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  • From the 2018 House of Delegates: Envisioning a Community

    If there was a single takeaway from the 74th gathering of the APTA House of Delegates (House), it's this: the House is working cohesively to see to it that as APTA approaches its centennial, the association continues to embrace its #BetterTogether ideal and lives out its commitment to making bold moves.

    Backed by a new mission statement rooted in community-building, the House took actions that point to the kind of community the association will build—one that's inclusive, collaborative, compassionate, and unafraid to take on issues that would impact pursuit of APTA's transformative vision. The actions taken by the House make it clear: for the foreseeable future, APTA will be an outward-facing organization that understands its capacity to be a change agent.

    Notable motions adopted by the House touched on the following topics:

    Sexual harassment
    In a unanimous vote, the House strengthened APTA’s position on sexual harassment in all forms, encouraging incidents of harassment to be reported, with permission of the affected individual, to that ensure others are not similarly harmed. Debate on the motion was marked by several delegates sharing their own experiences with sexual harassment.

    Person-centered services
    A resolution adopted by the House positions APTA squarely in opposition to policies that would permit a provider to deny services to a patient based on a provider's religious or personal objections to the patient that may be based on the patient’s age, gender, nationality, religion, ethnicity, socioeconomic status, sexual orientation, health condition, or disability.

    Essential health benefits
    The House adopted an APTA position that establishes the association's commitment to a specific set of comprehensive services it believes should be included in all insurance plans available to an individual across the lifespan and without limitations based on preexisting conditions.

    Elimination of the improvement standard
    The House charged the association with developing a long-term plan to pursue the elimination of the improvement standard—the idea that services are payable only if they result in the improvement of a patient's condition—in all settings and payment situations. The concept, debunked in Medicare thanks to the Jimmo v Sibelius settlement agreement, is used widely in other payment models.

    Physical therapist service delivery
    In a charge aimed at recognizing that physical therapists often provide person-centered services that are outside of the traditional episode of care model, the House directed APTA to explore revisions to the Standards of Practice for Physical Therapy that embrace concepts of long-term, lifetime, and ongoing relationships with patients.

    Professional well-being
    The House charged the association with developing a strategy to address issues that affect the overall well-being and resilience of PTs, physical therapist assistants (PTAs), and physical therapy students.

    The role of PTs and PTAs in disaster management
    The House directed the association to better define the role of PTs and PTAs in disaster preparation, relief, and recovery, and to promote this role to key stakeholders.

    Many other actions taken by the House were part of a 2-year effort to comb through all existing APTA House documents to bring them up-to-date, incorporate them into similar documents, or eliminate them. Topics addressed included durable medical equipment, clinical education, collaborative relationships with veterinarians, PTA supervision, mentoring, and pro-bono services.

    APTA members can view videos of the 2018 House of Delegates online once the archive is posted later this week. Final language for all actions taken by the House will be available by September after the minutes have been approved.

    What's New at MoveForwardPT.com, Summer 2018

    APTA's consumer information website, MoveForwardPT.com, is a continually expanding resource where patients can learn about the many conditions and patient populations physical therapists (PTs) treat. The site includes everything from condition-based guides, podcasts, tip sheets, and videos, to the popular and "Find a PT" tool that allows patients to locate a member PT in their area. It's also home to APTA's national award-winning #ChoosePT opioid awareness campaign and toolkit.

    Bottom line: MoveForwardPT.com is always evolving, and a great resource for members to share with patients and others to help increase public understanding of all that the profession has to offer.

    Here are some recent additions to the site:

    Move Forward Radio podcasts

    Lifecycle of the Pediatric ACL Injury
    Neeraj Baheti, PT, DPT, is a board-certified clinical specialist in sports physical therapy and a board-certified clinical specialist in orthopaedic physical therapy. In this episode he discusses who is more predisposed to these injuries and what they can expect in terms of recovery.

    Bowel Health: What You Should Know
    Jenn Davia, PT, DPT, is a board-certified clinical specialist in women’s health and director of education for the Section on Women’s Health. In this episode, she takes on the topics of bowel health, including breaking bad habits, importance of proper positioning, and tips to achieve o bowel health.

    Tai Chi and Physical Therapy
    Kristi Hallisy, PT, DSc, board-certified orthopaedic clinical specialist, reveals how she incorporates tai chi into clinical practice and outlines how its vast benefits help herself and her patients.

    Once a Physical Therapist, a Young Woman Navigates New Life With Quadriplegia
    Elizabeth Forst, PT, DPT, was in her early 30s,working as a traveling physical therapist, when the simple act of diving into a pool changed her life forever.

    Washington Spirit’s Joanna Lohman Reflects on her “ACL Journey”
    The Washington Spirit midfielder reflects on the physical, mental, and emotional aspects of her rigorous ACL recovery.

    Combat Athletes and Physical Therapy
    Former amateur and professional combat athlete and current instructor Kirstin Schmidt discusses the injuries she endured during her career, and how physical therapy not only kept her fighting, but became 1 of her tools to staying healthy. Her physical therapist, Jessica Probst, PT, who participates in combat sports and treats combat athletes joins the episode.

    Tips

    5 Tips for Creating Good Habits While Toilet Training Your Child

    6 Sports for People with Parkinson Disease

    5 Exercises to Reduce Knee Pain

    What is Pitcher’s Elbow?

    Did You Know?

    New Research Shows: Physical Therapy First for Low Back Pain Curbs Opioid Prescriptions and Lowers Costs

    New and Updated Condition-Based Guides

    Cuboid Syndrome New

    Female Athlete Triad

    Hamstring Injuries

    Hyperkyphosis

    Multiple Sclerosis

    Osteoporosis

    Pain

    Snapping Hip Syndrome

    2018 NEXT: Movement System Finding Its Way Into Education and Research

    As far as Paula Ludewig, PT, DPT, PhD, is concerned, the idea of anchoring physical therapy's identity in the movement system is, to put it simply, a big deal. "This is a huge opportunity for our profession," said the University of Minnesota professor and researcher. "We're at the doorstep of making significant change."

    The question is, just how does the profession get the door open?

    That was the idea at the heart of a presentation on incorporating the movement system into curriculum and research offered at APTA's 2018 NEXT Conference and Exposition in Orlando. Presenters offered 3 distinct perspectives: one from a physical therapist education program that has been infusing movement system concepts into its curriculum and other programs for years, one from a program that more recently accomplished what might be called a retrofit of its curriculum to create stronger links to the system, and one from a researcher and teacher who recounted her own transition away from the "pathoanatomic" perspective. The common thread: embracing the movement system concept can lead to stronger education programs, more useful research, and more effective practice.

    In her presentation on the longstanding incorporation of movement system concepts at Washington University in St Louis (WUSTL), professor Gammon Earhart, PT, PhD, outlined an approach that is now "the seat of everything we do in our department," informing not just education, but research and practice.

    According to Earhart, the first practical application of movement system concepts at WUSTL began with continuing education offerings. From there the concept expanded to residencies and fellowships, and finally worked its way into entry-level DPT training. Movement system concepts are now a part of every course offered in the program, she said.

    Likewise, the university's research efforts underwent a shift toward a more integrated system, resulting in the Department of Physical Therapy's Movement Science Research Center, a centralized facility that allows multiple disciplines to take a team approach to research.

    Eventually, the ripple effect touched the program's practice-related activities, making movement "the primary outcome and primary intervention," Earhart said. For example, patients who presented with back pain were offered another avenue of treatment: rather than focusing solely on exercises aimed at addressing a condition, PTs worked with patients to modify the ways they move in their everyday activities, such as loading a dishwasher or moving a vacuum cleaner.

    Sara Scholltes, PT, PhD, FAPTA, is a graduate of the Washington program and well-versed in the movement system approach, but she found herself teaching at the University of Montana's physical therapy program—which wasn't. Faculty in the program agreed that the school's curriculum needed to make a change, but where to start?

    In the end, it boiled down to tearing down silos, Scholtes said. Rather than structuring curriculum around isolated coursework (first semester, basic sciences; second semester, more of the same; second and third years, subjects seemingly cut off from each other), faculty began thinking about how movement system concepts and critical reasoning skills could be infused throughout the program. Classes were structured in ways that incorporated knowledge gained in other classes—and instructors were free to evaluate that combined knowledge. "The question 'is this exam cumulative?' didn't really matter anymore, because everything is cumulative," Scholtes said.

    For Ludewig, the transition to a movement system approach was personal. As a researcher focused on shoulder issues, Ludewig was driven by what she described as a pathoanatomic approach—"first I get the diagnosis, then I look at the impairment."

    The problem with this approach, Ludewig pointed out, is that it doesn't square with reality: patients don't present in homogenous groups that are cleanly identified within certain diagnostic buckets. They do present with various movement impairments that may share similar characteristics. Those perspectives make a difference. "When you address it from the pathoanatomic perspective, approaches [and] clinical reasoning are all over the place," Ludewig said.

    Instead, Ludewig began looking at impairment first, getting a bead on how patients were moving and associating those movement patterns with hypermobility, hypomobility, or what she termed "aberrant motion." It's a concept anchored in the movement system, and though use of the concept hasn't fully caught on at her school, Ludewig sees a transition happening, calling the shift a "work in progress."

    "We still care about pathoanatomy," Ludewig said. "But it's further down the food chain in how we think about it."

    2018 NEXT: McMillan Lecture: Wisdom and Courage Exemplify the Best of Our Profession

    McMillan Lecturer: Laurita Hack

    Both wisdom and courage are needed to effect positive change. Laurita M. (Laurie) Hack, PT, DPT, PhD, MBA, FAPTA, opened her delivery of the 49th Mary McMillan Lecture with these thoughts and with her insights into gaining more of the wisdom and courage that will move the profession forward. Hack addressed a capacity crowd on June 28 during APTA's NEXT Conference and Exposition. Beginning with a discussion of wisdom, Hack observed that it starts with knowledge but also must include good judgment to apply that knowledge. Best judgment doesn't always occur, she said, because of the way clinicians may frame or process information, especially in situations of uncertainty. But because judgment is paired with action, best judgment is imperative. "We have patients in front of us," Hack noted, "and we need to do something."

    How, then, do we improve our decision making? Hack said the literature on evidence provides a framework, reminding the audience of the 3 aspects of evidence-based practice (EBP): appraisal of the literature, decision making, and consideration of the patient's preferences.

    As for appraising the literature, Hack outlined 3 steps. First, she said "we need research we can trust." To maintain strong standards of publication, scholarly journals need the freedom to publish based on unbiased peer review, "not limited by inadequate resources or constrained by political influences." Hack suggested collaboration among journals—such as the 12 peer-reviewed journals published by APTA and its components—to combine financial and contributor resources to produce models for publication that reduce inefficiencies. Second, she said "we need research we can use," as patient care can't be suspended to wait on years-long research agendas. Hack suggested more emphasis on translational research and more access to research sources such as APTA's PTNow online clinician portal. Third, she said "we need to know how to use the research." For PTs, this doesn't mean PTs must understand research design and statistical analysis, she said. Instead, returning to reliable research, she said, "teaching clinicians how to recognize journals that can be trusted is more important than remembering which t-test should be used." When clinicians can trust in the literature they're reading, they can and should instead "focus on determining the generalizability of work to their patients." In discussing the second aspect of EBP—decision making—Hack identified biases that interfere with good decisions, such as outcome bias, selective recall, and selective exposure. Outcome bias is the assumption that when an outcome is negative, the process was poor; and when an outcome is positive, the process was good. Such bias "denies reality," she said, "since most biological events have some level of uncertainty." Selective recall is the tendency to unconsciously remember only certain information because it's perhaps more recent, more dramatic, or more personal—or confirms what someone already believes. Hack gave an example of a PT favoring a certain technique and being susceptible to recalling cases in which it decreased pain more often than recalling cases in which it didn't.

    Finally, selective exposure, Hack explained, describes tendencies to seek out people and resources that mirror one's own opinions and thus don't provide other perspectives, such as discussing a potential intervention with only like-minded clinicians or reviewing only research from journals and authors known to support a particular approach.

    To counterbalance biases, Hack suggested that clinicians seek a variety of viewpoints and resources, and "bring good data into our practices." One way to accomplish this, she continued, is to use evidence-based algorithms, which "consistently outperform human decision making." However, Hack noted that clinicians may be right to have reservations about embracing algorithms, given that so many clinical practice guidelines state that their evidence is poor or weak. "We need more and better data about lots more patients," she said. Fortunately, Hack said there is potential to accumulate this type of data through APTA's Physical Therapy Outcomes Registry, which will make data available for detailed analysis to describe patterns of practice, variations of those patterns, and associated outcomes. Hack noted that the Registry can move the profession past thinking about 1 patient at a time toward thinking about populations, which she called an essential move to "ensuring the role of physical therapy in the future and one that allows us to meet our vision of transforming society."

    McMillan Lecturer: Laurita Hack

    In discussing the third aspect of EBP—patient values—Hack cited the Code of Ethics for the Physical Therapist and the Vision Statement for the Profession as "powerful guides" to the standards clinicians must uphold in interactions with patients, clients, and colleagues.

    "Meeting these standards may take courage," she said, moving to her second exemplar of the profession. Hack borrowed from Glaser's 3 ethical realms to frame her thoughts on courage: individual, institutional, and societal. As individuals, excellent PTs exhibit courage when they use good evidence to make changes in practice, even when colleagues around them do not. It takes courage to resist temptations "to do things faster…to do more of the things that generate more income whether they are needed or not, to do…whatever seems more economically advantageous," she said.

    At the institutional level, lines between for-profit and not-for-profit facilities are blurring—as is the potential for profit from referral as the need for referral has disappeared. "We need to think differently about institutions," Hack said. Instead of categorizing institutions, we should be identifying the features necessary to ensure that clinicians provide appropriate care, such as the ability to make decisions without undue influence, collaborative leadership to enable all to contribute to decisions, and increased interprofessional practice.

    Turning finally to society, Hack noted that it is prominent in the APTA Vision for the Profession, "but we're slow to recognize that helping each person is excellent but not sufficient." To fulfill the vision promise of transforming society, Hack offered several recommendations:

    • Addressing social determinants of health
    • Engaging in social issues that reduce health inequities
    • Building a diverse workforce
    • Collaborating with patients, clients, colleagues, and communities
    • Empowering APTA to define the profession's moral agency beyond the patient level

    On the last point, Hack was optimistic. "We recently have seen willingness to show courage to act as moral agents on behalf of society," she said. One indication is a shift from "groupthink"—with its negative connotation of allowing biases to take hold that result in poor decisions—with "the wisdom of crowds" that uses "collaborative leadership and distributed power to collect broad and diverse input that instead can reduce the likelihood of these biases."

     

     

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    2018 NEXT: Making the Case for the PT and PTA Role in Disaster and Emergency Responses

    A panel of 4 physical therapists (PTs) with firsthand experience in responding to Hurricane Harvey, the Orlando Pulse mass shooting, the Great White concert fire, and other emergencies agree: PTs and physical therapist assistants (PTAs) have an important role to play in responding to these situations. The problem, they say, is that not everyone fully understands that role—including many PTs and PTAs.

    The panelists shared their perspectives at the APTA NEXT Conference and Exposition in Orlando, Florida, during a session that allowed each to tell their own story and share lessons learned. Though the details and circumstances differed, what emerged was a consensus thatfacilities and programs responding to emergencies often aren't prepared to put PTs and PTAs to best use, leaving therapists little choice but to take the reins wherever they can.

    Jessica West, PT, DPT, was thrust into emergency response when Hurricane Harvey devastated the Houston area in 2017. Just 2 years out of PT school, "I was truly going off my education," she said.

    She felt prepared to help, but unfortunately many in charge of the emergency response weren't prepared for her offer. "It was frustrating—they were relocating people to a conference center designed to hold 5,000 that was now holding 10,000 people," West said. "At the same time they were turning away therapists [who wanted to help]."

    When West was finally able to join providers onsite, she found a host of situations that were suited to responses from a PT—wound care, functional needs, basic screenings, and more. In her particular situation, West found that an obvious role for a PT would be to help temporary shelters better understand how to set up beds and other components in ways that account for the varying mobility needs of those being sheltered. "They should've had someone like me, like you, telling them how to set up a facility," West said.

    Erin Jones, PT, DPT, encountered a different situation when her hospital found itself taking in victims of the Pulse nightclub shooting that took place in Orlando in 2016. Although she didn't have much training in emergency management, she had experience in critical care—and, thankfully, her hospital had just finished a "massive" multifacility drill that tested responses to a campus shooter scenario.

    As did other panelists, Jones stressed the importance of drills of all kinds. "Prepare to know your role," Jones advised, adding that the preparation should include more than just a solid understanding of duties. Providers also need to prepare emotionally, particularly for the sudden, unexpected emergencies such as mass shootings. "These events can be emotionally draining," Jones said.

    As a PT with experience working with the Red Cross in Arizona, Gail Zitterkopf, PT, DPT, felt fairly well-versed in the workings of emergency response efforts. What she wasn't prepared for, after she moved to Texas, was being told when she showed up to join response efforts for Harvey to "go open up the Houston Astrodome" as a temporary shelter.

    Like West, Zitterkopf sees PTs and PTAs as eminently valuable components of an emergency response team. One example: the PT's understanding of the relationship between fatigue, body mechanics, and the potential for injuries. Victims of disaster need to be evaluated for their risk of experiencing further injury due to the impact of fatigue on their mobility, and that could be a crucial role for the PT, she said.

    Zitterkopf also echoed West's opinion that her PT training "well-prepared" her for a role in emergency response efforts. The problem is that the response system itself can be hamstrung by its own logistical inefficiencies—lack of coordination among multiple agencies, technical shortcomings, and provider transportation plans that don't always connect the provider with the closest facility. Then, of course, there are the even-more-basic things: "Often, volunteer registration websites do not provide PT or PTA options among its list of providers," she said.

    Jamie Dyson, PT, DPT, president of the APTA Florida Chapter, added to the discussion by describing his involvement in responding to natural disasters and other emergencies. Over the course of these events—not only responses to Florida hurricanes but also to victims of the Great White concert fire at a Rhode Island nightclub in 2003—Dyson said he has learned that "we have a lot of education that we need to do, both inward and outward."

    The challenge, according the Dyson, isn't just making the case to those in charge of emergency response programs—it's also about informing those within the physical therapy profession that they have a role to play and then getting them to take action.

    "Let's say someone wants to contact PTs to help in response to a disaster. That's great! But who do you call? We are not organized," Dyson said. "If we want to sit at the big table with health care, we have to put our big boy pants on and show what we can do."

    Panelists agreed that a directive adopted by the APTA House of Delegates just a day before their presentation could make a difference. The charge directs the association to work with other organizations and stakeholders to better define the role of PTs and PTAs in disaster relief and recovery, and to promote this role throughout the profession. "There's so much to learn about, and I'm really excited about what APTA will be able to do," West said.

    However, he added, with more disasters in the near future a near certainty, PTs and PTAs shouldn't wait for instructions from the association. "I want to encourage everyone to get out there and try," she said.

    2018 NEXT: 'You're Changing People's Lives' NEXT 2018 Attendees Told

    Professional beach volleyball player Gabrielle (Gabby) Reece told attendees at the opening event of NEXT 2018: "To serve others and help other people is a really important thing. You're changing people's lives."

    2018 - 06 - 28 - Gabby NEXT

    Although she didn't take up volleyball until 11th grade, Reece won an athletic scholarship to Florida State University, where she majored in communications and played volleyball. While there, she says, she developed sciatica. "They said I needed back surgery. That was a pretty serious situation. I went instead to a therapist and was able to play again" she said, explaining her growing appreciation of physical therapy. From that point, she continues, "I'd go to a physician and ask for physical therapy. That kept me going. Even then, I knew what a tool your craft is."

    Reece thanked her physical therapists (PTs) for the quality of attention and care she received. "I was always looked at as an individual person, not treated with a ‘cookie cutter' approach," she said. "In return, I was a very compliant patient because I knew their advice was designed specifically for me."

    As a professional volleyball player, Reece and her 4-person team took first place at the first-ever Beach Volleyball World Championships. She also competed domestically in the 1999-2000 Olympic Challenge Series. Reece was a contributing editor for Yahoo Health and has hosted "Insider Training" on the Fit TV/Discovery channel.

    A recent experience led her to offer the NEXT 2018 attendees another suggestion: "Two years ago, I finally had a knee replacement. I knew I had a lot of life left, so I was compliant. I forced the change, invited the change. You don't realize how powerful it is telling patients, ‘You'll get there.' That alone is powerful. Therapy got me back to my previous level."

    One action she didn't take, however, was using opioids for the pain. In addition to the danger of opioid medication, Reece explained, "I knew it would delay my recovery. The pain is there for a reason. The body is ready to figure out a way to health, and physical therapists help with that."

    2018 - 06 - 28 - Opening Sharon

    She also spoke about the importance of good nutrition and exercise, and offered this suggestion to people who might not regularly exercise or eat good food. "It's a lifestyle. I've created a system in which I can be successful. It's not about wanting to exercise every day," she said. Earlier in the evening, APTA President Sharon Dunn, PT, PhD, had spoken on the importance of building communities. Reece echoed this point when discussing a lifestyle to stay healthy, saying the key is "about finding your community."

    She concluded, "I'm inspired by you and take my hat off to you. It's a really honorable profession."

    Dunn, in her earlier remarks, also addressed the subject of change. She said, "There are so many opportunities in change…and I'm so excited where physical therapy fits in. It's the answer to a broken health care system. We're at a very pivotal point. We're thrilled with the alignment [of the many health care issues]. It's fun to be here right now."

    CMS Seeking Comments on Self-Referral Prohibitions in Stark Law

    In its ongoing efforts to decrease regulatory burdens, the US Centers for Medicare and Medicaid Services (CMS) has turned its attention to a law that, with the exception of physical therapy and a few other treatments and procedures, bars physicians from referring patients to services in which the physician has a financial interest. The CMS call for feedback—an effort largely focused on how the law might be loosened up—comes at a time when APTA and other organizations are voicing support for a bill that would do nearly the opposite by eliminating the exemptions allowing for self-referral for physical therapy and other services.

    The CMS Request for Information (RFI) is part of an initiative dubbed the "Regulatory Sprint to Coordinated Care." According to CMS, the focus of the initiative is on "identifying regulatory requirements or prohibitions that may act as barriers to coordinated care, assessing whether those regulatory provisions are unnecessary obstacles to coordinated care, and issuing guidance or revising regulations to address such obstacles and, as appropriate, encouraging and incentivizing coordinated care."

    According to the RFI, CMS is setting its sights on the Stark Law because of its potential to bump up against new models of care delivery by seemingly prohibiting systems that could be interpreted as forms of self-referral.

    "CMS is aware of the effect the physician self-referral law may have on parties participating or considering participation in integrated delivery models, alternative payment models, and arrangements to incent improvements in outcomes and reductions in cost," CMS states. "We are particularly interested in your thoughts on issues that include, but are not limited to, the structure of arrangements between parties that participate in alternative payment models or other novel financial arrangements, the need for revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law."

    The RFI includes 20 questions soliciting ideas on topics ranging from what additional exceptions to the Stark Law might be considered to how CMS could track physician overuse of self-referral. APTA is reviewing the RFI, and will collaborate with the APTA Private Practice Section and other stakeholders to provide comments by the August 24 deadline. The association also provides a template letter for individuals to submit comments directly to CMS via its regulatory issues webpage (scroll down to second bullet under "APTA's Current Regulatory Advocacy Efforts").

    The general aim of the RFI would seem to run counter to APTA's own efforts to toughen up the rules against self-referral. Last year, the association joined fellow members of the Alliance for Integrity in Medicare in support of a bill in the US House of Representatives that seeks to eliminate self-referral exemptions for so-called "in-office ancillary services"—physical therapy, anatomic pathology, advanced imaging, and radiation oncology. The idea of eliminating the loopholes is also supported by AARP. To date, the legislation has not been scheduled for House committee review.

    "APTA supports efforts to ease the regulatory and administrative burdens faced by health care providers, but those efforts need to be weighed against possible effects on patient choice and access to care," said Justin Elliott, APTA's vice president of government affairs. "Our response to this RFI will take great care to help CMS understand the possible unintended consequences of creating more ways around self-referral without other safeguards in place."

    Want more information on the Stark Law and the IOAS exceptions issue? Visit APTA's legislative issues webpage on self-referral.

    APTA 2018 House of Delegates Election Results Announced

    The following members were elected to APTA's Board of Directors and Nominating Committee on Monday, June 25, at the 2018 House of Delegates in Orlando, Florida.

    Sharon L. Dunn, PT, PhD, was reelected president.

    Matthew R. Hyland, PT, PhD, MPA, was elected vice president.

    Susan A. Appling, PT, DPT, PhD, Cindy Johnson Armstrong, PT, DPT, and Robert H. Rowe, PT, DPT, DMT, MHS, were reelected director.

    Dan Mills, PT, MPT, will serve the 2-year remainder of Hyland's unexpired term as director.

    Derek Fenwick, PT, MBA, was elected to the Nominating Committee.

    These terms become effective at the close of the House of Delegates on Wednesday.

    CDC: Concussion Rates Among High Schoolers May be Undercounted

    A new report from the US Centers for Disease Control and Prevention (CDC) says that in 2017, an estimated 15% of high school students experienced 1 or more concussions, and 6% experienced 2 or more. Authors of the study say that's a number higher than some previous estimates, probably because the CDC study includes anonymous self-reports from the students themselves, many of whom may try to hide the injury from coaches and parents.

    The data were drawn from the most recent Youth Risk Behavior Study (YRBS), which, in addition to gathering demographic variables, asked students “During the past 12 months, how many times did you have a concussion from playing a sport or being physically active?” Students were also asked to respond to the question, “During the past 12 months, on how many sports teams did you play? (Count any teams run by your school or community groups.)”

    Here's what researchers found:

    • Overall, 9.1% of high school students reported 1 concussion, 3.0% reported 2, 1.0% reported 3, and 2.0% reported 4 or more concussions related to sports or physical activity during the 12 months before the survey.
    • Male students were more likely to report 1, 2, and 4 or more concussions than were female students.
    • Students in grades 9, 10, and 11 were more likely to report a single concussion than were students in grade 12, and students in grade 9 were more likely to report a single concussion than were students in grade 10.
    • Black and Hispanic students were more likely to report 4 or more concussions than were white students.
    • Among students who played on 1, 2, and 3 or more sports teams, the prevalence of reporting having had at least 1 concussion was 16.7%, 22.9%, and 30.3%, respectively.

    According to the CDC, the study yielded higher prevalence rates than those from earlier studies based on emergency department reports and data from athletic trainers, which yielded rates of 622.5 per 100,000 and 1.8 per 100, respectively. Authors of the CDC report speculate that the numbers from both sources may be artificially low, as emergency department data lack information on concussions treated elsewhere, and athletic trainer data miss concussions sustained outside school sports—and neither include medically untreated concussions.

    The CDC report acknowledges that its higher numbers may reflect a greater awareness of concussion symptoms but says that another factor may be at play.

    "A study of high school athletes found that among athletes with concussions, 40% reported that their coach was unaware of their symptoms," the report states. "Students might not always recognize or remember that they have experienced a concussion, or they might not want to report having experienced a concussion. In this study, the opportunity to anonymously self-report a concussion, without negative consequences, such as a loss of playing time, might have aided in including concussions missed by other data sources."

    The bottom line, according to the report, is that concussions among high school students may be undercounted and that more needs to be done to educate students, parents, coaches, and school personnel to recognize and report the injury.

    "Coaches and parents can encourage athletes to follow the rules of play for their sport with an emphasis on player safety, which might reduce the incidence and severity of concussions," authors write. "It is important that any athlete with a suspected concussion be removed from practice and competition and not return to play without the clearance of a health care provider."

    Physical therapists have a critical role in concussion prevention and management. APTA offers multiple resources on concussion, which include a Traumatic Brain Injury webpage and a clinical summary on concussion available for free to members on PTNow. The association also offers a patient-focused Physical Therapist's Guide to Concussion on APTA's MoveForwardPT.com consumer website. Continuing education offerings from APTA include the prerecorded webinar "Managing Concussions With an Interprofessional Team" available through the APTA Learning Center.

    Multistate Practice Privileges to Become a Reality in 3 States

    It's on: 2 years after its launch as a concept, the Physical Therapy Licensure Compact (PTLC) is poised to become fully operational in 3 states, allowing physical therapists (PTs) and physical therapist assistants (PTAs) licensed in 1 of the states to obtain practice privileges in the other 2. The commission overseeing the compact system expects that over the coming months, the list of participating states will continue to grow as the 21 jurisdictions that have already signed on to the PTLC implement its provisions, and even more states adopt compact legislation. The compact was a project spearheaded by APTA and the Federation of State Boards of Physical Therapy (FSBPT).

    Beginning July 9, PTs and PTAs in Missouri, North Dakota, and Tennessee will be able to purchase the ability to legally practice in any or all of the 3 states. It's the first practical application of a concept that could revolutionize licensure mobility for the physical therapy profession by reducing the need for licensed PTs and PTAs to apply for separate licenses in additional states in which they want to practice. (Editor's note: for a more in-depth look at the system, check out this 2016 PT in Motion magazine article.)

    The road to becoming operational depended on meeting 2 important challenges: convincing state legislatures to change their licensing laws to allow for the compact system, and creating a centralized commission to oversee issuance—as well as denial and suspension—of compact privileges. To set up the Physical Therapy Compact Commission, a critical mass of 10 states needed to change their laws. That target was reached in April 2017, and the commission was established soon after. Its website offers information on the system and an online application for privileges.

    Rather than contacting individual licensing boards, PTs and PTAs must apply for privileges through the ptcompact.org website.

    Twenty-one states have adopted the compact language. In addition to the 3 states flipping the switch on July 9 are Arizona, Colorado, Iowa, Kentucky, Louisiana, Mississippi, Montana, Nebraska, New Hampshire, New Jersey, North Carolina, Oklahoma, Oregon, South Carolina, Texas, Utah, Washington, and West Virginia. Compact legislation has been introduced in Pennsylvania and is expected to be introduced in more states during future legislative sessions. The Physical Therapy Compact Commission's website features a map that tracks the status of compact participation.

    The conceptualization of the compact system was a joint effort by APTA and FSBPT, but much of the advocacy for change had to be done by state chapters of APTA, said Angela Shuman, APTA director of state affairs.

    "The launch of the compact is an historic moment for the physical therapy profession, but it never could have happened without the dedication and hard work of the chapters and their members," Shuman said. "APTA is proud that this collaborative effort between APTA, FSBPT, and our state chapters have made this concept a reality. The gains we've made so far have created momentum that will help the program continue to grow."

    Fighting the Opioid Crisis: APTA Releases White Paper Pointing the Way to Better Policies on Nondrug Pain Treatment

    A new white paper from APTA makes one thing clear to anyone looking for strategies to combat the opioid crisis in the US: no lasting gains can be made in the fight until stakeholders and policymakers in the country's health care system embrace the value of nonpharmacological approaches to chronic pain. And that embrace, APTA says, must include policy changes that increase patient access to physical therapy, as well programs that make it easier for health care providers to work in underserved communities especially hard-hit by the epidemic.

    In its new white paper titled "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health," APTA points out how the rise of opioid misuse and addiction rates can be linked directly to the widespread use of prescription opioids for the treatment of pain. In the last few years, that stark reality has in turn led to "a growing realization that current strategies for managing pain have to change—that opioid-centric solutions for dealing with pain at best mask patients’ physical problems and delay or impede recovery and at worst may prove to be dangerous and even deadly."

    APTA isn't a newcomer to the opioid fight. The association's involvement dates back to late 2015 and includes the award-winning #ChoosePT public awareness campaign. The white paper is a comprehensive summary of the problem and APTA’s recommendations to address it.

    "Moving forward, the health care system must reexamine its approach to pain, including how causal factors are identified, what tools or measures are used to quantify its impact, and how the approach to treatment is aligned with the patient’s goals and values," the association says in the paper.

    To help fuel that reexamination, the white paper provides a history of the use of opioids in pain treatment, an examination of concepts around pain, and case scenarios that demonstrate how treatment by a physical therapist (PT) can help patients reduce or eliminate opioid use. With context in place, the association then sets out 6 recommendations that it believes need to be part of "a comprehensive response to the opioid crisis:"

    • Better public awareness of pain assessment and options for pain management
    • Public and private health plans that include "benefit design, reimbursement models, and integrated team approaches that support early access to nonpharmacological interventions, including physical therapy, for the primary care of pain conditions
    • Reduction or elimination of patient out-of-pocket costs and increased "access to and payment for person-centered, nonpharmacological pain management and treatment interventions"
    • Stepped-up efforts by health plans to educate providers on the effectiveness of nonpharmacological approaches to pain treatment and best practices in assessment, treatment, and referral
    • Greater attention by policymakers to what's working in pain management care, and a willingness to commit to lower patient out-of-pocket costs and innovative approaches, including bundled-care models and the use of multidisciplinary teams
    • Federal and state student loan repayment programs that incentivize health care professionals to work in underserved communities, thereby increasing the availability of health care providers in areas disproportionately affected by the opioid crisis

    "The opioid crisis is a complex societal and public health issue," said Katy Neas, APTA executive vice president of public affairs. "This white paper addresses a major factor that has fueled this crisis, but there's much work to be done on multiple fronts. APTA and its members can be key contributors in what is truly a life-or-death fight."

    Study: Progressive Strengthening Program Shows Promise Over 'Standard of Care' Rehab for Patients Post-TKA

    In brief:

    • Reseachers studied 2 groups of adults 50 and over who underwent total knee arthroplasty (TKA): 1 group that engaged in "standard of care" rehabilitation, and 1 group that participated in a clinic's progressive strengthening program. The groups were compared with each other and with a group of adults 50 and older who had no joint pathology.
    • Function was assessed through knee flexion measures, knee extension measures, quadriceps strength measures, the timed up-and-go test (TUG), stair-climbing time (SCT), the 6-minute walk test (6MW), and patient self-reports.
    • Overall, neither the strengthening group nor the standard-of-care group achieved function equivalent to the control group, but the strengthening group more often achieved scores at or better than lower-boundary scores of the control group.
    • Authors believe a progressive strengthening approach can bring TKA patients closer to "normal clinical and functional scores" than can standard-of-care approaches focused on range of motion and exercises without weights.

    Adults 50 and older who undergo TKA may never fully achieve the same function as older adults without knee pain, but a progressive strengthening exercise program may bring them closer to those levels than would the variable approaches considered "standard-of-care," according to authors of a recent study.

    The study compared self-reported function and test performance for 3 groups: 88 adults aged 50 and older without knee or joint pain (and no TKA); 40 adults aged 50 and older who underwent TKA and participated in "standard-of-care" rehabilitation; and 165 adults aged 50 and over who underwent TKA and participated in what authors describe as an outpatient clinic program that "included progressive strengthening exercises that targeted muscle groups in the lower extremity." Results were published in Physiotherapy Theory and Practice (abstract only available for free).

    The strengthening program was conducted at a University of Delaware physical therapy clinic beginning 3 weeks after TKA, and consisted of at least 12 outpatient visits 2–3 times a week. The visits themselves focused on strengthening exercises that were progressively adjusted to maintain maximal effort for 3 sets of 10 repetitions for all exercises. The "standard of care" group participated in outpatient rehabilitation elsewhere for an average of 23 sessions that mostly focused on range of motion (ROM), stationary cycling, and "various straight-leg raising exercises without weights," according to the study's authors.

    Both TKA groups were evaluated 12 months after surgery by way of 7 measures: the Knee Outcome Survey-Activities of Daily Living (KOS-ADL) self-assessment, measures of active knee flexion, measures of active knee extension, measures of quadriceps strength, TUG, SCT, and 6MW. Researchers then compared these groups with each other, as well as with results from the 88 older adults who had no history of knee pain (control group). Authors of the study were especially interested in finding out how many participants in each TKA group achieved scores at the lowest bounds of the control group. Here's what they found:

    • The control group consistently reported higher KOS-ADL scores, greater active knee ROM, greater strength, and better performance on TUG, SCT, and 6MW than either TKA group—a result that authors say is consistent with past research showing that function post-TKA hardly ever reaches the levels of age-matched individuals without joint pathology.
    • Compared with the standard-of-care group, a higher percentage of strengthening group participants achieved scores at or above the lower-boundary control group cutoff in knee extension ROM (30% in the strengthening group versus 15% in the standard-of-care group), quadriceps strength (18% vs 5%), and SCT (34% vs 18%). No significant differences were found in KOS-ADL scores, knee flexion ROM, TUG, and 6MW.
    • Compared with the standard-of-care group, participants in the strengthening group were twice as likely to achieve performance above the lower-boundary cutoff for knee extension angle and SCT, and 4 times as likely as the standard-of-care participants to outperform the cutoff for quadriceps strength.
    • Overall, 67% of the strengthening group achieved an above-cutoff score in at least 1 of the 7 variables measured, compared with 47.5% of participants in the standard-of-care group.

    "A greater proportion of patients who participated in the progressive strengthening protocol achieved what could be considered normal clinical and functional scores," authors write. "This suggests that although clinicians cannot expect TKA to restore normative function for all individuals, participating in a progressive strengthening protocol may improve the likelihood of achieving normal age-matched outcomes for a subset of patients."

    Aside from their lack of focus on strengthening, "standard of care" approaches also may be less effective because often they are anything but "standard," according to authors.

    "The lack of consensus between therapists and surgeons on the optimal timing and amount of rehabilitation, and substantial variability in timing, amount, and exercise content of rehabilitation services, may potentially have important negative effects on postsurgical outcomes," they write. "Failure to restore function by 12 months after TKA may be deleterious, as outcome measures plateau around 12 months following TKA, and no meaningful gains have been observed with longer-term follow ups."

    Authors acknowledge several limitations of their study, including a smaller number of participants in the standard-of-care group, and the fact that both TKA groups were heavier than the control group.

    APTA members Federico Pozzi, PT, MA, PhD; Daniel K. White, PT, ScD, MSc; Lynn Snyder-Mackler, PT, ScD FAPTA; and Joseph A. Zeni, PT, PhD, were among the coauthors of the study.

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

    Collaborative Stop the Cap Efforts from APTA, AOTA, ASHA Receive National Award

    APTA has earned another national award—this time for collaborative efforts to push for an end to the Medicare outpatient therapy cap.

    The American Society of Association Executives (ASAE) announced that APTA, the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASHA) were the joint winners of a 2018 Power of A Gold Award for their combined "Stop the Cap" efforts. The work of the 3 associations was instrumental in a congressional decision to permanently end the flawed cap process.

    ASAE's Power of A (the A stands for "association") Awards, are the industry's highest honor, recognizing the association community's valuable contributions on local, national, and global levels. The award will be presented to APTA, AOTA, and ASHA at an ASAE awards dinner on October 3. As a Gold Award winner, the Stop the Cap program is 1 of 6 campaigns under consideration for ASAE's Summit Award, which will be announced later this summer.

    "This award underscores the importance and power of collaboration and coordination," said APTA CEO Justin Moore, PT, DPT, in an APTA news release. "For 2 decades our associations fought side-by-side for patients' rights to care and to tear down this arbitrary roadblock. And we did it. We stopped the cap. That accomplishment was only possible through teamwork. We appreciate this recognition and look forward to continued advocacy on behalf of the people we serve."

    The most recent ASAE award marks the fourth time APTA has been recognized by the association industry group in the past 2 years: in April, APTA's membership renewal efforts earned the association a Gold Circle award for an outstanding member retention campaign, and in 2017, ASAE recognized APTA's public service announcement video for its #ChoosePT campaign as the winner for best video of the year, as well as the entire #ChoosePT campaign as one of the nation's top public awareness campaigns.

    APTA Selects Rapport for Education Research Fellowship

    A physical therapist (PT) educator with more than 2 decades of education experience and more than 40 research publications has been selected as APTA's 2018 Visiting Scholar.

    Mary Jane K. Rapport, PT, DPT, PhD, FAPTA, has been selected as the recipient of the APTA Early-Investigator Research Fellowship. Rapport will spend her sabbatical year focusing on research related to physical therapy education and its impact on professional behaviors, clinical decision making, and/or clinical outcomes. Her responsibilities also will include other activities in support of research-related programs at APTA.

    Rapport is a professor at the University of Colorado School of Medicine, where she also is director of the pediatric physical therapy residency program. With a background that includes extensive publications on topics ranging from pediatric physical therapy to PT education and development of the physical therapy workforce, Rapport brings firsthand knowledge of the research landscape.

    "This is an important time for investigations into clinical education in physical therapy, and Dr Rapport will play a key role in helping APTA contribute to the body of knowledge that will guide the evolution of education programs," said Robyn Watson Ellerbe, PhD, APTA's vice president of research. "We are excited to have an investigator of such a high caliber join the APTA team."

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

    A (motor) learning experience: Mike Studer PT, MHS, outlines innovative ways to apply motor learning principles to rehabilitation. (The Perception & Action Podcast)

    No ordinary rehab: At her clinic, Patrice Hazan, PT, DPT, oversees a model of physical therapy that employs functional wellness classes. (Greenville, South Carolina, News)

    Quotable: "The cornerstone of treatment should be physical therapy." – Huaiyu Tan, MD, rehabilitation physician, on shifting away from the overuse of opioids in pain treatment. (Pensacola, Florida, News-Journal)

    Much-kneeded research: Jay Irrgang, PT, PhD, FAPTA, is leading a study aimed at finding the most effective physical therapy approach for people 45 and older with both osteoarthritis and a meniscal tear. (Pittsburgh Post-Gazette)

    The net benefits of physical activity: Allie Muller, SPT; Tara Dorenkamp, SPT, and other students from the Creighton University (Nebraska) physical therapist program joined with the CU men's basketball team to host a basketball camp for children with disabilities. (Live Well Nebraska)

    Quotable: "I believe that no matter what age you are, you have the ability to change your habits and turn back the hands of time. Maybe not the hour hands, but certainly the minutes. Well, my physical therapist believes that, and I believe her, so I am on a new journey." Column by Fred Goldenberg, who's making a commitment to get back in shape with the help of his PT. (Traverse City, Michigan Record-Eagle)

    Water you waiting for: Carol Oatis, PT, PhD, shares her perspective on the advantages of water-based exercise. (Consumer Reports)

    All in the family: Heather Dragg, PT, is working with a very special patient—her grandmother, Marolyn Dragg, PT, who opened the clinic now run by Heather. (Ardmore, Oklahoma, Daily Armoreite)

    Man up and do Pilates: Rachel Tavel PT, DPT, explains why Pilates shouldn't be considered solely a "woman thing." (Men's Health)

    Walking with technology: Kim Kobata, PT, describes how her clinic is using robotic technology to help a patient walk. (KOMO News, Seattle)

    Stretching out the possibilities: Karen Joubert, PT DPT; and Scott Weiss, PT, explore the pros and cons of assisted stretch classes. (Shape)

    Helping a miracle happen: Mandy Alaniz, PT, talks about the recovery of Julian Maldonado, age 8, who experienced a severe abdominal infection that resulted in the loss of his leg. (KIIITV3, Corpus Christi, Texas)

    New moms and exercise: Carrie Pagliano PT, DPT, explains the factors that should be considered by new mothers wanting to know how soon after birth they can return to exercise.(whattoexpect.com)

    Watch how you watch: Jean Weaver PT, MBA, offers postural advice for tv binge-watchers. (Consumer Reports)

    Quotable: "I wish that my parents had made me stick with my physical therapy. If Mom and Dad tell you that you should go three days a week until you’re 18, please, listen to them. It will help with so many complications once you’re an adult and you’ll get into a routine that will help you live your best life later on." –Kristen Parisi, who, at age 6, was involved in a car accident that paralyzed her from the waist down, on "what I wish I could tell my 6-year-old self about living with a disability." (Today.com)

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

    Study: A Few Tests (And Demographic Variables) Can Help Predict Success of Nonsurgical Treatment of ACL Injury in Athletes

    In brief:

    • Researchers in Norway and the US looked at tests and measures of 118 athletes who experienced an anterior cruciate ligament (ACL) rupture and did not have surgery within the first 6 months of the incident.
    • The same tests were administered both at baseline (as soon as possible after the injury) and then after 5 weeks of rehabilitation. Researchers then tracked the patients and administered the International Knee Documentation Committee subjective knee form (IKDC) after 2 years for all participants who did not eventually have surgery.
    • Of 97 patients reporting IKDC scores, 53% reported successful outcomes (at or above 15th percentile).
    • At both baseline and 5 weeks, the strongest indicators of later success of nonsurgical approaches were older age and being female. Higher quadriceps symmetry scores and Knee Outcome Survey – Activities of Daily Living Scale (KOS-ADLS) scores were predictive at baseline; higher IKDC scores were predictive of success after 5 weeks of rehabilitation.
    • Researchers believe their findings are an easy way to help patients and clinicians make decisions about whether to pursue surgical versus nonsurgical treatment for ACL injury.

    For athletes with ACL injuries, deciding whether to pursue surgical versus nonsurgical treatment can be a tough call. Now authors of a new study say that a few tests and outcome measures—and a few demographic factors—can help to shed light on the chances of a nonsurgical approach leading to success.

    The study, conducted in Delaware and Oslo, Norway, included 118 patients who experienced a unilateral ACL rupture and did not elect to have ACL reconstruction surgery (ACLR) by 6 months after the injury (although some did wind up undergoing surgery later on). All of the patients reported participation in a "pivoting sport"—for example, soccer, football, handball, basketball, tennis, skiing, snowboarding, baseball, or softball—for at least 50 hours a year. Researchers focused on 2-year outcomes for these patients in an effort to find out possible predictors for success in nonsurgical treatment, both at baseline and after a 5-week rehabilitation program.

    All participants first underwent rehabilitation to address effusion and range-of-motion deficits, and then were administered a battery of tests as well as the KOS-ADLS and the IKDC. Next, patients participated in a 5-week neuromuscular and strength training program that included 10 sessions of perturbation training, and were administered the same tests and measures. Researchers then tracked the patients for 2 years after baseline and readministered the IKDC. Researchers labeled a nonsurgical approach a success if, after 2 years, nonsurgical participants recorded IKDC scores at or above the 15th normative percentile.

    As for the participants, age at baseline ranged from 18 to 39, with a mean age of 28.6, and a fairly even split between males and females (49.2% and 50.8%, respectively). Demographics at the Oslo and Delaware sites didn't vary much in terms of age, sex, or preinjury activity, but patients in Delaware did report a higher average body mass than the cohort in Oslo. The study was published in the Orthopaedic Journal of Sports Medicine.

    Among the findings:

    • Of the 97 patients for whom 2-year IKDC scores were available, 52 (53%) were found to have a successful outcome; of the 45 patients classified as having an unsuccessful outcome, 33 underwent late ACLR, with 12 remaining nonsurgically treated but scoring below the target IKDC percentile.
    • Patients who scored above the target percentile at the 2-year followup averaged a 94.2 on the 100-point IKDC scale; those who scored below the target averaged a score of 73.2.
    • When comparing the results with tests and measures conducted at baseline, higher KOS-ADLS scores and quadriceps symmetry index scores (LSI) above 89% as assessed through the single-leg hop test were predictive of success after 2 years. Older age and being female also increased the chance of a successful outcome.
    • The 5-week assessments yielded somewhat different predictors of success from the baseline tests, with a higher IKDC score being a stronger indicator of future success. As with baseline assessments, older age and being female increased the odds of success at the 2-year mark, but the LSI score didn't generate any predictive power. "It is possible that when knee function improves with rehabilitation, the measures of knee function lose the variance that is required for predictive ability," authors write.

    Authors see several compelling reasons for using these tests to help make a patient arrive at a decision about whether to continue nonsurgical treatment—primary among them the fact that the models can be easily applied and yield reliable results. As an example, they calculate that a 30-year-old women who scores 90 on the KOS-ADLS and has an LSI of 90% or above early after injury has an 85% probability of a successful nonsurgical outcome 2 years after injury. By contrast the same woman scoring a 65 on the KOS-ADLS and an LSI below 90% would have only a 29% probability of success after 2 years.

    "These differences in prognoses provide a powerful argument for why clinicians should routinely assess the patient's knee function after injury," authors write.

    As for the better probabilities of success with age, authors point to a problem in ACL treatment overall—namely, that younger athletes also tend to have lower success rates for surgical treatment compared with older athletes.

    "Our results in nonsurgically treated patients, as well as previous studies on surgically treated patients, support the growing concern that our current treatment methods are not successful enough for the youngest and most active patient group," authors write. "For those who have good prognoses with nonsurgical treatment, however, our results can help clinicians and patients to have more confidence in a nonsurgical treatment choice (active rehabilitation)."

    The researchers believe their study is a solid investigation into predictive factors around ACL treatment, but they see possibility for the inclusion of more variables as predictors of success, including anatomic factors, associated injuries, laxity, and psychological components. Still, they see the current results as helpful.

    "Clinicians and patients can have more confidence in a nonsurgical treatment choice in athletes who are female, are older, and have good knee function early after ACL injury," authors write. "A simple set of measures, assessed either before or after a short period of rehabilitation, can provide 2-year prognoses and thereby aid shared treatment decision making."

    APTA members Elizabeth Wellsandt, PT, DPT, PhD; and Lynn Snyder-Mackler, PT, ScD, FAPTA, are among the coauthors of the article.

    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.

    CMS to Expand List of DMEPOS Requiring Prior Authorization

    Physical therapists (PTs) who are providers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) take note: the US Centers for Medicare and Medicaid Services (CMS) is adding 31 codes to its list of devices that require prior authorization under Medicare. The additional codes will go into effect on September 1 of this year.

    The codes, all related to power wheelchairs, already were subject to prior authorization in 18 states as part of a demonstration project aimed at reducing improper payment. With that demonstration project set to end on August 31, CMS decided to expand the requirements to all states and fold the list into its broader DMEPOS demonstration project launched in 2015.

    CMS offers a webpage focused on the DMEPOS prior authorization program and has published a notice and list of the 31 codes to be added. A full list of DMEPOS requiring prior authorization (minus the 31 codes to be added in September) is also available from CMS. APTA offers more resources at its DMEPOS webpage as well as through a clinical mobility device documentation guide.

    APTA Provides an Easy Way to Share Your Comments on Proposed SNF Rule

    If a rule from the US Centers for Medicare and Medicaid Services (CMS) is adopted as proposed, physical therapists (PTs) and physical therapist assistants (PTAs) who work in skilled nursing facilities (SNFs) could find those facilities facing some major changes in payment. Those changes could include a new case-mix methodology system and altered therapy reporting requirements, according to CMS.

    The rule won't be finalized until later this year. In the meantime, CMS is asking for public comments on its proposal. APTA has made it easy for you to participate.

    APTA offers a template letter for PTs and PTAs who want to comment on the proposed 2019 skilled nursing facility prospective payment system (SNF PPS) and the plans for implementation of the Patient-Driven Payment Model (PDPM) to replace the Resource Utilization Groups Version IV (RUG-IV). Among other comments, the letter encourages CMS to take a careful look at how proposed coding requirements associated with the PDPM would "pose significant administrative, financial, and compliance burdens on SNFs."

    Posted as a Microsoft Word file, the letter was created with the technical formatting that CMS is accustomed to, but it also includes areas that can be personalized with details and examples from the individual PT's or PTA's practice. Those personal touches can help to underscore the messages that the letter's shared elements deliver to CMS with a unified voice.

    APTA outlined the basics of the proposed rule in an APTA fact sheet and will submit its own comments to CMS by the June 26 deadline. CMS has also issued a fact sheet on the proposed rule.

    APTA's May 16 "Insider Intel" program covered the proposed SNF rule. A recording of the full session is now available.

    From PT in Motion Magazine: Diversifying the Profession

    As society becomes increasingly diverse, it's important for the profession to reflect those differences. But as of a 2013 APTA member demographics profile, nearly 70% of APTA member physical therapists (PTs) were female and 88.5% were white. So how will the profession look in the future, and how is APTA responding to the need for a diverse physical therapy workforce?

    A feature in this month's PT in Motion magazine examines the importance of diversity within the physical therapy profession to improve the health of an increasingly diverse society. Author Michele Wojciechowski reports how several PTs' diverse backgrounds have helped them offer person-centered care that is sensitive to patients' needs and beliefs.

    "Increasing the diversity of the profession and providing information on the importance and understanding of cultural competence have been part of APTA's vision, guiding principles, and mission for many years," said Johnette L. Meadows, PT, MS, program director of minority/women's initiatives in APTA's Department of Practice.

    The PTs interviewed reflect on how their personal backgrounds have given them a unique ability to connect with other minority patients. "We live in a diverse world, and our clients and patients come from diverse communities," noted Dave Kietrys, PT, PhD. "We should be mirroring that. We also should be welcoming people from all backgrounds into our profession. The greater our diversity, the deeper and richer our understanding will be of the needs of a varied population. We'll naturally be more sensitive to underrepresented communities—what they're going through and how they might have been marginalized, stigmatized, or treated with bias."

    "Who Are Tomorrow's PTs and PTAs?" is featured in the June issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them one of the benefits of belonging to APTA. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.

    CMS Reports High Levels of Participation in MIPS; Will It Be Expanded to PTs in 2019?

    Things are looking good for the Merit-Based Incentive Payment System (MIPS), according to the US Centers for Medicare and Medicaid Services (CMS). According to CMS, participation in MIPS—which could be required of physical therapists (PTs) as early as next year—was just above 90% during its first year of operation.

    The 91% clinician participation rate was slightly better than the CMS goal of 90%, and included particularly strong performance from accountable care organizations and physicians in rural areas, which reported at rates of 98% and 94%, respectively, according to a blog post from CMS administrator Seema Verma. Beginning in 2019, clinicians can earn Medicare payment increases or face penalties based on quality reporting data provided through the program.

    MIPS is part of a broader effort by CMS to shift toward value-based payment systems through the Quality Payment Program (QPP). Under QPP, providers can choose 1 of 2 paths: reporting through MIPS, or participating in an Advanced Alternative Payment Model (AAPM). MIPS requires reporting in 4 performance categories—quality, promoting interoperability, clinical improvement activities, and cost. Providers earn points in each category, producing a total annual MIPS score, which in turn determines whether the providers earn a payment incentive, remain neutral in payment, or be subject to a penalty. Several of the data points must be reported electronically through certified EHR vendors or registries like APTA’s Physical Therapy Outcomes Registry.

    Although PTs are not yet required to report outcomes through MIPS, they can participate voluntarily—an option strongly encouraged by APTA, given that all indications point to PTs being required to participate in MIPS or APMs as early as 2019. CMS is expected to make its decision on the inclusion of PTs in MIPS in early July 2018.

    According to Verma, while CMS presses for broader participation in MIPS, it will remain "committed to removing more of the regulatory burdens that get in the way of doctors and other clinicians spending time with their patients" through its "Patients Over Paperwork" initiative.

    "We’re also eager to improve the clinician and patient experience through our Meaningful Measures initiative so that clinicians can spend more time providing care to their patients and improving the quality of care their patients receive," Verma writes. "Within MIPS, we are adopting measures that improve patient outcomes and promote high-quality care, instead of focusing on processes."

    Get ready for the future of PT payment: APTA offers a wide range of online resources on value-based care in general and MIPS in particular, including a readiness self-assessment quiz, a podcast series, a video, a frequently-asked question page on MIPS, and more. Additionally, APTA's Physical Therapy Outcomes Registry has earned "qualified clinical data registry" status from CMS, meaning that PTs who participate in MIPS can use the PTOR to submit their data to CMS.

    AMA: Drop in Opioid Prescription Rates Good News; More Nonopioid Pain Treatment Needed

    The American Medical Association (AMA) is applauding new data showing that opioid prescriptions fell dramatically in 2017—and using the news as an opportunity to promote access to "affordable, non-opioid pain care."

    In its report, AMA cites statistics from IQVIA Institute for Human Data Science, which found that opioid prescription rates fell by 10% in 2017, the steepest drop in 25 years. All 50 states reported decreases in prescriptions of 5% or more. Additionally, the report states that physicians are increasing their use of prescriptions drug monitoring programs and expanding their treatment capacity through certifications to administer in-office buprenorphine, a drug used in the treatment of opioid use disorder.

    That's all good news, the AMA report says, but more needs to be done, both in terms of the nation's addiction treatment efforts and the health care system's overreliance on opioids in the treatment of pain. Among AMA recommendations: a call for "all public and private payers… [to] ensure that patients have access to affordable, non-opioid pain care."

    “While this progress report shows physician leadership and action to help reverse the epidemic, such progress is tempered by the fact that every day, more than 115 people in the United States die from an opioid-related overdose,” said Patrice A. Harris, MD, MA, chair of the AMA Opioid Task Force in an AMA news release. “What is needed now is a concerted effort to greatly expand access to high-quality care for pain and for substance use disorders. Unless and until we do that, this epidemic will not end.”

    APTA has made the opioid crisis a priority in its public education and advocacy efforts through the #ChoosePT opioid awareness campaign and participation in multiple multiorganization initiatives, including a National Quality Partners "Opioid Playbook" that offers actions that can be taken to shift health care away from the overuse of opioids for treatment of noncancer pain. Earlier this year, APTA hosted a live Facebook-broadcast panel discussion titled "Beyond Opioids: Transforming Pain Management to Improve Health."

    CMS Hopes to Reboot 'Pre-Claim Demonstration' Proposal for HHAs in 5 States

    The US Centers for Medicare and Medicaid Services (CMS) plans to revive a home health agency (HHA) "pre-claim demonstration" project it shelved in 2017 due in part to criticism that the program created significant administrative burdens and reduced access to care. The reconstituted project will be implemented in 5 states and is described as "optional," though HHAs that choose not to participate would face a 25% cut in payments.

    The demonstration project will be carried out in Florida, Illinois, North Carolina, Ohio, and Texas, and would offer HHAs 3 paths in seeking payment for Medicare beneficiaries: submit documentation for 100% of Medicare patients while they are receiving care (a "preclaim review"), submit 100% of all claims for a postpayment review, or opt out entirely and swallow a 25% payment cut with the possibility of review by a recovery audit contractor. The previous version of the project included only the preclaim review provisions; according to a statement from CMS administrator Seema Verma, the new plan "offers new flexibility and choice for providers."

    CMS' earlier attempt at the project was implemented in Illinois but was suspended after some HHAs were forced to close their doors, pointing to the program's administrative burdens as part of the cause. Federal lawmakers requested that the program be shut down until a better plan could be developed.

    Like its earlier version, the project is aimed at reducing what CMS has identified as high rates of Medicare fraud among HHAs. CMS stated that although it will limit the project to 5 states initially, it may consider expanding the project to other states in the Palmetto/JM jurisdiction—mainly southern states as well as New Mexico, Indiana, and Kentucky. CMS has not yet set a start date for the program.

    APTA will provide comments to CMS within the 60-day window triggered by publication of the proposal in the Federal Register, and will share information on how individuals can provide comments at the APTA federal advocacy webpage.