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  • Final HHS Report on Pain Management Adds to Drumbeat for Better Access to Nondrug Approaches

    The final report from a US Department Health and Human Services (HHS) inter-agency task force on pain management best practices is out, and its call for greater collaborative care and improved access to physical therapy comes through loud and clear. It's a report that in many ways echoes APTA's white paper on opioids and pain management published nearly 1 year ago.

    The "Report on Pain Management Best Practices" changed little from its draft version released in January [Editor's note: this PT in Motion News article covered the draft in depth]. Like its predecessor, the report identifies gaps and inconsistencies in pain management that can contribute to opioid misuse.

    While the task force acknowledges that opioids may be appropriate when carefully prescribed in some instances, it also argues that other approaches—including "restorative therapies" furnished by physical therapists and other health care professionals—should be on equal footing with pharmacological alternatives, particularly when it comes to reimbursement and patient access.

    "Restorative therapies play a significant role in acute and chronic pain management, and positive clinical outcomes are more likely if restorative therapy is part of a multidisciplinary treatment plan following a comprehensive assessment," the report states, while pointing out that "use of restorative therapies is often challenged by incomplete or inconsistent reimbursement policies."

    APTA submitted comments on the draft report, and offered members a chance to contribute to the report's development through a customizable template letter. Association staff members also met in person with Vanila M. Singh, MD, task force chair, and provided public commentary to the task force on 2 occasions.

    The HHS report is consistent with a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches.

    "This report from HHS adds to an overwhelming body of knowledge that spells out the need for patient-centered, collaborative care that makes nonpharmacological approaches to pain management more accessible to public," said Katy Neas, APTA executive vice president of public affairs. "But the question is, what will the public, federal agencies, and other stakeholders do with the information in this report and so many others like it? Will payers actually change their reimbursement guidelines to align with best practices, or should more regulatory changes be brought to bear? The path forward is clear, and some positive changes are happening, but as this report makes clear, it's time to pick up the pace."

    APTA continues to build on its successful #ChoosePT campaign to educate the public on safe, effective alternatives to opioids for pain management. The most recent addition: a downloadable pain profile chart that makes it easy for patients to assess the severity and impact of the pain they're experiencing.

    Study Reveals Racial Disparities in Postdischarge Rehab After Traumatic Injury

    The road to recovery after a moderate-to-severe traumatic injury can be daunting for anyone, but a new study suggests that individuals who are African American may face an even more challenging path. Researchers found that in groups matched for age, injury type, and injury severity, African Americans were on average 36% less likely to use rehabilitation services and 40% less likely to have outpatient visits postdischarge.

    The presence of the apparent difference echoes APTA's characterization of racial and ethnic disparities as existing "across a range of illnesses and health care services."

    The study's conclusions are based on an analysis of 2.5 years' worth of patient-reported data linked to trauma treatment records from 3 Boston-area level 1 trauma centers participating in the Functional Outcomes and Recovery after Trauma (FORTE) project. Patients included in the study experienced moderate-to-severe trauma, defined as an Injury Severity Score (ISS) of 9 or greater, and participated in phone interviews conducted 6 to 12 months after trauma center discharge. Results were published in the American Journal of Surgery (abstract only available for free).

    Researchers were interested in patient answers to 2 primary questions: whether they received any rehabilitation services by way of discharge to a rehabilitation facility or skilled nursing facility, or through home or outpatient services such as physical therapy; and whether they received injury-related outpatient follow-up in a clinic setting. Participants also were asked about use of emergency departments (EDs) for an injury-related problem.

    The findings: of 1,299 patients studied, 79.8% of Caucasian patients reported receiving rehabilitation services, compared with 64.3% of patients who were African American. Injury-related outpatient clinic visits were reported at a rate of 47% for Caucasians and 40% for African Americans. Injury-related ED visits were reported by 10.1% of Caucasians, compared with 18.7% of African Americans.

    Researchers further analyzed the data by using a "Coarsened Exact Matching" algorithm to create groups of Caucasians and African Americans that were comparable in terms of injury type and severity as well as age and gender. That process reflected similarly significant differences in rehabilitation and outpatient visits but did not show a difference related to use of the ED.

    Other differences in the patient populations also emerged in the study. Caucasian patients tended to be older, with a mean age of 65 compared with a mean age of 45 for African Americans; additionally the Caucasian population reported a move even gender distribution (51% male) compared with the African-American group (67% male). Initially, researchers found differences in the discharge dispositions (home versus rehab facilities) among the groups, but those differences disappeared after adjusting for demographic and injury-related variables. Almost all participants had health insurance.

    "Our results suggest that racial disparities exist in the post-discharge utilization of health care services, which we know affect long term functional outcomes after injury," the authors write, noting that while discharge dispensation may not differ between the groups, patients reporting as African American were less likely to actually receive the rehabilitation services. "These racial discrepancies in post-discharge health services utilization may contribute to worse long-term trauma outcomes," they add.

    The study's authors believe there are "likely many factors" that play a role in these differences, but they speculate that "unconscious provider bias, patient understanding, miscommunication, access to care, and evidence of mistrust toward medical providers" are among the elements at work. Pinpointing the causes, they argue, "may provide insight into avenues for equalizing long-term outcomes for traumatically injured patients."

    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.

    CoHSTAR Pilot Study Deadline June 1

    A deadline is fast approaching for Center on Health Services Training and Research (CoHSTAR) opportunities to develop pilot studies that would help set the stage for larger efforts to advance a wide range of health services research. Letters of intent are due by June 1, 2019.

    The selected pilot studies would address research questions in CoHSTAR's 4 areas of specialization—analysis of large data sets, rehabilitation outcome measurement, cost-effectiveness, and implementation of science and quality improvement research—and the CoHSTAR Pilot Study Program webpage lists examples of specific types of studies that would qualify for funding. Each pilot study will receive $25,000 in funding for direct costs.

    APTA was a major financial contributor to the development of CoHSTAR, having donated $1 million toward the center's startup in 2015. In addition to APTA’s $1 million donation, funding for CoHSTAR also came from APTA components, individual PTs, foundations, and corporate supporters.

    Study Identifies 11 Guideline-Based Recommendations for Musculoskeletal Pain

    A multidisciplinary group of researchers, including physical therapists (PTs), has identified a core set of 11 clinical practice guideline (CPG) recommendations for treating adult musculoskeletal (MSK) pain, according to a new article in British Journal of Sports Medicine (BJSM). Authors hope the recommendations will assist emergency and primary care clinicians in providing evidence-based care, as well as help consumers make informed health care decisions.

    Authors write that while "care that is more concordant with CPG recommendations results in better patient outcomes and lower costs," providers across disciplines too often do not practice according to guidelines, resulting in overuse of imaging, surgery, and opioids, and a failure to provide patient education and advice. There are many reasons for this, according to authors: CPGs often are not "user-friendly"; they often lack guidance on how to implement recommendations in practice; and different guidelines for a single condition may include conflicting recommendations.

    To help bridge these "evidence-to-practice gaps"—and help consumers understand what best practice looks like—authors examined 44 CPGs addressing 3 of the most common areas for MSK: spinal pain; hip/knee pain, including hip/knee osteoarthritis; and shoulder pain. The CPGs reviewed were published within the last 5 years, included information on how they were developed, and were published in English. Researchers excluded guidelines that focused on a single treatment modality, traditional medicine, traumatic MSK pain, specific diseases such as inflammatory arthritis, and those that required payment to access.

    Included in the analysis was the Academy of Orthopaedic Physical Therapy guideline "Low back pain: clinical practice guidelines linked to the international classification of functioning, disability, and health."

    Authors performed an AGREE II analysis on each CPG. A guideline was classified as "high-quality" if it received an AGREE II score that was at least half of the maximum possible score in 3 separate areas: rigor of development, editorial independence, and stakeholder Involvement.

    The 11 consistent recommendations include:

    1. Care should always be patient centered. Patient-centered care, according to authors, is characterized by effective communication, individualized care, shared decision making, and prioritizing patient preferences.
    2. Patients should be screened for serious pathology or "red flag" conditions. Providers should screen for causes of pain such as infection, malignancy, fracture, inflammation, neurological deficit, as well as conditions that mimic MSK pain.
    3. Psychosocial factors should be included in a patient's assessment. Providers should assess patients for psychosocial factors—such as depression, anxiety, kinesiophobia, and recovery expectations—that may affect their prognosis, in order to develop an appropriate plan of care.
    4. Radiological imaging is unnecessary in most cases. Many guidelines discourage the use of radiological imaging, except when a more serious pathology is suspected, the patient is not responding to treatment, or the imaging results are "likely to change management" of the patient's condition.
    5. Assessment should include physical examination to assist in diagnosis and classification. Physical assessments mentioned in the CPGs include tests for mobility/movement, strength, position and proprioception, and neurological function.
    6. Providers should evaluate patient progress and use validated outcome measures. In the CPGs authors examined, outcome measures assessed patients' pain intensity, functional capacity and activities of daily living, and quality of life.
    7. Patients should receive individualized education about their condition and treatment options. Authors recommend patient education to "encourage self-management and/or inform/reassure patients about the condition or management."
    8. Treatment should address physical activity and exercise. All of the CPGs reviewed included recommendations on either general or specific exercise and physical activity to increase mobility, strength, and flexibility.
    9. Manual therapy should be used only as an adjunct treatment. Seven CPGs included manual therapy as a "could-do" element of care, but only as part of a more comprehensive plan of care.
    10. Nonsurgical care should be the first line treatment. Unless a "red flag" condition indicates otherwise, patients should receive nonsurgical care before considering surgery.
    11. Treatment should facilitate return to work. Providers should encourage patients to remain active and engage with appropriate social service supports, employers, and health providers to enable a patient to return to work.

    Looking beyond the clinical application of the recommendations, authors suggest that a "broader strategy" for policy makers and health services researchers "could be the continued development of the common recommendations into a set of quality indicators that could be used for reporting or to benchmark care quality."

    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.

    America's 'Fittest Cities' Ranked

    Live in or near Arlington, Virginia? Congratulations: you reside in the nation's most fit city, according to results of a new study that ranks cities across the United States.

    The rankings are part of the 2019 American College of Sports Medicine's (ACSM) "Fitness Index," a project that analyzed health and environmental data to arrive at an overall fitness score. Health data included exercise prevalence, the percentage of residents meeting aerobic and strength activity guidelines, diet, and levels of conditions such as obesity, diabetes, and hypertension. Environmental data took in factors including air quality, access to recreational facilities, and walkability. ACSM received assistance from the Anthem Foundation in creating the report.

    In the end, Arlington came out on top of the 100-city list and earned first place rankings in both the health and environmental subscores. Seattle came in second, followed by Minneapolis, San Francisco, and Madison, Wisconsin. The 5 lowest-ranked cities were Indianapolis; Toledo, Ohio; Tulsa, Oklahoma; North Las Vegas, Nevada; and Oklahoma City, Oklahoma. The report provides a detailed accounting of the study's methodology, and ACSM also offers an online tool to compare statistics on as many as 3 individual cities.

    APTA and ACSM have a history of collaboration, and earlier this year the 2 organizations entered into a formal partnership.

    Visit APTA's prevention and wellness webpage for resources on how physical therapists and physical therapist assistants can help individuals become more physically active, and share the latest PA information from APTA's consumer-focused MoveForwardPT.com with your patients, clients, and others interested in the benefits of exercise and movement. Want to connect with others interested in physical therapy's role in improving health? Join APTA's Council on Prevention, Health Promotion, and Wellness.

    Move Forward Radio: Individuals Who Are Transgender Deserve Person-Centered Care – Just Like Everyone Else

    Sometimes the journey toward better health must begin at the beginning—with an actual acknowledgement that there's a problem, and a sense of self-worth strong enough to allow a person reach out for help. Just ask "Greg," a transgender man who endured pelvic pain for years.

    "My body was, for me, this thing that I fed, and got it in a car, and drove places, and it did the work I wanted it to do," Greg said. "Because I spent so much of my life feeling betrayed by it, it was just this thing I didn't want to pay attention to."

    That all changed when he met Hannah Schoonover, PT, DPT.

    Now available on Move Forward Radio: a conversation with Greg and Schoonover, the physical therapist (PT) who helped Greg see his body—and his connection to it—in a new way. The podcast is a must-listen for anyone seeking a better understanding of not just the challenges faced by the transgender population, but the importance of providers honoring the individual stories every patient brings to the clinic.

    The episode, hosted by PT in Motion magazine associate editor Eric Ries, follows Greg's initial reluctance to seek treatment for pelvic pain, his tentative first steps with Schoonover, and, finally, the development of a strong therapeutic alliance that brought relief—and helped Greg embrace a body he once viewed with disdain. Schoonover and Greg talk about the ways in which pelvic floor physical therapy can address pain, but they also discuss the obstacles to care that can arise when providers see patients simply as a collection of symptoms.

    Schoonover believes that health care providers need to understand that trauma plays a particularly powerful role among individuals who are transgender—and that this can deter them from seeking care.

    "Their experience is going to be different," Schoonover tells Ries. "There's going to be more sexual assault, there's going to be more violence, there's going to be more discrimination, more bias." That understanding is at the heart of Schoonover's Washington, DC, clinic, Body Connect and Wellness, which specializes in physical therapy for the transgender community. The clinic's baseline is that "all bodies are good bodies, and we're going to make sure that all bodies feel the way they're supposed to feel," she explains.

    It's a philosophy that has made a difference in Greg's life.

    "I'm feeling more open, I'm feeling more confident in my body," Greg says in the podcast. "We carry around emotional pain and we don't think it affects our bodies, but it does."

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

    Legislation to Include PTs in Student Loan Relief Program Now in House and Senate

    A little more than 1 month after its companion bill was introduced in the US Senate, legislation that could open up student loan repayment opportunities for physical therapists (PTs) has been introduced in the House of Representatives. The proposed change, strongly supported by APTA, would allow PTs to participate in the National Health Services Corps (NHSC), a federal initiative that provides greater patient access to health care in rural and underserved areas—and incentivizes health care provider participation through a student loan forgiveness program.

    Like the Senate version (S 970), the House version, titled the "Physical Therapist Workforce and Patient Access Act" (HR 2802), would allow PTs to participate in the NHSC loan repayment program. The initiative serves an estimated 11.4 million Americans who live in designated Health Professional Shortage Areas (HPSA) and repays up to $50,000 in outstanding student loans to certain health care professionals who agree to work in an HPSA for at least 2 years. The House bill is cosponsored by Reps Diane DeGette (D-CO) and John Shimkus (R-IL).

    "If enacted, this legislation would be very good news for PTs, and even better news for patients who need increased access to care," said Katy Neas, APTA's executive vice president of public affairs. "Legislators on both sides of the aisle are recognizing that access to physical therapist services can be a useful tool in the fight against the opioid crisis, which has been especially devastating in rural and underserved areas. Physical therapists are expert in musculoskeletal systems and can provide invaluable services to patients with acute and chronic pain, and this bill will make it easier for patients in rural and underserved areas to access those services."

    In addition to its positive impact on health care access, the legislation could also provide some relief for the rising level of student debt being experienced by graduates of physical therapist education programs. It's a challenge that APTA is working to address, according to APTA Vice President of Government Affairs Justin Elliott

    "APTA's strategic plan envisions a physical therapy profession that's as diverse as the patient population it serves, and that means we must take a hard look at barriers to pursuing a career in physical therapy," said Elliott. "Clearly one of those barriers is the cost of physical therapist education. While this bill doesn't solve the problem, it could provide at least some relief for PTs facing significant student debt."

    APTA encourages members to join the push for the bills by contacting their legislators to urge them to become cosponsors by way of a prewritten letter, available at the APTA Legislative Action Center, that helps to deliver a unified message (member login required).

    APTA staff will closely track the progress of this legislation—be on the lookout for more opportunities to advocate for this important change.

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

    Heard the one about the PT? Kyle Gadapee, SPT, was among the comedians featured in the 10th Annual Women in Comedy Festival sponsored by HBO. (St Johnsbury, Vermont, Caledonian Record)

    The dangers of neck-cracking explained: In the wake of headlines about a man who suffered a stroke while trying to crack his neck, Rob Sillevis, PT, DPT, PhD, shows just how it could happen. (NBC News2, Fort Meyers, Florida)

    Quotable: "Surely physical therapy is about healing and recovery, but for anyone with a physical disability—it is more about creating realistic ways to move toward wellness and away from pain and illness on a daily basis." -Katy Fetters, Colorado University-Boulder graduate student with cerebral palsy, on how physical therapy is helping her stay physically active. (CU Boulder Today)

    Physical therapy and engineering: Rachael Biega, SPT, describes her experiences working with engineering students on developing adaptive devices. (phys.org)

    Back to physical therapy: Todd Kruse, PT, MPT, makes the case for trying physical therapy first for back pain. (KEYC12, Mankato, Minnesota)

    Best in snow: Dave Callaghan, PT, has received a National Appointment from the National Ski Patrol. (UPMatters.com)

    Prepping for Archie: Marianne Ryan, PT, BS, provides insight on how Meghan Markle and other expectant moms can prepare for labor. (Fox News)

    Feel better in the long run: Marsena Morgan, PT, DPT, offers tips on recovering after running a marathon. (Fox25 News, Oklahoma City)

    Pelvic floor health: Holly Tanner, PT, DPT, MA, stresses the importance of seeking help from a PT for pelvic floor problems. (Today Show)

    Taking the pain out of paying for physical therapy: Denise Buher, PT, DPT, explains how high copays are depriving patients of the physical therapy they need. (Glen Falls, New York, Post-Star)

    Spreading the interprofessional message: Jody Frost, PT, DPT, PhD, FAPTA, has been named president of the National Academies of Practice. (napractice.org)

    The endurance PT: Verrelle Wyatt, PT, DPT, took first place in the 2019 Pro Football Hall of Fame Marathon. (Akron, Ohio, Beacon Journal)

    Your IT: Bridget Dungan, PT, offers advice on how cyclists can avoid IT band-related pain. (Bicycling)

    Quotable: "They helped me strengthen my legs and prepare for this. They had some steps that I practiced going up and down so I could be able to handle the steps," – Margaret Planter, who participated in physical therapy to prepare her for ziplining on her 100th birthday. (Local12 News, Cincinnati)

    Adaptive triathlon: Jeff Krug, PT, and Kayla Friesen, SPT, share their experiences in helping to oversee an adaptive triathlon sponsored by Missouri University's physical therapy program. (Columbia, Missouri, Missourian)

    Getting hip to getting strong: Doug Kechijian, PT, DPT, suggests exercises to help build hip strength and resilience. (Outside)

    When your jumping's jacked: Keaton Ray, PT, DPT, ATC, covers the proper way to do jumping jacks. (Women's Health)

    Living with Parkinson: Kari Torgerson, PT, outlines the physical and emotional toll of Parkinson disease. (It Takes Two podcast)

    Help for sciatica: Jason Dudzic, PT, MSPT, explains how physical therapy can make a difference for individuals experiencing sciatic nerve pain. (CBS21 News, Harrisburg, Pennsylvania)

    Raising the barre: Rebecca Strabala, PT, has combined her background in dance with her training as a PT to help dancers recover from injury. (Davenport, Iowa, Gazette)

    Quotable: "Physical therapy was once something that seemed pointless for me to try. My arms and legs are pretty much just for show, so why bother? Now, I’m grateful for how persistent my doctor was with me a few years ago. The thing that I once dreaded is now something that I eagerly anticipate every week." –Kevin Schaefer, who has spinal muscle atrophy, on how regular aquatic physical therapy sessions have changed his outlook. (SMA News Today)

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

    Study: Patients in Cardiac Rehab Are Older, Less Healthy, and Have More Diverse Needs Than Patients 20 Years Ago

    The use of cardiac rehabilitation (CR) has grown over time, but with that growth comes changes to patient demographics that present new challenges to providers, say researchers who studied the CR patient population in 1 health system over 2 decades. They describe today's CR patients as older, more overweight, and having a higher prevalence of coronary risk factors than CR patients in the past, with an expanded range of reasons for receiving CR that makes the population more diverse than ever.

    The study analyzed data from 5,396 patients who received CR at the University of Vermont Medical Center over a 20-year period between 1996 and 2015, taking in a host of variables, including the reason for participation in CR, the presence of comorbidities, BMI, age, sex, and medications taken. Results were published in the Journal of Cardiopulmonary Rehabilitation and Prevention (abstract only available for free).

    Among the findings:

    • The average age of CR patients changed from 60.8 to 64.2 over the study period—an average yearly increase of 0.23 years. The number of CR patients 65 and older grew at an average yearly rate of 0.6%, while the yearly growth rate for patients 75 and older grew by 0.4%.
    • Women, while still underrepresented, are a growing part of the CR population, and now make up 29.6% of patients, compared with 26.8% in 1996.
    • The percentage of patients considered obese (BMI of 30 or more) increased from 33.2% to 39.6%, reflecting an average yearly increase of 0.5%. While mean weight and waist circumference didn't change, researchers attribute the more steady rates to the growing number of women receiving CR, which tamped down the rise of overall averages. When waist circumference and weight were controlled for sex, both were shown to have increased significantly over time.
    • The prevalence of cardiac risk factors increased in several areas. The rate of diabetes rose from 17.3% to 21.7% of patients, while the percentage of patients with hypertension increased from 51% to 62.5%. The number of patients reporting current smoking also increased, from 6.6% to 8.4%. Both diabetes and smoking rates were about the same between men and women, but women had an 11% higher rate of hypertension.
    • The underlying reasons for receiving CR were among the most dramatic shifts noted by researchers, with the percentage of heart valve replacement patients rising from 0% to 10.6% of the overall CR population. Patients receiving CR as part of treatment for myocardial infarction also increased to 39.6% of the CR population, compared with 29.7% in 1996. At the same time, the percentage of coronary bypass patients decreased significantly, from 37.2% to 21.6%, as did angina patients (5.4% to 1.5%).
    • The use of cardiovascular medications has also increased, with the most dramatic change being in the use of statins by 98.7% of the CR population. Statin use was at 63.6% in 1996.
    • Despite its growth, authors describe CR as still "underutilized," with only 35.5% of people who survive a myocardial infarction participating.

    Authors say that the wider use of CR is fueling at least some of the changes in patient characteristics, with heart valve replacement patients having a seemingly significant impact. The valve replacement patients were, on average, 2.3 years older than other CR patient groups, with a higher percentage of women, lower obesity rates, and generally lower prevalence of cardiac risk factors. As an example of the way valve replacement patients may be shifting overall numbers, authors point out that when valve replacement patients are taken out of the total CR population, the obesity rate jumps from 39.2% to 41.2%.

    Authors acknowledge that their study is limited by its focus on a single health system with a "relatively homogeneous" population, and a less-than-comprehensive range of diagnostic categories included. They assert, however, that the changes observed over time need to continue to be monitored for future trends—and should inform current practice.

    "Given the increase in patient heterogeneity, programs could benefit from having staff with diverse skill sets and able to handle the unique needs of patients with different medical needs," they write. "The ability to individualize patient treatment plans will need to increase. Patient complexity will also differ, suggesting a potential need for increasing staffing ratios."

    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.

    30 Minutes of 'Acute' Exercise Temporarily Boosts Memory-Related Brain Activity, Strengthens Brain Over Time

    That name on the tip of your tongue might be easier to retrieve after 30 minutes of moderate-intensity exercise, according to new research that links "acute" bouts of exercise with increased activity in areas of the brain associated with a certain type of memory. Researchers believe that the postexercise spike in activity may function as a kind of workout for the brain that, over time, can increase neural efficiency and slow cognitive decline associated with aging.

    In the study, published in the Journal of the International Neuropsychological Society, researchers monitored brain activity of 26 adults between 55 and 85 years old as they were quizzed on their recognition of famous names (the "Famous Names Task," or FNT). Each adult was tested twice: once after sitting quietly for 30 minutes, and on another day after engaging in 30 minutes of moderate-level exercise on a stationary cycle.

    The computer-based FNT presents subjects with names of famous people and names of individuals randomly selected from a phone book. Test-takers press 1 key for a famous name, and a different key for a name they don't recognize as famous. For the study, participants' brain activity was monitored as well as their speed and accuracy on the FNT.

    Researchers were focused on areas of the brain associated with semantic memory, the type of memory used to access the store of knowledge humans accumulate over time. Difficulty with semantic memory—for instance, an inability to remember a name—is one of the most common complaints of older adults, and has been associated with early stages of more severe cognitive decline.

    Researchers already knew that regular physical activity can improve cognition in older adults by sparking as-yet understood neurological changes that make the brain work less hard, and that's what they expected to see happening in the brains of participants who had recently exercised. Indeed, participants did score better on the FNT after exercise; but instead of seeing a more efficiently operating brain post exercise, researchers recorded increased levels of brain activity, a kind of short-term supercharging of some of the areas they were studying.

    Authors of the study think that the increased activity is related to the use of "compensatory neural networks," the networks associated with the "cognitive reserve" observed in physically active older adults. In other words, that postexercise brain activity workout may be clearing the way for more efficient cognitive operations over time.

    "We speculate that performing a single bout of exercise elicits a short-term impact on the upregulation and expression of neurotransmitters and neural growth factors that promotes increased neural activation," authors write. "With regular participation in exercise, this process repeatedly occurs; a stress to the system followed by recovery and adaptation. This may promote a greater capacity within neural networks."

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

    CDC: Arthritis Affects 1 in 4 in US; More Emphasis on Physical Activity Needed

    The US Centers for Disease Control and Prevention's (CDC's) latest snapshot of arthritis prevalence, severity, and related physical inactivity reported in 2017 looks a lot like its previous one, based on 2015 data. As then, an estimated 1 in 4 US adults have the condition, almost 27% of whom experience severe joint pain. Making matters worse, says CDC, of those with arthritis, around a third report that they don't engage in any physical activity, the very thing that "can improve physical functioning in adults with joint conditions."

    The latest report is based on a nationwide survey conducted in 2017 in which 435,331 adults across the country responded to questions related to whether they have been diagnosed with arthritis, rheumatoid arthritis (RA), lupus, gout, or fibromyalgia; the severity of pain they experienced during the past 30 days; and their participation in any PA (other than PA associated with their jobs) over the past month. Researchers then compared these data with respondent demographics, including geographic areas, to get a picture of how arthritis is affecting the country.

    The findings point to a position long-supported by APTA: increased PA among individuals with arthritis can have a marked impact on reducing pain severity and increasing function. The association offers resources on encouraging healthy, active lifestyles at APTA's Prevention, Wellness, and Disease Management webpage as well as information on arthritis management through community programs. Members also can dive deeper into the issues by joining APTA's Council on Prevention, Health Promotion, and Wellness in Physical Therapy. Patient-focused resources are available through APTA's MoveForwardPT.com website; additionally the Osteoarthritis Action Alliance offers a free booklet to help consumers participate in its "Walk With Ease" program.

    Among the findings of the CDC study:

    Overall rates of arthritis remain about the same as they were in 2015—and follow the same geographic trends.
    The latest study revealed an estimated 54.4 million US adults have diagnosed arthritis—about 1 in 4 Americans. Of those, about 27% report experiencing severe joint pain. From a geographic perspective, prevalence and pain severity varies by state but are worse in Appalachia and the Lower Mississippi Valley. Prevalence ranges from a low of 15.7% in Washington, DC, to 34.6% in West Virginia, with severe joint pain rates varying from a low of 30.3% in Colorado to 45.2% in Mississippi.

    The prevalence of arthritis increased with age and was higher for some demographic groups, including women.
    Among adults aged 18-44, 8.1% reported being told they had arthritis, RA, lupus, gout, or fibromyalgia. That rate climbed to 50.4% among adults 65 and older. More women than men reported having arthritis (25.4% vs 19.1%), as did adults with obesity compared with healthy weight or underweight adults (30.4% vs. 17.9%). Among ethnic groups, non-Hispanic American Indian/Alaska Natives reported a 29.7% prevalence, while other groups reported rates ranging from 12.8% to 25.5%. Hispanic and non-Hispanic Asians reported the lowest arthritis prevalence among ethnic groups.

    About 1 in 3 respondents with arthritis reported severe joint pain, but that rate declined with age.
    Overall, the rates of "no/mild," "moderate," and "severe" joint pain reported was 36.2%, 33%, and 30.8%, respectively. Among respondents who reported severe joint pain, the rates dropped from 33% of those 18-44 to 25.1% among adults 65 and older.

    Higher rates of severe joint pain were associated with education, socioeconomic status, and sexual orientation, among other characteristics.
    Age-standardized severe joint pain was reported at rates above 40% for respondents who had less than a high school diploma (54.1%) and respondents living at or below 125% of the poverty level (51.6%). Among other demographic groupings, severe joint pain prevalence above 40% was recorded for non-Hispanic blacks (50.9%), retired persons (45.8%), Hispanics (42%), non-Hispanic American Indians/Alaskan Natives (42%), and individuals identifying as lesbian/gay/bisexual/queer/questioning (40.7%, but reported in only 27 states). Two-thirds of those reporting arthritis and identified as unable to work or disabled reported severe pain.

    PA inactivity prevalence varied by socioeconomic factors, too, and included a geographic element.
    Overall, physical inactivity increased with reported pain levels, from an inactivity rate of 22% among those with no/mild pain to a 47% inactivity rate for those reporting severe pain. Groups whose rates of reporting little or no PA in the past month were above 40% included respondents with less than a high school diploma (46.4%) and those at or below 125% of the poverty level (42.6%). Overall inactivity rates also increased as rurality increased, ranging from a 30.7% rate in large metro centers to 38.7% in noncore rural areas.

    In its discussion of the findings, CDC focuses much of its attention on PA levels and engages in a kind of collective head-scratch as to why more Americans aren't pursuing "an inexpensive intervention that can reduce pain, prevent or delay disability and limitations, and improve mental health, physical functioning, and quality of life with few adverse effects."

    "Arthritis-appropriate, evidence-based, self-management programs and low-impact, group aerobic, or multicomponent physical activity programs are designed to safely increase physical activity in persons with arthritis," the CDC states in the report. "These programs are available nationwide and are especially important for those populations that might have limited access to health care, medications, and surgical interventions."

    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.

    From PT in Motion Magazine: 50 Years of PTAs

    Turns out 1969 wasn't all Woodstock and moonwalks: the year was also an important date for what has become a crucial part of the physical therapy profession—the physical therapist assistant (PTA).

    This year marks the 50th anniversary of the first graduates of PTA education programs. To honor that milestone, PT in Motion magazine offers a history of the PTA that highlights the challenges, struggles, and ultimate victories that have shaped an increasingly important career pathway.

    The article explores the evolution of the PTA concept, from the first discussions of a possible need for the designation in the early 1960s to its current status as a licensed profession. Along the way, author Michele Wojciechowski shares the efforts of PTAs to have a voice at the APTA table, strengthen and refine PTA education programs, and flex their advocacy muscle. The bottom line: it's been 1 giant leap for PTA-kind.

    "Celebrating a Milestone: 50 Years of PTAs" is featured in the May issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them 1 of the benefits of belonging to APTA. Also open to all: "Rewiring the Brain to Ease Chronic Pain," a look at how PTs are helping to lead the way in new strategies for treating pain.

    Study of Health System Reveals Good Functional Outcomes for Patients in Bundled Care Model

    Bundled care models for total joint arthroplasty (TJA) may be popular with payers and policy makers, but do they work for patients? A new study says yes.

    Researchers arrived at their conclusion after tracking TJA episodes in the University of Utah health care system during its switch from a more traditional approach to Medicare's Bundled Payment Care Improvement (BCPI) model 2. Similar to other bundled care models, the BPCI reimburses providers a set amount for an entire episode of care, from admission to 90 days after the patient is discharged, rather than for specific services provided during care.

    The before-and-after pictures focus on functional recovery, based on data from 680 prebundle and 1,216 postbundle patients gathered between 2014 and 2016 (the health system launched the BCPI in July 2015). Researchers used the Activity Measure for Post Acute Care (AMPAC) mobility assessment and the PROMIS Physical Function Computer Adaptive Test (PF-CAT) to track function outcomes. The AMPAC was used at various points during the hospital stay, and the PF-CAT tracked function presurgery and then 2 weeks, 6 weeks, and 12 months afterwards. Results were published in Arthroplasty Today.

    APTA members Joshua Johnson, PT, DPT, ATC; Caitlin Miller, PT, DPT; Julie Fritz, PT, PhD, FAPTA; and Robin Marcus PT, PhD, were among the study’s authors. Johnson is a recipient of the 2015 Florence P. Kendall Doctoral Scholarship and a 2017 Promotion of Doctoral Studies I Scholarship from the Foundation for Physical Therapy Research, both of which were used to support the study in part. APTA also provided partial funding for the study.

    Limited to elective procedures only, the study included 1,666 patients associated with 1,896 TJA episodes. The majority of TJA procedures were for knee replacement (57.9%). Patients had an average age of 62, and most were women (57.3%). Here's what researchers found:

    • Postoperative mobility measured through the AMPAC was slightly better for the postbundle group, but not significantly so—and only at day 0. By days 1 and 2, there were no differences in average AMPAC scores.
    • The PF-CAT also uncovered no significant differences between the pre- and postbundle groups at 12 months or any earlier points.
    • The postbundle group averaged slightly shorter hospital stays than the prebundle group, with an average stay of 2.1 days compared with the prebundle group's average of 2.3 days.
    • Bundled care was associated with decreased odds of patients being discharged to a postacute care (PAC) facility: in the study, 10.9% of the postbundle patients were discharged to a PAC, compared with 26.9% of the prebundle group.

    "The big takeaway here is that, at least in the health system in this study, we see that joint replacement bundles achieve patient outcomes that are similar to nonbundled systems, and that's good news," said Heather Smith, PT, MPH, APTA director of quality. "The whole basis of the shift to bundled payment models is to control and decrease costs while still achieving good outcomes, and that's what seems to have happened here."

    Smith acknowledges that part of the study's positive results may be due to overall changes made to TJA care in the year prior to the system's switchover to a bundle model—changes that included adding a swing shift for inpatient physical therapy staff to ensure earlier ambulation postsurgery, as well as greater emphasis on patient education and increased crossdisciplinary work. But she sees this as more good news for bundled care models.

    "The changes the system made to its care pathways are part of the success of this study, but the important point is that the bundled model could absorb them," Smith said. "These kinds of redesigns applied to value-based models represent some real opportunities for physical therapy to become an even more important component of care."

    The results are encouraging for another reason: bundled care is probably here to stay. While voluntary Medicare models such as the BCPI have been around for years, a mandatory Medicare bundle program, known as the Comprehensive Care for Joint Replacement (CJR) was introduced in 2016 and affected some 800 hospitals in 67 geographic areas. The program has been scaled back since then and now applies to about 450 hospitals in 34 geographic areas, but the US Centers for Medicare and Medicaid Services (CMS) doesn't seem poised to dismantle the program—particularly if data show decreased costs and better patient outcomes.

    "CMS may have tapped the brakes on its move toward bundled care in 2017, but it's still moving and focused on shifting to value-based payment models," Smith said. "And if more studies emerge like this one showing that patient outcomes are unaffected by the change, that focus will likely increase."

    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.

    Time to Standardize Acute Care Rehab for Patients Poststroke, Say Researchers

    Not all rehabilitation is equal for acute care hospital patients with ischemic stroke, say researchers in an article published in the May issue of PTJ(Physical Therapy). Authors found “significant variation” in the use of hospital-based rehabilitation services that “suggest a timely opportunity to standardize rehabilitation service delivery in acute settings for patients with ischemic stroke.”

    While current guidelines recommend early mobilization during hospitalization for ischemic stroke, authors write, they do not “provide clear recommendations on the optimal dosage of therapy.” This, combined with no incentive for hospitals to report on functional status to the US Centers for Medicare and Medicaid Services (CMS), led researchers to examine Medicare claims data from 104,295 patients in 2010 to identify what factors were associated with the type and amount of rehabilitation services patients received while in acute care settings.

    Overall, authors found that only 85.2% received any rehabilitation services: 61.5% received both physical and occupational therapy; 22% received only physical therapy; and 1.7% received only occupational therapy.

    Patients were more likely to receive any type of rehabilitation services if they were older than 70 years of age, had longer lengths of stay, or had received tissue plasminogen activator (tPA).

    However, patients were 16% less likely to receive rehabilitation services if they were dual-eligible for both Medicare and Medicaid, and 11% less likely if they had a recent prior history of hospitalization. Men also were less likely to receive therapy, and patients with more severe stroke—who required an ICU stay or feeding tube—were significantly less likely to receive rehabilitation services.

    There also was variation in the number of minutes of therapy patients received. While patients received an average of 123 minutes of therapy over 4.8 days, authors write, “dual-eligible patients received 5 minutes less therapy compared with non–dual-eligible patients, and patients receiving tPA received 16 more minutes of therapy.” Patients with a feeding tube received 5 more minutes of therapy than those without, on average. [Editor's note: APTA's PTNow online resource offers a clinical summary on stroke as well as guidelines on interventions to address neuroplasticity.]

    In addition, certain hospital characteristics played a role: Rural hospitals, hospitals with a higher volume of patients with stroke, and hospitals with an inpatient rehabilitation unit were linked to a higher likelihood of receiving rehabilitation services. Patients who received rehabilitation services in a limited teaching hospital or nonteaching hospital received an average 19 and 20 more minutes of therapy, respectively.

    Authors found substantial variability in use of rehabilitation services across acute care hospitals, even after accounting for length of stay and other patient and hospital-level factors. Approximately 38% of hospitals provided significantly less (76.3 minutes during the whole length of stay) than the national average of rehabilitation services minutes (123 minutes), whereas 22.4% provided significantly more (180.7 minutes) than the national average. Authors suggest a number of factors contributing to this variation, including a “lack of clear guidance on rehabilitation timing and dosage in the acute care setting” and a hospital reimbursement structure that encourages cost savings by decreasing length of stay and rehabilitation services.

    However, hospitals with inpatient rehabilitation units were more likely to deliver rehabilitation services to these patients, possibly because they are specialized in providing comprehensive care, and therapists “can be proponents of providing upstream rehabilitation interventions to improve downstream outcomes.”

    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: 54% of Middle-Income Seniors Won't be Able to Afford Assisted Living Costs, Medical Expenses in 10 Years

    Authors of a new study say that as the wave of aging baby boomers advances, the middle-income elderly population could find itself in a particularly problematic situation—at least when it comes to finding housing that can accommodate declining mobility and increased care needs. By researchers' estimates, in as few as 10 years, over half of middle-income adults 75 and older, too affluent to qualify for Medicaid assistance, won't be able to afford many of the private seniors' housing options available today.

    The study, appearing in Health Affairs, looked at the current population of adults 75 and older in terms of population, demographics, and income status, and compared those data with projections for 2029. Authors then extended trends for health and mobility limitations to create a glimpse into what the housing landscape could be like in a decade. The results aren't encouraging for middle-class seniors, defined as those 75 and older with annuitized financial resources of between $25,000 and $74,298 in 2014 dollars.

    Among the findings:

    The senior population will increase dramatically, with middle-income seniors outpacing the high- and low-income group.
    The population of individuals 75 and older is expected to balloon from an estimated 20 million in 2014 to 33.5 million in 2029—a 68% increase. Of those 33.5 million, 43% will be seniors at the middle-income level, approximately 14.4 million people. The number of middle-income seniors ages 75-84 will nearly double, from 5.57 million in 2014 to 10.81 million in 2029. By that point, middle-income seniors will constitute the largest segment of the 75-and-older population.

    1 in 5 middle-income seniors will have 3 or more chronic conditions and 1 or more limitations in activities of daily living (ADL) by 2029—and 60% will have mobility limitations that could prevent them from living independently.
    If current prevalence levels continue, 20% of middle-income seniors will classify as "high needs," and 3 in 5 will have significant mobility limitations—factors that increase the chances that they will require more assistance in living arrangements. Additionally, an estimated 6% of middle-income seniors 75-84, and 15% of those 85 and older, are expected to have cognitive impairments.

    An estimated 54% of middle-income seniors won't have enough annual financial resources to pay for average assisted living costs and medical expenses—and that's a best-case scenario.
    Researchers say that in 2014 dollars, the annual average cost for assisted living rent and "estimated medical out-of-pocket spending" is about $62,000. Only 46% of the middle-income population will have that much available to them. The percentage drops even further among middle-income seniors who lack equity in housing, where only 19% are anticipated to have enough money to pay for average costs.

    "This confluence of factors creates a significant unmet future need, which demands new housing and care solutions to support the emerging generation of America's seniors," authors write, suggesting that responses need to come from both the public and private sectors. And those responses need to take a 2-pronged approach, by lowering the cost of assisted living and making it easier for seniors to continue living in their own homes for as long as possible.

    Researchers say that in the private sector, technology improvements could make a difference by increasing staff efficiency and thereby reducing costs, as could systems that "more formally involve family caregivers, outside volunteers, and healthier residents" in providing care, and those that offer "a la carte" care models. Authors also suggest that the private sector could respond to the coming gap by dialing back expectations for return on investments by, among other things, "charging less rent and reducing profit margins." Some of that sacrifice, they add, could be buffered through tax incentives

    In the public sector, authors suggest raising eligibility limits for housing assistance, providing subsidies and voucher programs, and encouraging "housing communities with sufficient capacity to establish their own Medicare Advantage plan." They also contemplate wider use of a 2019 change to Medicare Advantage that allows administrators to offer supplemental benefits to cover nonmedical services, including in-home modifications.

    Authors add that Medicaid could also play a role by "broadening eligibility and expanding coverage to home and community-based services for beneficiaries with higher incomes and less acute health needs." Doing so, they write, may "forestall health and functional deterioration and keep seniors in noninstitutional settings longer, when preferred."

    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.