie Fritz, PT, PhD, FAPTA, a co-author of the study. "This message applies to physical therapy as [much as] it does to all other providers who may continue to advocate for overuse of ineffective treatments such as opioids and imaging. Professional stewardship demands that we examine our own profession even as we critique aspects of practice in other professions."

    By way of example, the Lancet articles point out that physical modalities such as transcutaneous electrical stimulation (TENS) or ultrasound have been found to be ineffective but often are recommended by PTs in many countries. One study cited found that 75% of US PTs used lumbar traction, and 38% of Swedish PTs used TENS; another cited study from India reported that one-third of PTs preferred physical modalities as first-line interventions.

    The gap is even more prevalent when it comes to the use of psychological therapies in combination with physical modalities—an approach that has proven to be effective. According to the Lancet articles, a recent study found that just 8.4% of patients with LBP in the US were prescribed cognitive behavioral therapy.

    "Care for patients with chronic conditions such as low back pain is inherently multidisciplinary," says Fritz. "There are opportunities for innovative care delivery models that integrate mental and physical health care providers, and PTs should welcome the chance to be a part of these programs. Triaging patients based on their mental health needs should be a part of physical therapist practice in the same manner as triage for physical needs."

    According to the Lancet authors, the problem isn't just about lack of action by providers—patient barriers to proper care for LBP also play a role in the problem on a worldwide scale. Authors advocate changes from health care systems that often reimburse surgery or medication over other interventions to systems that reimburse only evidence-backed treatments. Experts also recommend the development of "clear care pathways, referral, funding, and information technology systems" that would help clinicians deliver the most effective care at the right time.

    "All countries seem to be struggling with the same fundamental problem of closing the evidence-practice gap for patients with low back pain but there are lessons to be learned," Fritz observes. "Payment models in other countries are quite different from our fee-for-service model in the United States. These payment models certainly influence the overutilization of high-cost, low-value care such as back surgery. Other countries are also beginning to modify the basic care pathways for musculoskeletal pain conditions, with greater opportunity for physical therapists to serve as first-contact providers. Efforts in the Netherlands and United Kingdom, among others, bear watching."

    Upcoming Issue of PTJ Focuses on Building the Evidence Base for Physical Therapy in Pain Management

    When it comes to promoting better, safer ways to manage chronic pain, the physical therapy profession is motivated and enthusiastic—and that's exactly the kind of energy that needs to be applied to pursuing evidence that supports physical therapy's role in transforming care, say authors of a guest editorial in an upcoming issue of PTJ (Physical Therapy) devoted exclusively to pain and pain management. The editorial was released ahead of issue publication.

    The special May issue "serves as a reminder that there are lessons still to learn about optimizing nonpharmacological pain management," write guest co-editors Steven George, PT, PhD, FAPTA, an APTA member and director of medical research at the Duke Clinical Research Institute; and Arlene Greenspan, PT, MPH, DrPH, associate director of science and injury prevention and control at the Centers for Disease Control and Prevention (Greenspan's contributions were made as a personal outside activity). They describe the upcoming issue as "a good indication of the current state and possible future" of nonpharmacological approaches to pain.

    According to George and Greenspan, articles in the special issue are rooted in 4 basic priorities that have emerged as pain management and the use of opioids have received national attention: gaining a better understanding of how acute pain becomes a chronic condition; ensuring better access to frontline nonpharmacological treatments; developing ways to foster self-management of chronic pain; and advancing implementation of strategies proven to be clinically effective.

    But that doesn't mean the papers are repetitive in focus or approach. "Because pain is an individual phenomenon with tremendous variation in its presentation, the papers in this special issue cover different approaches, techniques, and philosophies," the editors write. Topics in the issue include psychologically informed practice, mechanism-based approaches, and sleep disturbances, with original research papers on topics including pain neuroscience education, rates of health care use after physical therapy, and the effectiveness of a home-based, telephone-supported physical activity program.

    "These papers showcase diversity in approaches, techniques, and philosophies needed to make meaningful progress," write George and Greenspan. "Perhaps most important, these papers convey the complexities involved with providing effective nonpharmacological options for pain relief."

    George and Greenspan believe that, collectively, the articles in the pain issue support the physical therapy profession's commitment to positive change.

    "Our profession's vision is to transform society by optimizing movement to improve the human experience," they write. "At this time in history, few societal needs are more urgent than improving a physical therapist's ability to deliver effective nonpharmacological pain management."

    PTJ is APTA's scientific journal, available for free to all APTA members. The journal is published online. Look for the special issue on pain in late April.

    Want to understand the basics of pain and the role for physical therapy? Check out George's online course "A Primer on Pain for the Practicing Physical Therapist," available in the APTA Learning Center. And be sure to catch this year's Rothstein Roundtable at the 2018 NEXT Conference and Exposition, "Physical Therapy Decreases Opioid Use: What Will It Take to Change Policy?"

    CMS, APTA: OIG Report on Outpatient Physical Therapy Claims Contains Possible Flaws and Questionable Assumptions

    A US Department of Health and Human Services Officer of the Inspector General (OIG) report makes claims about physical therapy billing under Medicare, and both the US Centers for Medicare and Medicaid Services (CMS) and APTA are pointing out how flawed processes and misinterpretations are coloring the findings.

    The OIG report, issued in late March, is based on a random sample of 300 Medicare outpatient claims for physical therapy made in 2013. According to the report, OIG was looking for instances in which claims were made for services that were not medically necessary, properly coded, or properly documented. The review, which identified 184 noncompliant claims totaling $12,741, extrapolated that the pattern indicates that Medicare may have paid out as much as $367 million in physical therapy claims that didn't meet CMS standards.

    CMS was quick to disagree with many of the OIG findings, arguing that a more thorough analysis would be required to back up the OIG estimate. Additionally, CMS pointed out that the OIG misinterpreted CMS coverage policies related to the concept of "significant improvement." That interpretation ignored CMS policy, clarified through the settlement in the Jimmo v Sebelius case, that puts an end to the "improvement standard" myth. "Most of the findings identified by OIG are likely attributable to documentation errors as opposed to fraudulent activity," according to statement from CMS.

    APTA has also taken issue with the OIG findings. In addition to supporting CMS' position that OIG's analysis included a flawed interpretation of the "improvement standard," the association also points out that the OIG study panel failed to include a single physical therapist on the team that reviewed claims and documentation. "Given the potential for misinterpretation of Medicare policy on outpatient therapy services and the role of physical therapists, APTA supports the inclusion of a physical therapist as part of the team conducting such reviews," APTA wrote in response to requests for comment on the report.

    "This report is 1 of hundreds of such documents produced by OIG every year—by no means is physical therapy singled out in the broader context of the OIG's work," said Justin Elliott, APTA vice president of government affairs. “However we agree with CMS that further analysis of the sampled claims is warranted to determine if the OIG findings accurately align with Medicare payment policy.”

    "APTA has always been committed to ensuring that outpatient physical therapy services meet Medicare requirements," Elliott said. "We also stand ready to work with CMS on providing additional education and resources for providers on correct coding, billing, and documentation, as well as identifying administratively burdensome requirements, which may be contributing to provider confusion and reporting errors.”

    The importance of accurate claims and documentation has been at the forefront of APTA education for years, particularly in 2013, when functional limitation reporting and G-codes were introduced, and later in 2016, when CMS adopted a tiered Current Procedural Terminology (CPT) coding system. This year, APTA launched retooled web resources on defensible documentation.

    Lynda Woodruff, Leader in Physical Therapy Education, Dies at 70

    Lynda D. Woodruff (1947-2018)

    Lynda Woodruff, PT, PhD, an educator and trailblazer in the physical therapy profession, died at her home on March 20. The APTA lifetime member was 70.

    Woodruff was a visiting professor at Alabama State University (ASU) and began the transitional doctor of physical therapy program there in 2008. She continued as a consultant until her death. In 2012 ASU established the Baines-Woodruff Endowed Lectureship on Health Disparities to honor Woodruff and Ruth E. Baines, PT, PhD, former assistant chancellor of health sciences for the State University of New York Central Administration.

    Earlier, Woodruff was the founding director and professor in the department of physical therapy at North Georgia College, having retired in 2005. The department was the state university system’s first postbaccalaureate physical therapist education program. In 1971 she received her master’s degree in physical therapy at Case Western Reserve University, and in 1974 she was the first African American to join the faculty in the Division of Physical Therapy at the School of Medicine at the University of North Carolina at Chapel Hill. In 1978 she joined the faculty in Georgia State University’s Department of Physical Therapy, and in 1984 Georgia State awarded her a PhD.

    At the age of 13, Woodruff was 1 of 2 African American students to desegregate EC Glass High School in Lynchburg, Virginia, resulting in the first court-ordered desegregation since the landmark Brown v Board of Education decision in 1954.

    Woodruff would go on in her academic career to direct an award-winning program for minority student recruitment and retention at Georgia State. In 2014 she received the Education Achievement Award from the Physical Therapy Association of Georgia for her exceptional commitment to student learning and growth of the profession, as well as for her work to advance research and evidence-based practice. A member of the APTA Academy of Clinical Electrophysiology and Wound Management, Woodruff made particular strides in that field of practice. She also was a member of the Academy of Physical Therapy Education, a trustee for the Foundation for Physical Therapy, and a Georgia delegate to the APTA House of Delegates, and she served on the House Elections Committee.

    Woodruff was instrumental in establishing APTA’s original Advisory Council on Minority Affairs and the Office of Minority Affairs, and in establishing the Minority Scholarship Fund and the Minority Scholarship Award for Academic Excellence.

    Among Woodruff’s other numerous recognitions were APTA’s Lucy Blair Service Award, the Kellogg Fellowship for International Leadership, the Distinguished Service Award for the (then) Section on Clinical Electrophysiology, designation as a fellow of the American Academy of Physical Therapy, and a gubernatorial appointment to the Georgia State Board of Physical Therapy on which she served for more than 10 years. In 2006, the Georgia Senate declared February 24 as Dr Lynda D. Woodruff Appreciation Day.

    "The profession of physical therapy grieves the loss of Lynda Woodruff, a truly legendary champion for positive change," said APTA President Sharon L. Dunn, PT, PhD. "Dr. Woodruff’s spirit was big and her presence was powerful—a fact evidenced not just in her curriculum vita, but through the stories and successes of those she mentored and inspired, her 'Woody Babies.' Our profession has lost a an important voice, a stalwart advocate for our professional conscience for diversity and inclusion, a driver of clinical excellence in electrophysiological diagnostics, and a matriarch for others’ pursuit of opportunities within the profession and beyond. We will honor Dr. Woodruff’s legacy and her relentless pursuit of 'better' by doing better and being better at all the things for which she dedicated her life and career. Her loss will leave a void in many hearts."

    APTA has issued a statement on Woodruff from Dunn. Additionally an oral history of Woodruff, recorded in 2002, is part of APTA’s archives that association members can check out. Visit the Oral Histories webpage for instructions on borrowing and returning materials.

    Those wishing to make a donation to the APTA Minority Scholarship Fund in honor of Woodruff may make checks payable to "PT Fund," with "Minority Scholarship Fund" noted in the memo line. Checks should be mailed to APTA, 1111 North Fairfax Street, Alexandria, VA, 22314; ATTN: Minority Scholarship Fund.

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    Researchers Say Tai Chi Shows Promise Over Aerobic Exercise for Fibromyalgia

    In brief:

    • Researchers measured outcomes of 226 adults with fibromyalgia divided into 2 groups: 1 group received twice-weekly 60-minute aerobic exercise classes for 24 weeks; the second group received tai chi classes and was further divided into 12- and 24-week program groups, with some participants receiving tai chi once a week and others receiving the class twice a week.
    • At 24 weeks, the twice-weekly, 24-week tai chi group reported the most significant improvement compared with the aerobic exercise group—an average 16.1 point difference on the Fibromyalgia Impact Questionnaire (FIQR).
    • All tai chi groups reported better scores than the aerobic group on secondary outcome measures including global assessment, efficacy, depression, coping, and anxiety.
    • All groups—tai chi and aerobic exercise—reported decreased use of drugs including analgesics, antidepressants, and muscle relaxers.
    • Researchers believe the mind-body approach of tai chi may contribute to its effectiveness and suggest it may be useful in reducing opioid use

    Tai chi may not just be another option in the management of pain for individuals with fibromyalgia— according to authors of a new study, it may actually be a more effective physical activity than aerobic exercise, arguably the most common nondrug treatment approach for the condition.

    In a randomized controlled trial, researchers analyzed the progress of 226 adults with fibromyalgia over a 52-week period. Participants were placed into 1 of 5 groups: an aerobic exercise group that met twice weekly for 24 weeks; a tai chi group that met once a week for 12 weeks; a tai chi group that met twice a week for 12 weeks, and once weekly and twice weekly tai chi groups that met for 24 weeks. The outcomes, measured at 12, 24, and 52 weeks, covered a wide range of areas, but researchers focused on improvements to the fibromyalgia impact questionnaire (FIQR) as the primary outcome. Results were published in BMJ.

    The aerobic exercise group participated in a "closely supervised" group program "consistent with current recommended guidelines of moderate intensity exercises for fibromyalgia," according to authors. That program included an active warm-up with stretching, "choreographed aerobic training" that progressed from low to moderate intensity, and a cool-down involving low intensity movements and stretching. The hour-long sessions were customized to each participant and were adjusted over time to reach training heart rate goals ranging from 67.9% to 79.5% of maximum heart rate. Individuals in the aerobic group also were encouraged to walk 30 minutes daily.

    All tai chi groups received the same Yang-style tai chi instruction, provided by experienced instructors who participated in a training session on protocol and concepts related to fibromyalgia. The only differences were in the frequency and timeline for the 60-minute sessions: once weekly versus twice weekly, and 12 weeks versus 24 weeks. As with the aerobic exercise group and encouragement to walk, tai chi participants were encouraged to engage in tai chi outside of the scheduled classes for at least 30 minutes a day. Both groups were instructed to continue exercise after they completed their programs.

    While researchers mainly were focused on FIQR scores, they also recorded outcomes for secondary measures including depression, global assessment, self-efficacy, sleep, overall health, social support, and physical activity. Physical assessments also were included by way of the chair stand, 6-minute walk test, and balance tests.

    Authors of the study describe participant characteristics—mean age of 52, 92% women, 61% white, with an average reported duration of body pain of 9 years—as balanced among all 5 groups. Likewise, participant baseline treatment expectations were similar.

    Here's what researchers found:

    • At 24 weeks, the combined tai chi groups (once and twice weekly) improved FIQR scores over the aerobic group by an average of 5.5 points on the 100-point scale—a "significantly" different improvement rate, yet one that authors describe as not clinically important. However, when researchers compared groups with similar intensity—the twice-weekly 24-week aerobic group matched against the twice-weekly 24-week tai chi group—the improvement difference rose to an average of 16.2 points on the FIQR scale, doubling the minimum clinically significant difference mark identified by researchers.
    • The 24-week tai chi group recorded greater improvement than the 12-week group in FIQR and depression scores, but those differences tended to fade at the 52-week mark.
    • All groups—tai chi and aerobic—reported lower use of analgesics, antidepressants, muscle relaxants and antiepileptic drugs.
    • All tai chi groups reported significantly better improvements than the aerobic group in several secondary outcomes including global assessment, anxiety, self-efficacy, and coping strategies.
    • Tai chi participants attended 62% of possible classes, compared with a 40% attendance rate among the aerobic group.

    "By improving psychological wellbeing, coping, and self-efficacy, tai chi mind-body exercise may help to bolster confidence of patients with fibromyalgia to engage in behaviors that help them manage their symptoms and to persist in those behaviors," authors write. "Tai chi might also help buffer the negative impact of fibromyalgia on the patients' physical and psychosocial wellbeing."

    Authors note several limitations that may have affected the results. First, they write, patients were aware of their treatment group, and expectations could have produced placebo or nocebo responses. Second, the class attendance rates for both groups were not great, and they differed substantially between the tai chi and aerobic groups. Third, they write, there was a substantial loss of patient reporting due to dropoff as the study progressed, "a common problem in clinical trials of participants with chronic pain." The researchers also acknowledge that tai chi may not be a viable option in many places (their study was conducted in the metro Boston area).

    Authors believe that among the listed limitations, the attendance rate differences also may be interpreted as an indicator of the potential for tai chi as an intervention. "Attendance can be considered part of the intervention, and so part of the benefit of tai chi is that patients are more likely to continue to practice it," authors write. And while both the aerobic and tai chi groups reported decreased use of drugs, authors write that the fact that the tai chi group tended to stick with the program longer suggests that "tai chi, which can address both the physical and the psychological symptoms in chronic pain, could be particularly effective in targeting opioid use and misuse."

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

    The Crisis Continues: Opioids in the News, March 2018

    Last week President Trump signed a 2018 budget bill that includes more than $3 billion for opioid efforts. The plan allocates $500 million in grant funding for research on opioid addiction, development of opioid alternatives, pain management, and addiction treatment; $20 million for telemedicine and distance learning in rural areas to help address opioids; and $1 billion among states and American Indian tribes. The spending plan includes wins for other areas of health care, even as some providers and public health experts say it falls short of what's needed.

    But that's just 1 recent development related to the nation's opioid crisis. Here's a brief roundup of other recent opioid-related news reports and stories.

    Opioid Painkiller Is Top Prescription in 10 States
    Hydrocodone/acetaminophen (brand name Norco or Vicodin) is 1 of the most commonly filled prescriptions in the United States, according to an analysis by GoodRx, an online prescription cost service.

    Measuring the Toll of the Opioid Epidemic Is Tougher Than It Seems
    Comprehensive national data on opioid prescribing, treatment, overdoses, and deaths is often incomplete, contradictory, or simply unavailable.

    Americans Take More Pain Pills—but not Because They're in More Pain
    Despite levels of chronic pain similar to Italy and France, researchers say Americans consume 6 to 8 times as many opioid painkillers per capita.

    The Opioid Crisis Is Surging In Black, Urban Communities
    Because African Americans have "historically been less likely" to be prescribed pain medication, it probably protected them from the initial wave of opioid addiction that hit white suburban and rural areas, says a DC physician who treats patients with opioid use disorder. But with the introduction of fentanyl, opioid overdose deaths among black individuals in urban counties are increasing at a faster rate than in suburban and rural areas

    ER Visits for Opioid Overdose Up 30%, CDC Study Finds
    Increases were highest in the Midwest and lowest in the Southeast. The largest state-level increases were in Wisconsin, Delaware, and Pennsylvania, while Kentucky saw a slight decrease.

    One Call Care Management to Change Referral Practices as Result of Court Settlement

    A third-party provider network manager in California has changed the ways it works with physical therapists (PTs), thanks to a successful settlement agreement stemming from a lawsuit brought forward by the Independent Physical Therapists of California (iPTCA).

    The original lawsuit alleged that One Call Care Management engaged in a number of unfair business practices around referral for PT services. Under a settlement reached in late 2017, One Call has been directed to modify its patient referral and authorization process, increase transparency around its scoring of physical therapists, and enhance its electronic billing and payment system. A summary of the changes included in the settlement is now available.

    One Call began implementing the payment policy changes, which are specific to California, in February. APTA and the California Chapter endorsed the lawsuit, which also received donations from the Private Practice Section of APTA. . Individuals who have compliance disputes should email iPTCA at admin@iptca.org.

    2018 Candidate Information, Statements Posted

    Additional information on candidates for APTA national office is now posted on the APTA website. New resources include candidate statements and biographical information.

    Elections for national office will be held at the 2018 House of Delegates on June 25, 2018. Please contact Justin A. Lini in APTA’s Governance and Leadership Department for additional information.

    Study: More 'Collaboration and Consistency' Needed Between PTs and Surgeons in TKA, THA Measures

    As health care moves toward value-based approaches, it's going to become increasingly important for physical therapists (PTs) and orthopedic surgeons (OSs) to pursue more "collaboration and consistency" when it comes to outcome measures used in total knee and hip arthroplasty cases, say authors of a new study. That study, based on a survey of PTs in New England, found that many PTs relied on a range of performance-based outcome measures (PBOMs) and were less likely to use certain patient-reported outcome measures (PROMs) preferred by OSs—though that could be changing.

    The study, which appears in Arthroplasty Today, is based on a survey of 122 PTs in Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, and Connecticut. Researchers were trying to uncover differences between outcome measures commonly used by PTs, and those recommended for use in the American Joint Replacement Registry (AJRR), which authors of the study believe reflects measures most commonly used by OSs.

    To qualify for inclusion in the survey, a PT must have treated patients undergoing total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) in the past 5 years. PTs were asked to rate their current use of various outcome measures on a 4-point scale, from "not familiar" to "considerable experience." The respondents further were asked to estimate their future use of the outcome measures, also based on a 4-point scale: "unable to rate," "unlikely to use," "likely to use," and "will use and recommend."

    As for the outcome measures being evaluated, authors selected the Lower Extremity Function scale (LEFS), the numeric pain rating scale, Oxford Knee Score (OKS), Oxford Hip Score (OHS), EQ-5D quality of life measure, Knee Injury and Arthritis Outcome Score (KOOS), Hip Injury and Arthritis Outcome Score (HOOS), and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) as the PROMs. For PBOMs, they asked PTs to rate walking speed, the 6-minute walk test, timed up-and-go (TUG), timed stair climb, Tinetti Mobility Test, Single-Leg Balance Test, and functional reach test.

    Here's what they found:

    Respondents. The PTs included in the survey were mostly from mixed urban-rural areas (62.3%). Over half (53.5%) reported practicing in a private practice clinic; nearly 1 in 5 (18%) practiced in an outpatient clinical associated with an academic hospital or medical center. About a third of respondents (32.8%) reported 25 years' experience or more; 17.2% reported between 10 and 14 years of experience, and 13.9% listed experience at between 15 and 19 years. Just over 42% of PTs surveyed said they'd treated 25 or fewer TKA/THA patients in the past year; nearly that many (38.9%) reported treating between 26 and 49 such patients during the past year.

    Use of PROMs. The Numeric Pain Rating Scale and the LEFS were the measures most often cited by the respondents in terms of both current and future use of patient-reported data. Nearly all (99.2%) of the PTs reported current considerable experience with the pain rating scale, with 97.5% saying that they'd use and recommend the scale in the future. LEFS was also popular among the PTs, with 76.2% reporting considerable current experience and 77% supporting future use and recommendation.

    Use of PBOMs. In the performance-based category, the PTs cited the Single-Leg Balance Test and the TUG as the most relied-upon measures. For the Single-Let Balance Test, 90.2% of respondents reported current use, with 87.7% saying they would use and recommend that test in the future. The TUG was even more popular, with 93.4% of the PTs reporting current use, and 85.2% reporting future use and recommendation.

    The problem, according to the study's authors, is that the PTs' choices for PROMs don't line up with the AJRR recommendations, which lean more toward general quality of life measures and specific joint measures such as the HOOS, KOOS, and Oxford knee and hip measures. "It is difficult to explain why [the surveyed PTs] prefer the LEFS," authors write. "LEFS is easy to implement and broadly applicable to all lower extremity sites in various stages of disability, but is not specific to hip and knee osteoarthritis. The HOOS and KOOS are joint specific, including the [WOMAC] score, and have been shown to be more sensitive and responsive than the LEFS in total joint replacement. However, they take longer to administer." [Editor's note: APTA encourages the use of HOOS and KOOS for PTs participating in the Comprehensive Care for Joint Replacement bundled care model.]

    And while authors point out that PROMs are probably more reflective of the direction health care is heading, they acknowledge that PBOMs such as TUG have their place, too.

    "PROMs may overestimate patient mobility, especially in the immediate postoperative phase after both TKA and THA," authors write. "Because [PTs] evaluate TJA [total joint arthroplasty] patients multiple times in the early postoperative period, they may utilize PBOM more frequently to avoid overestimation of function during the early phase of rehabilitation." It's an approach that the researchers say echoes recommendations from the Osteoarthritis Research Society International, which supports use of the sit-to-stand test, walking speed test, timed stair climb, 6-minute walk test, and TUG.

    "PROMs and PBOMs also assess different time periods of recovery," authors write. "PROMs generally assess a period of weeks of overall symptoms and function while PBOMs objectively measure function at a particular point in time. Both types of information are valuable in assessing patient recovery."

    Still, they argue, the evolution toward patient-centered care means that patient-reported outcomes are likely to become more important in the future. And while the PTs surveyed may not yet be fully in sync with this trend in THA and TKA measures, there are some signs of positive movement.

    "This study showed that of the 16 outcome measures queried for clinical decision making, [PTs] indicated that they were less likely to use 4 of them in the future, all them PBOMs, and more likely to use 2 in the future, both PROMs," authors write. "As surgeons and [PTs] work more closely, developing better understanding and consensus in the use of PROM and PBOM between surgeons and physical therapists will allow for improved assessment of TJA patient outcomes."

    Authors acknowledge several limitations of their study, including a low response rate and the lack of data indicating when the various measures were used in the course of treatment. Another potential limitation: a large proportion of PTs (42.6%) reported seeing fewer than 25 patients with THA or TKA annually.

    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: Adding Dry Needling to Exercise for Shoulder Pain Could Reduce Broader Costs

    Adding trigger point dry needling to an exercise program for patients with chronic shoulder pain may be more cost-effective than exercise alone, according to a recent clinical trial. The combined intervention led to “improved quality of life and lower…costs than exercise alone,” write authors in Pain Medicine (abstract-only available for free).

    The study is an expansion of earlier published results of the trial, which indicated that including trigger point dry needling was just as effective as exercise alone at reducing shoulder pain intensity, and better at improving pain-related disability. That open-access article appears in The Journal of Pain.

    Researchers recruited 50 participants with unilateral shoulder pain lasting more than 3 months from a hospital in Madrid, Spain. All patients had been diagnosed with subacromial pain syndrome and had no history of shoulder or neck injury, cervical radiculopathy, fibromyalgia, shoulder or neck surgery, shoulder steroid injections, or any type of shoulder or neck intervention.

    Patients were randomly assigned to 1 of 2 groups; both groups received treatment once per week for 5 weeks. Both groups received a supervised, clinical practice guideline-based exercise program of 3 exercises targeting the supraspinatus, infraspinatus, and scapular stabilizer musculature. The second also received trigger point dry needling on the second and fourth sessions.

    Authors analyzed societal costs and measured health-related quality of life during the 12-month follow-up period. Here’s what they found:

    Direct health care costs. Patients in the exercise-only group made more visits to their physicians. They also received more supplemental treatments, such as cold packs and extra physical therapy sessions, compared with the exercise plus trigger point dry needling group.

    Indirect costs of lost productivity. Work absenteeism and average cost of absenteeism were significantly higher for patients in the exercise-only group.

    Quality of life. Patients who also received trigger point dry needling “reported significantly better quality of life” compared with those who only received exercise.

    Cost-effectiveness. Exercise plus trigger point dry needling was “more likely to be cost-effective” than exercise alone. The greatest cost savings, say researchers, came from lower work absenteeism in the trigger point dry needling group.

    While authors acknowledge that the study results do not necessarily apply to other countries, they suggest “these differences would not alter the direction of current results.”

    Authors of the study include APTA members Joshua Cleland, PT, DPT; and Shane Koppenhaver, PT, PhD. Both Cleland and Koppenhaver are board-certified orthopaedic clinical specialists and fellows of the American Academy of Manual Physical Therapy.

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

    APTA's New Mission Statement: A Healthier Society Through a Strong Community

    APTA has a new mission, and it's all about bringing people together.

    "Building a community that advances the profession of physical therapy to improve the health of society" is now the official mission statement for APTA. Developed by the APTA Board of Directors after the 2017 House of Delegates entrusted the Board to update and maintain the association's mission, the statement is strongly integrated with APTA's vision statement for the profession of physical therapy: "Transforming society by optimizing movement to improve the human experience."

    "The vision statement APTA adopted in 2013 positions the association as an outward-facing organization committed to positive change," said APTA President Sharon L. Dunn, PT, PhD. "Our new mission statement articulates the association's role in that change—by being a place of engagement, where multiple perspectives can be brought together in support of advancing physical therapist practice to create pathways toward a healthier society."

    According to Dunn, as the APTA Board of Directors explored the creation of a new mission statement, members realized that in many ways the association already is living out its mission.

    "Our emphasis on being better together, our recommitment to diversity and inclusiveness, and our energized and connected members pointed the way toward this new mission statement," Dunn said. "We believe it's a forward-looking mission, but it's also a mission firmly rooted in our profession's values and its history of compassion, concern for society, and willingness to make bold moves.

    Move Forward Radio: Avoiding Muscle Atrophy When Injured

    It's not unusual for people who work out or participate in sports on a regular basis to experience an injury. It's also not unusual for the physically active-but-injured to be hesitant to take a break from or alter their activity while they seek care from a physical therapist (PT). They may fear losing muscle mass, gaining weight, or simply surrendering that regular sense of well-being. But under the right care, it doesn't have to be that way.

    Now available from APTA's Move Forward Radio: a conversation with Ryan Balmes, PT, DPT, who addresses many common questions and concerns about what happens when the body is recovering from injury and the role of the PT in that process. “If you’re injured, it’s not the end of the day,” he says, “but there’s a process” to avoid further injury.

    Balmes describes for listeners how he helps injured athletes safely stay in shape while still treating their injuries, how age affects injury recovery and prevention, and how patients and clients can work collaboratively with a PT to meet their unique needs and treatment goals. Balmes is a board-certified clinical specialist in both sports physical therapy and orthopaedic physical therapy.

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

    Other recent Move Forward Radio episodes include:

    Beyond Opioids: Transforming Pain Management to Improve Health
    On February 5, 2018, APTA convened a panel of 7 experts to discuss how pain management in America can move beyond opioids and improve the health of society. The panel was broadcast live on Facebook and included the debut of APTA’s latest public service announc
    ement for the #ChoosePT opioid awareness campaign.

    Optimal Breathing and the Role of Physical Therapy
    Rohini K. Chandrashekar, PT, describes the mechanics of respiration, the causes and effects of breathing dysfunction, how breathing can affect movement and pain perception, and how PTs can help people breathe easier.

    Girl Power: Keeping Female Adolescent Athletes Healthy and Prepared for Sports
    Kate Hamilton, PT, DPT, discusses the safe, supportive, and fun environment she has created for adolescent girls only. The spectrum of services they provide range from individual and group strength and conditioning to performance enhancement, injury prevention, and physical therapy.

    Surfing and the Role of Physical Therapy
    Mark Kozuki, PT, DPT, explains the physical demands and challenges of surfing, how it’s different for recreational versus professional surfers, and what things surfers of any ability level should keep in mind to minimize injury risk and maximize performance.

    The Good Stuff: Members and the Profession in the Media, March 2018

    "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!

    James Lewis, PT, MS, outlines the do's and don'ts of fitness apps. (Dallas News)

    Widener University PT student Jackie Krempasky, SPT, received a unique opportunity to put her clinical skills to use. (Delaware County, Pennsylvania, Daily Times)

    Ashley Hubregtse, PT, DPT, ATC, discusses the careful approach necessary in helping injured student athletes return to play. (KSFY News, Sioux Falls, South Dakota)

    "I, like many Olympians, have learned the value of a physical therapist. After surgery, to avoid it, or to help strengthen an area of the body and relieve pain, they are worth their weight in gold. The process is painful at first, but yields valuable gains from the pain. The healing process reveals strength, helps to mend, lessens soreness, and gives patients the ability to meet their goals – whatever they may be." –Opinion piece by Beth Willis Tedio (Tallahassee, Florida, Democrat)

    Jessie Fisher, PT, MPT, explains the differences between acupuncture and dry needling. (Reno, Nevada, Gazette Journal)

    Want stronger ankles? Robert Gillanders, PT, DPT, shares tips. (Spartan)

    “We really push physical therapy prior to surgery, as well as strengthening prior to chemotherapy. We want to optimize physical function, so we’ll do exercises that focus on endurance, gait, balance and strengthening. Physical therapy is quite important.” --Ekta Gupta, MD, assistant professor of palliative, rehabilitation and integrative medicine in the Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, on the role of physical therapy in cancer treatment. ("Let's Get Physical," curetoday.com)

    A. Lynn Millar PT, PhD, suggests questions patients should ask their physical therapists. (Outside)

    Luke O'Brien, PT, offers advice on exercises to help avoid knee pain. (Men's Health)

    Andwele Jolly, PT, DPT, MBA, MHA, has received a prestigious Eisenhower Fellowship. (Eisenhower Fellowship newsletter)

    "… it's such a vexing issue for anyone who treats chronic pain. Some of the treatments that have been proven more effective, and safer, and have better outcomes, such as physical therapy, may have a $20 to $40 copay for each visit, versus an opioid, which might have a $5 copay for an entire month's supply. So it's a huge problem that insurance companies…need to contend with across the country. There are all sorts of hidden additional costs with prescribing an opioid, and in the long run, it may be that using these nonopioid approaches, like physical therapy, and other medications, really provides the best improvement in chronic pain but also lowers costs. -Ajay Wasan, MD, professor and vice chair for pain medicine at the University of Pittsburgh Medical Center ("Questions and Answers About Opioids and Chronic Pain," National Public Radio)

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

    Study: Optimal Exercise Dose for Knee Disorders Still Unclear

    While much research has shown positive effects of therapeutic exercise for common knee disorders, “optimal dosing is still unclear,” say experts, largely a result of the way authors report their results. Identifying the best dosage is important, they write, because overdosing can have adverse effects, while underdosing can lead to no improvement for the patient.

    In a systematic review published in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free), authors examined 45 “fair-quality” studies on the use of therapeutic exercise to treat knee osteoarthritis (OA), patellar tendinopathy, or patellofemoral pain (PFP). Researchers analyzed duration of a single session, frequency of sessions, total number of sessions, duration of treatment, and effect size. Here's what they found:

    • Effect sizes in the included studies varied widely because so many different outcome measures were used, even for the same conditions.
    • For all 3 conditions, some studies did not report or were unclear about the length of each therapy session, frequency of sessions, and whether or not the exercise was supervised.
    • While nearly all studies clearly reported total number of sessions, the number ranged from 3 to 108 for knee OA, from 36 to 180 for patellar tendinopathy, and from 12 to 146 for PFP.
    • Researchers were able to identify only 3 trends from their analysis—all for knee OA. Both 24 total number of sessions and 8-week and 12-week durations were most often related to large effect sizes.
    • Once-per-week session frequency had no effect for knee OA.

    The review’s findings illustrate the challenge of appropriate dosing.

    “Exercise dosing is complex,” note authors, speculating that “an identical bolus of 315 minutes of exercise per week could be disseminated in a variety of ways.” More frequent sessions could be more effective, they write, but that would likely be affected by the duration and intensity of each session.

    Authors acknowledge the balancing act between tailoring exercise prescription to each patient while establishing general dosage parameters that help “standardize effective care, inform clinical practice guidelines, and decrease dosage variance in clinical trials.” It is critical, they say, to improve the quality of dosage reporting in clinical trials, because “these data can better allow researchers to fine tune exercise dosage in subsequent trials, and improve our understanding of exercise parameters that work better than others.”

    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 Contributes to New 'Playbook' on Pain Management and Opioid Stewardship

    Understanding the link between overreliance on opioids for pain management and the broader opioid crisis in the US isn't difficult: identifying realistic steps to break that link is another matter. A high-profile national partnership that includes APTA is hoping to change that with the release of an opioid "playbook" focused on realistic, patient-focused, and scalable actions to transform health care's approach to pain.

    The National Quality Partners Playbook: Opioid Stewardship , released on March 12, aims to provide "a blueprint to help address the nation's devastating opioid epidemic," according to Shantanu Agrawai, ME, MPhil, president and CEO of National Quality Forum (NQF), which sponsored the creation of the resource. The guide is the product of an NQF "action team" composed of representatives from more than 40 health care and provider organizations including the US Centers for Disease Control and Prevention, BlueCross BlueShield Association, the American Nurses Association, the American Society of Health Systems Pharmacists, Magellan Health, and the Veterans Health Administration. APTA was represented on the action team by Alice Bell, PT, DPT, senior payment specialist for the association.

    The playbook is built around 7 "fundamental actions" that authors believe could help shift health care patterns away from the overuse of opioids for noncancer pain. Those actions are rooted in the concept of opioid "stewardship"—the idea that health care systems, clinicians, and patients must take a shared approach to the use of opioids that recognizes their potential for harm and looks to nonopioid options whenever possible. Those actions are:

    • Promoting leadership commitment and culture that support nonopioid pain treatments and demonstrates that support through allocation of resources
    • Implementing organizational policies to support evidence-based approaches to multimodal pain management
    • Advancing clinical knowledge, expertise, and practice to ensure that clinicians understand the science of pain and techniques for patient communication
    • Enhancing patient and family caregiver education and engagement around pain management and the risks of opioids
    • Tracking, monitoring, and reporting performance data on opioid prescribing, patient-reported outcomes, and adverse events
    • Establishing accountability around communicating and maintaining "a culture of opioid stewardship"
    • Supporting collaboration with community leaders and stakeholders to achieve maximum impact

    "The playbook highlights the importance of incorporating a multidimensional approach to pain management, including physical therapy, as a critical component of addressing this epidemic in a meaningful way," said Bell. "The diverse group of organizations and individuals who contributed brought a comprehensive perspective and a real commitment to providing a useful and effective tool to health care organizations and providers."

    The recommendations from the NQF group are consistent with APTA's #ChoosePT opioid awareness campaign, which stresses the importance of clinician-patient communication about pain management. Many of the playbook's themes were also echoed by participants in a recent live FaceBook broadcast from APTA, "Beyond Opioids: Transforming Pain Management to Improve Health."

    "It's critical that health care organizations and providers examine their approaches to pain management to ensure that individuals are aware of all of their options, including more active approaches to care, such as physical therapy," Bell said. "The playbook creates a pathway for making these needed changes at such a critical time—this epidemic continues to impact so many, and the need for a collaborative solution is clear."

    The playbook was released in conjunction with the opening day of the NQF annual conference, which features a panel discussion on the resource. Additionally, NQF will host a public webinar on March 29 and an in-person workshop on May 1 in Washington, DC.

    NQF is a nonprofit organization known for developing resources in the areas of health care quality measurement and improvement. The opioid playbook was 1 of 2 such resources released on March 12; the second is a playbook addressing shared decision-making in health care.

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    Study: Falls Among US Adults 65 and Older Cost $50 Billion in 2015

    The US health care system spent an estimated $50 billion on falls in 2015, an amount representing 6% of all Medicare payments and 8% of all Medicaid payments, according to a new study. Authors say that unless the US steps up its game when it comes to falls risk assessment and prevention, costs are certain to climb steadily higher as the baby boomer generation continues to age.

    Researchers based their estimates on data from the Medicare Current Beneficiaries Survey (MCBS), then applied these data to data from the National Health Expenditures Accounts (NHEA) to estimate nonfatal falls expense. For fata falls, they used the Web-based Injury Statistics Query and Reporting System (WISQARS) to assess expense. The final MCBS sample included 3,460 community-dwelling individuals 65 and older. Respondents who were employed, died during the survey period, or lived in Puerto Rico were excluded.

    Results of the study were published in the Journal of the American Geriatrics Society. Among the findings:

    • Based on the survey, researchers estimate total 2015 health care expenditures for nonfatal falls in the US at $49.5 billion--$28.9 billion for Medicare, $8.7 billion for Medicaid, and $12 billion for other payment sources including private insurance and out-of-pocket expense.
    • Nearly 1 in 4 adults in the survey reported a fall in the past year. Of those, 52.1% fell once, 21.3% fell twice, and 24.1% fell 3 or more times.
    • Individuals who reported falls had significantly lower self-rated health and more chronic conditions, and were more likely to be female, white, and from lower income levels.
    • Estimated costs were not distributed equally among service types, with an "other" category—spending in areas such as home health services, long-term care facilities, and durable medical equipment—leading the way at $29.2 billion. That amount was more than double hospital-related spending, which was second at $12.9 billion, followed by physician/other provider spending ($10.8 billion), prescription drugs ($2.1 billion), and dental ($400 million).
    • Unintentional fall deaths were recorded at a rate of 59.64 per 100,000 population in 2015, with associated medical costs of $754 million—about 1% of the total estimated expenditures.
    • Overall, spending on falls in 2015 increased by nearly 32% from 2013, when total spending was estimated at $38 billion.

    "The economic burden from falls is likely to increase substantially in the coming years," authors write. "Monitoring cost trends is important, because 75% of the cost of older adult falls is financed through public health insurance programs that are already financially stressed."

    Authors believe that given the undeniable demographic pressure that will increase as baby boomers age, it's imperative that more attention be given to falls assessment and prevention.

    "Preventive strategies that reduce falls in older adults could lead to a substantial reduction in health care spending," authors write.

    The researchers stress that "evidence-based strategies including medication management and strength and balance exercises…have been associated with reductions in older adult falls," and point to guidelines such as those included in the US Centers for Disease Control and Prevention's Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative as a good place to start

    But there's no time to lose, they add. Authors of the study believe that providers need to act with urgency and do a better job of identifying falls risk, assessing which risk factors may be modified and providing evidence-based interventions to decrease that risk.

    "Clinical care is an important component of falls prevention," they write. "By broadly implementing and scaling up initiatives like STEADI, we can improve health and decrease the future economic burden of older adult falls."

    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.

    Editor's note: Want more on falls prevention? Check out the falls-related resources at PTNow, including 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. APTA also offers resources on its Balance and Falls webpage.

    JAMA Study: Opioids No Better Than Nonopioids in Improving Pain-Related Function, Intensity for Chronic Back Pain, Hip/Knee OA

    In brief:

    • 240 patients with chronic back pain or hip or knee osteoarthritis pain were divided into 2 treatment groups: 1 group received opioids, 1 group received nonopioid medications
    • After 12 months, researchers found no differences between the groups' reported improvement in function, and a slightly better improvement rate in pain intensity for the nonopioid group
    • Among individuals who achieved improvements of 30% or more, numbers were nearly equal for the 2 groups in terms of function, and better for the nonopioid group in terms of pain intensity
    • Authors conclude that given the potential risks associated with opioids, results of the study do not support opioid prescription for chronic back pain or knee or hip osteoarthritis pain

    APTA's #ChoosePT opioid awareness campaign makes the case that opioids simply "mask" pain—but a new study in JAMA has concluded that the drugs probably don't even do that much, at least not any more effectively than nonopioid medications. The research, which focused on individuals with chronic back pain or hip or knee osteoarthritis (OA) pain, led authors to an unequivocal conclusion: there's no support for opioid therapy for moderate-to-severe cases of those types of pain.

    The published findings (abstract only available for free) are based on a study of 240 randomized patients in the Minneapolis, Minnesota, Veterans Affairs (VA) health care system who reported chronic back pain or knee or hip OA pain, defined as daily moderate-to-severe pain for 6 months or more with no relief provided by analgesic use. Participants were divided into 2 groups: 1 that received an opioid regimen, and a second group that received nonopioid drugs.

    To more closely resemble real-world treatment, researchers used a "treat-to-target" approach that stepped up the drugs as needed for participants to reach identified goals. The opioid regimen began with immediate-release morphine, hydrocodone/acetaminophen, and oxycodone, but the regimen could advance to sustained-action morphine and oxycodone, and on to transdermal fentanyl. The nonopioid approach began with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS), but it could move on to topical analgesics and finally to drugs requiring prior authorization (such as pregabalin and duloxetine), including tramadol. All participants also were permitted to pursue nondrug treatment during the study, but researchers did not evaluate data related to those treatments.

    Participants were monitored throughout the study and evaluated at 12 months using a range of tests, with the primary focus on how pain interfered with function, assessed through the Brief Pain Inventory (BPI); and pain intensity, measured using the BPI severity scale. Both measures are 10-point scales, with higher numbers indicating more pain-related interference or pain intensity. Other areas assessed as secondary outcomes included quality of life, depression, sleep disturbance, headache, anxiety, sexual function, and fatigue.

    At the 12-month mark, researchers found no significant differences in pain-related interference between the 2 groups (average BPI function scores of 3.4 in the opioid group and 3.3 in the nonopioid group), and a greater reduction of pain intensity among the nonopioid group (average of 3.5 in the nonopioid group vs 4.0 in the opioid group).

    When it came to the achievement of what authors called a "functional response"—a 30% or better improvement in a BPI score—the number of participants who achieved that level of improvement in function was roughly equal among groups, with 69 patients in the opioid group and 71 patients in the nonopioid group reaching the threshold. But the difference was notable in pain intensity scores, with 63 participants in the nonopioid group reporting improvement of 30% or more, compared with 48 participants in the opioid group reaching that level of improvement.

    The researchers also analyzed group differences by the type of pain treated:

    Back pain

    • Average score, interference with function: 2.9 in opioid group; 3.3 in nonopioid group
    • Average score, pain intensity: 3.7 in opioid group; 3.6 in nonopioid group

    Hip or knee OA

    • Average score, interference with function: 4.4 in opioid group; 3.4 in nonopioid group
    • Average score, pain intensity: 4.5 in opioid group; 3.4 in nonopioid group

    Similar to a study published recently, researchers also found that quality-of-life measures did not differ significantly between the 2 groups. The only area in which results from the opioid group bettered the nonopioid group in a notable way was in reduction of anxiety symptoms, although authors point out the only a small number—9% of all participants—reported moderate-to-severe anxiety at baseline.

    Authors acknowledged observational studies that associate long-term use of opioids with poor pain outcomes but say that those outcomes may not tell the whole story.

    "In this trial, pain-related function improved for most patients in each group," authors write. "Poor pain outcomes associated with long-term opioids in observational studies may be attributable to overprescribing and insufficient pain management resources rather than to direct negative effects of opioids."

    Still, they argue, given the "risk for serious harms without sufficient evidence for benefits," there seems to be no compelling reason to even begin a course of opioid-based treatment for certain conditions

    Among patients with chronic back pain or hip or knee osteoarthritis pain, treatment with opioids compared with nonopioid medications did not result in significantly better pain-related function over 12 months," authors write. "Overall, opioids did not demonstrate any advantage over nonopioid medications that could potentially outweigh their greater risk of harms."

    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's award-winning #ChoosePT campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Members can also learn more about the PT's role in pain management through offerings on PTNow, including a webpage with resources for pain management and an opioid awareness checklist.

    Easier Said than Done: A Third of Patients Told to Lose Weight Have Functional Limitations That Could Make Exercise Difficult or Unsafe

    Physicians increasingly may be prescribing exercise for patients who need to lose weight, but nearly a third of those patients have functional limitations that could interfere with their ability to safely follow those recommendations, according to new study. Researchers see physical therapists (PTs) as providers who are uniquely positioned to help fix that disconnect.

    The study's findings, published in Physiotherapy Theory and Practice (abstract only available for free) are based on data from 5,480 participants in 2 rounds of National Health and Nutrition Examination Surveys (NHANES) who answered yes to 1 or more of 3 questions about whether a doctor or health professional had recommended physical activity or weight loss in the past 12 months. Researchers looked at how this group answered other questions about functional limitations—activities such as walking for a quarter mile, walking up 10 steps without resting, preparing meals, dressing, standing up from an armless chair, and pushing or pulling large objects—as well as questions about past attempts at weight loss. Here's what they found:

    • Among respondents (56.5% female, 43.5% male ranging in age from 40 to 65) who were told to lose weight, nearly 1 in 3 (31%) reported 1 or more functional limitations.
    • More than 20% reported difficulties with instrumental and basic activities of daily living (IADL and BADL) and with lifting, pushing, or pulling objects.
    • More than 90% of respondents who reported difficulties with IADL and BADL also had a history of obesity, prediabetes, diabetes, hypertension, heart failure, angina, or a myocardial infarction, either alone or in combination.
    • Among the functional limitation group, 57.6% reported intentionally attempting weight loss, with 40.7% using exercise as a weight-loss method.
    • Only 9.9% of respondents who were told to lose weight reported seeking professional advice for weight loss: 48% of that group sought advice from a nutritionist or dietitian, 26% sought out a personal trainer, 23.5% met with a "doctor," and 2% reported "other." Physical therapists were not listed as a separate option.

    Authors of the study acknowledge that while the relationship between functional limitations and lower levels of physical activity (PA) may be a 2-way street, with low levels of PA leading to functional limitations and vice-versa, this relationship only underscores the need for carefully planned and monitored prescriptions for exercise in this population. That's where they believe PTs can play an important role.

    "Physical therapists are well-suited to manage the PA and exercise programs of individuals with functional limitations given [their] education, expertise, and documented self-efficacy in primary, secondary, and tertiary prevention with exercise testing, prescription, and implementation," authors write. "This perspective is strengthened by the documented low self-efficacy of physicians with PA counseling."

    Authors acknowledge that their study may have limitations, including the "bidirectional" relationship between low PA and functional limitations and the NHANES loose use of provider terminology—specifically its reliance on the generic term "doctor." Additionally, they write, more research is needed to assess the impact of functional limitations on the ability to exercise, as well as to explore why PTs don't seem to be a regular part of prescribed weight-loss efforts.

    Nevertheless, they argue, the data in the study point to the need for a more thoughtful approach to weight-loss recommendations.

    "Individuals with these limitations should be identified at the time of health professional recommendation to increase exercise or lose weight and referred to an appropriate health professional for exercise testing, prescription, and program implementation," authors write. "Physical therapists have an opportunity to assist with these efforts."

    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.

    Editor's note: APTA offers resources on encouraging healthy, active lifestyles at APTA's Prevention, Wellness, and Disease Management webpage as well as its webpage on arthritis management through community programs. The association has also launched a new knowledge-sharing opportunity: The Council on Prevention, Health Promotion, and Wellness in Physical Therapy.

    From PT in Motion: PT 'Boomers' Offer Advice on Life in the Clinic and Beyond

    With so much focus on the aging patient population, it's easy to forget that the physical therapist (PT) population is aging as well, with the percentage of PTs ages 55 and older rising from 11.1% in 2000 to 24.7% in 2013, according to an APTA survey. And while PTs in the clinic can remain passionate about their profession as they age, keeping up with the physical demands of the job may be another matter. Fortunately, there are a variety of ways older PTs can adapt to their changing capacities.

    This month's PT in Motion magazine includes “Career Transitioning Advice for Aging PTs,” an exploration of how long-time clinicians are adjusting their routines or transitioning to new career paths, and the life circumstances that led them in that direction.

    One example from the article: Damien Howell, PT, DPT, who was in his mid-60s when he was diagnosed with rheumatoid arthritis (RA). Although clinical practice became more difficult, he decided it wasn't yet time to retire. "I loved my job and loved working with my patients. I wasn't about to give all of that up," he told PT in Motion. "So, instead, I focused on making improvements where I could—on trying to adjust my practice so I could continue to work." For example, Howell began to teach patients more self-mobilization techniques, and he has moved toward telehealth services.

    Other PTs featured in the article found a new direction with less demanding hours. Randy Roesch, PT, DPT, MBA, FAPTA, transitioned from clinical practice to business consulting when she acknowledged that her "workaholic" tendencies were pushing her toward 80-hour work weeks. Physical therapy, Roesch notes, "is hard physically, mentally, and emotionally, mainly because we get so involved."

    "Career Transitioning Advice for Aging PTs,” is featured in the March issue of PT in Motion magazine. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.

    Study: Opioids Don't Improve Quality of Life for Individuals With Chronic Noncancer Pain

    Researchers have found that for individuals with chronic noncancer pain, opioids probably aren't delivering on what many presume to be their primary function—to improve overall quality of life by reducing pain and the emotional toll it takes.

    In a study published in Health Services Research (abstract only available for free) researchers tracked data from individuals who participated in the Medical Expenditure Panel Survey (MEPS), a project that collects health information by way of 5 rounds of surveys, each spanning a 2-year period. The survey asked about respondents' level of pain, use of opioids, and health-related quality of life (HRQoL) based on responses to 2 questionnaires, 1 on mental health and 1 on physical health.

    Authors of the study then focused on 5,876 respondents who reported chronic noncancer pain (CNCP), further dividing them into 3 groups: a no-use group, nonchronic opioid users (those who reported receiving at least 1 opioid prescription over a 12-month period but with a supply for fewer than 90 days), and chronic opioid users—those who reported receiving a prescription for opioids with a supply of 90 days or more in a 12-month period.

    After controlling for demographic variables, comorbidities, and diagnoses, researchers found that physical and mental health scores did not vary significantly among chronic, nonchronic, and no-use groups—a result indicating that the use of opioids did not improve HRQoL any better than no opioids for individuals experiencing the same kinds of pain.

    In fact, researchers point out, if there was any change to be noted, it would be that the chronic-use group reported slightly decreased physical health scores over time—but those changes did not result in a minimally clinically important difference from the other 2 groups.

    "The ultimate goal of using opioids for the treatment of CNCP is to ease the burden of pain and hopefully improve HRQoLs," authors write. "Overall, these results suggest that opioid use for CNCP is not associated with better HRQoL [as measured through the tests included in MEPS]. Considering the risk of development of opioid dependence and addiction and unclear benefit on HRQoL, clinicians should carefully evaluate a treatment goal and whether participants with CNCP should continue receiving opioid therapy."

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

    APTA's award-winning #ChoosePT campaign is aimed at informing consumers that physical therapy is an effective alternative to drugs for the treatment of pain. Members can also learn more about the PT's role in pain management through offerings on PTNow, including a webpage with resources for pain management and an opioid awareness checklist.

    Washington Post: End of Therapy Cap a 'Long-Awaited Gift'

    The end of the hard cap on payment for therapy services under Medicare was big news for patients and the profession—a fact that hasn't escaped the notice of The Washington Post.

    The March 1 edition of the Post featured a story from Kaiser Health News on the elimination of the cap, which is described as a change "buried" in the federal spending plan approved by Congress in February, albeit one that "reveals much about how health care financing often gets done—or undone—in Washington."

    The article recounts the birth of the cap in 1997, efforts to repeal it, and the regular scrambles to apply temporary exceptions to the policy. And to help illustrate the long slog that finally led to repeal, Kaiser reporter Shefali Luthra retells the story of an ambitious physical therapist who left his practice in Michigan and headed to Washington, DC, nearly 20 years ago to help advocate for an end to the cap. His name: Justin Moore, PT, DPT—as it happens, the same Justin Moore who's now CEO of APTA.

    The unceasing advocacy efforts of "a small but impassioned therapy contingent" of APTA members, association staff, and patients is what "laid the groundwork" for the cap fix, according to the Post article. As for Moore, he's quoted as saying "I've got to figure out what to do next." Insider tip: he's joking.