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  • Expanded Health Reimbursement Arrangement Rule May Widen Use of the Employer Offering

    A final rule from the US Department of Health and Human Services (HHS) will expand small employers' ability to offer Health Reimbursement Arrangements (HRAs), a change that may make it easier for more Americans to purchase health insurance that they don't receive from their jobs. While it's still too early to tell if the change will significantly impact patients seen by physical therapists (PTs), APTA's advice is to keep an eye open, and be aware of the nuances of HRA payment.

    The new rule, set to go into effect January 1, 2020, will allow qualified small employers to offer what's being called an "Individual Coverage HRA" as an alternative to traditional group coverage plans. The idea behind HRAs is that employers provide a monthly tax-free allowance to employees, who can be reimbursed for health care-related expenses up to the allowance limit. The changes set to go into effect next year would permit HRAs to be used to pay for health insurance purchased on the individual market, and allow employers to offer "excepted benefit" HRAs to supplement employer-sponsored insurance—even if the employee isn't enrolled in the group plan.

    HHS believes that the change will open up coverage options for more than 11 million employees and family members and increase insurance portability, according to an HHS press release. APTA submitted comments to the proposed rule that largely supported the changes, but recommended that any individual health insurance paid via an HRA must be a policy deemed compliant with the Affordable Care Act. The final rule supports APTA's position.

    Those numbers are just estimates, however, and there's no way of knowing just how the use of HRAs will shake out next year, said Kate Gilliard, APTA regulatory affairs senior specialist.

    "PTs need to understand that these HRAs will be out there, and that whether the patient can use the HRA for copays depends on how it's set up with the employer," Gilliard said. "Some HRAs are only good for premium payments, so we're advising our members to verify the details of a patient's HRA. If it's found appropriate for use, the HRA can be processed just like a health savings account or flexible spending account."

    APTA regulatory affairs staff will monitor rollout of the rule and share new information in PT in Motion News and elsewhere.

    Older-Adult Deaths From Falls Have Increased; Intervention May Help Decrease Falls in the Future

    Researchers analyzing health statistics have uncovered some disturbing news: in 2016, adults 75 and older were dying from falls-related injuries at more than double the rate they were in 2000. And while authors of a recent JAMA editorial on the numbers say the reason for the dramatic increase "is not fully understood," a separate study in the same issue of the journal points to a physical therapist (PT)-led falls prevention program as a potentially effective way to counteract the trend.

    Using data from the National Vital Statistics System, authors of "Mortality from falls among US adults aged 75 years or older, 2000-2016" found that, in adults over age 75, the number of deaths from falls increased from 8,613 in the year 2000 to a staggering 25,189 in 2016. The age-adjusted mortality rates in 2016 was 42.1 per 100,000 people for those aged 75–79 and 590.7 for individuals aged 95 or older.

    Mortality rates increased for both men and women. The age-adjusted mortality rate for men rose from 60.7 deaths per 100,000 people in 2000 to 116.4 in 2016. Likewise, among women, rate of death from falls went from 46.3 per 100,000 people to 105.9 in 2016.

    Authors of the editorial say the reason for the increase in deaths resulting from falls "is not fully understood." Still, they write, while older adults clearly have the highest risk for falls, they also have the highest potential for cost-effective interventions that make a difference.

    One such promising intervention for secondary fall prevention in community-dwelling older adults is the Otago home-based exercise program. In a study (abstract only available for free) published in the same issue of JAMA that includes the falls editorial, researchers including APTA member Teresa Liu-Ambrose, PT, PhD, write that the program "may have been effective because it reduced the number of falls among individuals who fell repeatedly."

    Researchers for the recently published JAMA study designed a randomized controlled trial to specifically examine whether the Otago exercise program could do so for adults over age 70 who previously had experienced a fall. Upon seeing a physician after a fall, patients were randomly assigned to receive 12 months of "usual care" or usual care plus the home-based strength and balance retraining program. Usual care included fall risk and medical assessment; treatment by a geriatrician, including lifestyle recommendations; and referral to other providers as necessary.

    In the Otago program, a PT delivers balance, strength, and walking exercises that increase in difficulty over time. Participants in the JAMA study were instructed to repeat the exercises 3 times a week and walk for 30 minutes each week. The PT returned every other week to adjust the exercises, and individuals were evaluated by a physician at 6 and 12 months.

    Authors found that falls were significantly reduced among those who completed the Otago program (236 falls) compared with those who only received usual care (366 falls). While a majority of participants experienced additional falls, the rate was 1.4 per person-year for the Otago group compared with 2.1 for the usual care group.

    However, consistent with previous research, there were no significant differences between groups in fall risk, general balance, and mobility. "It is possible to observe a significant reduction in falls without significant improvements in physical performance," authors conclude. APTA provides extensive resources on falls prevention at its Balance and Falls webpage. Offerings include consumer-focused information, online courses, and links to other sources of information, including the CDC and the National Council on Aging. In addition, APTA's PTNow evidence-based practice resource offers a unilateral vestibular hypofunction clinical summary, a summary on falls risk in community-dwelling elders, an osteoporosis clinical summary, and tests and measures such as a fracture risk assessment, a clinical test of sensory interaction and balance, and a self-paced walk test. The association's scientific journal, PTJ (Physical Therapy) has published a clinical guidance statement from the APTA Academy of Geriatric Physical Therapy on management of falls in community-dwelling older adults.

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

    PTJ's Research Impact on the Rise

    The influence of PTJ (Physical Therapy), APTA's scientific journal, continues to grow: according to Journal Citation Reports (JCR), the frequency with which PTJ is cited in other journals—its "impact factor"—made PTJ #7 among rehabilitation journals and #16 among orthopedic journals in 2018. A journal's impact factor is used by many researchers to decide where to publish their work.

    The JCR rating isn't the only indicator of PTJ's increasingly high profile. Another rating, called the Eigenfactor score, ranks PTJ fourth among rehabilitation journals even after excluding self-citation (references from one article in a journal to another article in the same journal).

    "The improved impact factor is a direct result of the hard work and commitment of our Editorial Board members, our reviewers, and, most of all, our authors," noted Editor in Chief Alan Jette, PT, PhD.

    To mark the occasion, Jette has posted a special selection of PTJ's top-cited papers on a PTJ "High Impact Research" webpage.

    News From NEXT: Rural Health Care has Plenty of Challenges, Promising Opportunities

    When it comes to rural health, there's no denying that there are demographic and financial challenges that can affect care. But there are also opportunities for improvement, and physical therapists (PTs) and physical therapist assistants (PTAs) need to be ready to advocate for—and when necessary, create—those opportunities. That was the message of a session on rural health care delivered June 14 during APTA's 2019 NEXT Conference and Exposition in Chicago.

    The session explored the factors that make rural health care different from health care in more urban areas---factors that in some instances point to the need to rethink how funding is allocated. Presenters pointed to the possibility that the US Centers for Medicare and Medicaid Services (CMS) might be in the early stages of doing just that. Meanwhile, they said, the possibilities for better patient access through telehealth need to be seized in the short-term.

    Presenter Jeremy Foster, PTA, boiled down the status of rural health care into a single sentence: "We have all these conditions that are worse in rural settings, but the money's not there."

    Foster led attendees through a tour of the demographic elements that create challenges, including a higher percentage of people who describe themselves as having "fair or poor" health compared with those in urban settings, and a generally older population. Other disparities include higher rates of tobacco use, an average annual income gap of $9,242, and life expectancy that averages 2 years shorter than the life expectancy of the urban-dwelling population.

    Access to care is, of course, a significant problem in rural areas, Foster explained, and though critical access hospitals (CAHs) often provide high-quality, patient-centered care, current funding systems tend to be based on population more than on need. Under those assumptions, gaps can arise when a smaller population begins to experience conditions that lead to worse health conditions.

    This must change, Foster said, because CAHs are providing much-needed care and economic benefits that are worth supporting, including contributing more than $7.1 million to local communities annually through wages and benefits, and providing needed care---an average of 39 million outpatient visits, 809,000 adult hospital admissions, and 82,000 infant deliveries per year.

    "There needs to be a lot more research around rural health care," Foster noted, but he added that providers in the rural setting have a responsibility to be "trustees of the money we receive."

    Brendon Larsen, PTA, BS, took a deeper dive into the current state of CAHs and rural health care in general, saying that rural health providers are challenged to care for a population that is considered "older, sicker, and poorer" than its urban counterparts.

    CAHs’ challenges include an aging infrastructure and a workforce shortage that isn't limited to clinicians, Larsen said, with CAH leaders reporting a 61% shortage in applicants for nonclinical and administrative support positions. At the same time, the type of services provided by CAHs is evolving, with outpatient treatment now making up 60% of CAH gross revenue. The problem, he explained, is that many funding assumptions around rural health care are rooted in inpatient care. When those factors are added to ever-increasing regulatory burdens, CAHs and other rural health providers find themselves struggling to stay afloat at a time when the need for better patient access is increasing---including the need to respond to the nation's opioid crisis.

    But could some relief be on the way? Maybe, said Larsen: CMS has formed a Council for Rural Health that is looking at developing a rural health policy initiative. The idea, Larsen explained, is to apply a "rural lens" to CMS programs, with the aim of maximizing providers' scopes of practice, empowering patient decision-making in rural areas, supporting new partnerships, and further expanding telehealth opportunities in rural areas.

    Of those potential improvements, telehealth could be of the most immediate benefit, explained Carmen Cooper-Orguz, PT, DPT, MBA. Cooper-Orguz rounded out the program by describing the promise of telehealth, and specifically telerehab, for improving patient access to care.

    There are more 'cans' than 'cannots' when it comes to telerehab," Cooper-Orguz told the audience while running through a list of the assessments and treatments that could be accomplished remotely.

    The problem, she explained, is that while most providers understand the potential for telerehab, the on-the-ground conditions for providing it need to improve. That will take action from the physical therapy community to advocate for changes to payment policies, state licensing laws and regulations, and provision of rural broadband.

    Cooper-Orguz believes one of the most important ways for PTs and PTAs to pave the way for better policy around telerehab is to press for adoption for the Physical Therapy Licensure Compact in all states. By dismantling geographic boundaries to practice, the compact opens up the possibility for increased use of telerehab---but only if compact adoption is accompanied by licensing laws and regulations that permit remote practice, she added.

    News From NEXT: Understanding Personality Types Can Enhance the PT-Patient Relationship

    Understanding one’s own personality, as well as the personalities of coworkers and patients, can make physical therapists (PTs) and physical therapist assistants (PTAs) more successful in both their workplace and home life, according to Jacky Arrow, PT, DPT. Arrow presented “He Said, She Said: How personality and communication can improve patient education” on June 14 at the 2019 NEXT Conference and Exposition.

    She pointed out that in communication between the PT and the patient, “It’s not their responsibility to come to us or to meet us half way. It’s our responsibility to meet them.”

    She first recommended that the attendees determine their own personality types. She mentioned several tests but focused on the Myers-Briggs Type Indicator, which places a person on 4 scales: extraversion vs introversion, sensing vs intuitive, thinking vs feeling, and judging vs perceiving.

    For example, Arrow explained, an introvert typically waits to be asked a question and then needs time to construct an answer. Extraverts, on the other hand, tend to be talkative and fast-paced. Regarding body language, extraverts tend to lean forward and talk with their hands, while introverts pause before answering and often sit back, sometimes with arms crossed. When treating patients who are introverts, she suggested, provide information in advance or tell them you plan on asking specific questions. Be prepared for follow-up questions either later in a session or at the next session. A strategy to working with extraverts includes active listening, thinking out loud, and planning talking points.

    Another example she provided related to judgers vs perceivers. Judgers respect rules and deadlines such as structured activity, she said, and they prefer a specific plan of care with milestones. Perceivers tend to be flexible with rules and deadlines and are open to adjustments in a plan of care. For those reasons, judgers do better with a written program calendar, while perceivers like to link progress to big-picture goals. To illustrate, she suggested that if the goal is to have a patient do an exercise for 30 seconds, tell a judger to exercise for 30 seconds. Tell a perceiver to sing the song “Twinkle Twinkle Little Star” to gauge the elapsed time.

    Understanding the personality types of colleagues also can be beneficial. “Knowing the other personality types fosters better working relationships. And it allows PTs and PTAs to practice their skills with those of other personality types,” Arrow said.

    News From NEXT: Attendees Rebuild Toy Cars to Aid Children’s Mobility

    PVC ratchet cutters, screwdrivers, and wire strippers may not be among the tools usually used by physical therapists (PTs) and physical therapist assistants. But at the APTA NEXT Conference and Exposition session "Go Baby Go: Mobility Research, Design, and Technology," those and other devices---such as electrical tape, collections of screws, a power drill, and myriad other items---were literally part of a clinician’s toolbox.

    Jason Craig, PT, DPhil, and Skye Donovan, PT, PhD, led the session, which addressed the importance of mobility for young children. The program---conducted on both June 13 and 14---primarily focused on actually converting 9 battery-powered children’s ride-on cars into effective, affordable mobility devices. Go Baby Go is a national program developed by Cole Galloway, PT, PhD.

    The cars that arrive from the toy manufacturer are designed to be operated with a foot pedal. But Craig explained, "Most kids can't operate a pedal, so we have a large button that can be positioned anywhere on the car." Usually the button is in the steering wheel---which was where conference participants placed them in the 9 onsite cars---but the location can change based on the child’s need. "We've placed it behind the head when the goal is to improve a child's posture," Craig said. "We placed one on the seat so the car would move only when the child stood up; it stopped as soon as he sat down."

    In addition to enhancing interventions, the modified toys serve another purpose. "This is about providing the children an experience they haven't had. By providing these cars, the children can explore the world," he said.

    It's also affordable. The cars as modified cost approximately $150 "versus thousands for a motorized wheelchair."

    Pointing to an array of unmodified, rideable cars on tables in the room, Craig then told the session attendees: "We need you to build these, because the kids are coming in later today for their cars." Each car was accompanied by an information sheet on the child---including his or her name, age, diagnosis, and interests.

    The session attendees worked in teams of 4 to 6 to modify the cars---disconnecting the pedal power control and connecting the large red plastic button the size of a small plate to the center of the steering wheel. The task was challenging not only because many PTs weren't familiar with the hardware tools and wiring schematics but also because of variations in both the cars and the needs of the children.

    About an hour into the session, the children and their parents began arriving, with the children telling the PT team working on "their" car what customizations and decals they wanted. Most of the cars were finished that day---a few needed additional work---and the session ended with the children test-driving their cars around the room and down the hotel's halls.

    'Allow Mistakes': Study of Infants With CP Emphasizes Importance of Balanced Approach to Movement Learning

    Infant prone mobility, considered strongly linked to later mobility gains and psychological development, can be difficult for children with cerebral palsy (CP), putting them at a disadvantage later in childhood. Now authors of a new study believe that pairing special assistive technology with a careful combination of movement learning strategies could facilitate important gains in this population. The study was published as part of a special issue of PTJ (Physical Therapy) focused on the intersection of pediatric physical therapy and development science.

    Researchers were particularly interested in impacts of 2 separate learning "mechanisms" that have been shown to have positive effects on skill learning in adults with neurological deficits: reinforcement learning (RL) and error-based learning (EBL). RL is aimed at optimizing the reception of rewards or penalties, focusing on the outcome; in contrast, EBL focuses on the errors made in movement.

    Both EBL and RL can be useful approaches, authors write, but they each have pros and cons: EBL promotes faster learning but is easier to forget; RL tends to be a longer process with more exploration (and variability) involved but is better retained. Authors of the study hypothesized that infants with CP would achieve better prone mobility gains through a combination of the 2 mechanisms than from RL alone.

    To test their hypothesis, researchers used the Self-Initiated Prone Progression Crawler (SIPPC), a device developed by study coauthor Thubi Kolobe, PT, PhD. The SIPPC resembles a skateboard outfitted with special motors and monitors. Infants are placed on them in a prone position that allows them to move their arms and legs. The SIPPC can then be programmed to sense and respond to movement the child initiates.

    Thanks to the addition of a specially wired onesie, the SIPPC's movement response was able to work as both an RL and EBL mechanism. Calibrated one way, the SIPPC reinforced RL by rewarding a movement that is consistent with achieving a goal—for instance, moving toward a toy. Set another way, the SIPCC could add an EBL element by picking up on movements that are not consistent with the goal achievement and move the infant in unintended directions.

    For the study, researchers divided 30 infants aged 4.5–6.5 months into 3 groups: infants with CP who received SIPPC sessions with the special suit that could combine RL and EBL, infants with CP who received only an RL experience through the SIPPC, and typically developing infants who received the RL experience only through the SIPPC. The sessions involved 3 5-minute trials that included caregiver-led movement of the SIPPC and of the infants' arms and legs as well as periods during which the infant was encouraged to move independently toward either a toy or the caregiver. Sessions were conducted twice a week for up to 12 weeks.

    Researchers found that after 12 weeks, infants in the combined RL and EBL group made improvements over the RL-only group in the areas of rotational amplitude—essentially, the amount of trial-and-error used—and the length of linear paths achieved. Wrist and foot path lengths remained about the same between the groups, but the combined group registered significantly higher scores than the RL-only group in the Movement Observation Coding Scheme (MOCS), a measure of goal-directed movement.

    "Overall the findings support the differential effect of RL and EBL in skill learning in infants with CP," authors write, adding that the greater use of trial-and-error methods among the combined group reflects the ways that infant learning of new motor skills may at times require RL but at the same time involve uncoordinated movements, a cognitively demanding process "that is likely to respond better to EBL." The ultimate result: greater travel distances and more goal-directed movement among the combined group.

    In a video interview at the 2019 APTA NEXT Conference and Exposition, Kolobe boiled down the essential findings of the study. [Scroll down for video]

    "Allow mistakes," Kolobe said, "because that's part of [infants'] repertoire of learning how to do something. Allow them to go after other options, because eventually they get the right one."

    Kolobe also believes the study scratches the surface of another important consideration—the complex nature of cognitive elements during movement learning.

    "A lot of cognition enters into [learning movement]," Kolobe said. "Infants do strategize. There's a lot of executive function required to move."

    Authors believe the executive function demands may be of special note among infants with CP. In their study population, they write, "adapted behaviors were not readily repeated at the next sessions"—a finding that partly may be attributable to the ease with which EBL can be forgotten and partly attributable to the type of brain insult associated with CP. The memory decay "highlights the need to carefully balance RL and EBL approaches," they add.

    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.




    UnitedHealthcare Announces New Pilot Program to Increase Access to Physical Therapist Services as Result of Collaboration With APTA

    This week, UnitedHealthcare (UHC) announced a pilot program in 5 states that will waive the cost of copays and deductibles for 3 physical therapy sessions for patients with low back pain (LBP) living in Connecticut, Florida, Georgia, North Carolina, and New York. The pilot, which could affect as many as 1 million enrollees, goes into effect July 1, 2019. Other states will join the program in 2020 and 2021.

    Specifically, the pilot will be available to UHC enrollees with new onset of LBP when receiving care from an outpatient in-network provider. This benefit change will not extend the enrollee’s physical therapy or chiropractic benefit maximum, and will apply only to services related to treating back pain. Enrollees must have physical therapy or chiropractic benefits remaining in order to use this benefit.

    UHC will send emails about the benefit change on a quarterly basis to enrollees in the 5 states as they gain access to the benefit. Information also will be included on myuhc.com in the enrollee’s benefit information under Rehabilitation Services - Outpatient Therapy and Chiropractic (Manipulative) Treatment.

    This pilot follows a multiyear collaboration between APTA, OptumLabs, and UHC that included publication of a study in the American Journal of Managed Care (subscription required). This study affirms that higher copays and payer restrictions on provider access may steer patients away from more conservative treatments for LBP, including physical therapy and chiropractic services. "Innovative modifications to insurance benefits," authors write, "offer an opportunity for increased alignment with clinical practice guidelines and greater value."

    "This type of collaboration between a professional association and a private insurer is key to advancing the essential role of the physical therapy profession in improving outcomes for patients," says Carmen Elliott, MS, APTA's vice president of payment and practice management. "APTA continues to advocate for benefit design that is validated by data and meets the needs of patients, providers, and payers.”

    The study's authors, which include APTA member Christine M. McDonough, PT, PhD, hypothesized that patients with LBP who had easier access to a wider array of providers and lower out-of-pocket costs would be more likely to first seek out conservative approaches such as physical therapist (PT) or chiropractic services.

    Researchers looked at 5 years of claims data from OptumLabs Data Warehouse for 117,448 adult patients to determine the relationship between health plan benefit design and patient choice of primary care physician (PCP) versus a physical therapist or chiropractor as the first-line provider for new-onset LBP.

    Patients were excluded if they were not enrolled 2 years before and after the onset of LBP with no prior diagnosis of LBP or back procedures, or if they had filled opioid prescriptions within a year of LBP onset. Included patients could not have had any neoplasm diagnosis in the previous year or recent LBP-related diagnoses, such as spinal fractures, that would require more intensive treatment.

    For the analysis, authors divided the patients into 2 groups: those who first sought treatment from either a PCP or a PT, and those who first sought treatment from either a PCP or chiropractor.

    Their findings include:

    Only 2.8% of the 82,052 patients in the PCP-versus-physical therapist group chose to see a PT first, while 31% of the 115,144 patients in the PCP-versus-chiropractor group chose to see a chiropractor first. The majority of patients had a point-of-service (POS) health plan, and approximately 30% had no copayment or deductible to meet.

    Fewer restrictions on provider access was associated with higher likelihood of seeking out physical therapy or chiropractic treatment. Compared with patients with a POS plan, patients enrolled in a preferred provider organization (PPO) plan—the least restrictive option—were 32% more likely to see a physical therapist first. Patients in exclusive provider organization (EPO) plans were 16% less likely than POS patients to see a physical therapist first. These findings were similar for choosing a chiropractor versus a PCP.

    Higher copayments decreased the likelihood of a patient seeing a physical therapist as first provider. Patients with a copayment over $30 were 29% less likely to see a physical therapist first than were patients with no copayment. This association was not evident for chiropractic.

    As deductibles increased, the odds of a patient seeing a PT first declined; this association was not consistent for chiropractic. Patients with a deductible between $1,001 and $1,500 were 19% less likely to see a PT first (as opposed to seeing a PCP) than were those who had no deductible, while patients in this level were more likely to see a chiropractor first. Patients with a deductible of $1,500 or more were 11% less likely to see a PT first and 7% less likely to see a chiropractor first.

    There were mixed results for consumer-driven health plans (CDHPs) such as health reimbursement accounts (HRAs) and health savings accounts (HSAs). Patients with HRAs were 16% less likely to see a PT first compared with patients without CDHPs, but they were slightly more likely to see a chiropractor first. Patients with HSAs were 25% more likely to see a PT first compared with patients without CDHPs. HSAs had no effect on the chiropractic group.

    "Our study has demonstrated that patients experiencing LBP are moderately responsive to network restrictions and cost sharing in their choice of entry-point provider," authors write. "Reductions in spending are not necessarily accompanied by improvement in value, particularly if patients bypass routine care that would prevent higher downstream costs."

    [Editor's note: McDonough is also the recipient of a 2015 Foundation for Physical Therapy Research Magistro Family Foundation Research Grant as well as a recipient of the 2009 New Investigator Fellowship Training Initiative in Health Services Research.]

    News From NEXT: 2018-2019 Marquette Challenge Raises Over $266,000 for the Foundation

    Students from across the country were recognized June 13 during the Foundation for Physical Therapy Research (Foundation) awards luncheon for their participation in the 31st annual Marquette Challenge—which for 2019-2020 will be called the VCU-Marquette Challenge. Virginia Commonwealth University (VCU) was recognized as the top fundraising school, raising $34,327. The challenge now takes on VCU’s name along with host Marquette University as part of the contest's tradition.

    Earning second place was the University of Pittsburgh ($22,648), and coming in third was the University of Delaware ($18,323). The Foundation also recognized Marquette University students for their financial commitment to the challenge in raising $25,000.

    The annual challenge is a grassroots fundraising effort coordinated and carried out by student physical therapists and physical therapist assistants across the country.

    This year, more than 150 schools nationwide participated in creative efforts to support the Foundation, raising a total of $266,019.

    Funds raised through the challenge go toward physical therapy research grants and scholarships and support the rigorous scientific review process that helps the Foundation identify the most promising new investigators. Since 2002, 27 research grants and scholarships have been awarded in the name of the challenge. Funds from the challenge also supported a recent high-priority research grant to look at physical therapist interventions for older adults who have multiple chronic conditions.

    To view the complete list of participating schools visit the Foundation's webpage.

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

    Feeling the beat of pain management: Don Walsh, PT, DPT, MS, associate professor of physical therapy at North Georgia University, has teamed with professors from the school's music department to offer a drum circle as part of a pain management program—an idea funded in part by Move Together's Pro Bono Incubator. (Gainesville, Georgia, Times)

    Helping to shape health care policy: Alan Meade PT, ScDPT, MPH, has been appointed to the US Centers for Medicare and Medicaid Services Advisory Panel on Outreach and Education. (CMS announcement)

    Assistant coach/PT: Maral Javadifar, PT, DPT, talks about the path that led her to her position as an assistant coach for the Tampa Bay Buccaneers. (ESPN)

    Foam roller risks: Danielle Weis, PT, DPT, has a few words of warning for foam roller fanatics. (wellandgood.com)

    I like big putts and I cannot lie: Morgan Lemos, PT, DPT, describes how physical therapy can keep golfers on the course. (NBC2 News, Fort Meyers, Florida)

    Quotable: “Physical therapy and occupational therapy are important to him because he’s trying to gain the strength to stand from his chair for his badge pinning and salute for the national anthem." -Jessica Greenfield, whose 11-year-old son Miller aspires to become a police officer as he struggles with the challenges of a neurodegenerative disease. Miller was recently accepted as a cadet in the Sacramento, California, police department. (CBS13 News, Sacramento)

    Strength, courage, and inspiration in fighting cancer: Michelle Masterson, PT, PhD, delivered a moving speech at a cancer survivor celebration held by the Eleanor N. Dana Cancer Center at the University of Toledo Medical Center. (Toledo, Ohio, Blade)

    Bringing a PT perspective to CMS: Carmen Cooper-Orguz, PT, DPT, MBA, has been named to the US Centers for Medicare and Medicaid's annual advisory panel on hospital outpatient payment. (Federal Register)

    Sculpting a PT vision: Richard Smith PT, MS, has retired from his clinic position and is now making his mark as a sculptor. (Fairfield, Montana, Sun-Times)

    Getting in the swim of things: Laura Diamond, PT, MSPT, MS, leads a swim team of patients, family, and friends that competes in local fundraising events for cancer research. (Lincoln, Massachusetts Wicked Local)

    A PT's testimony on serving in the military as a transgender woman: Army Capt. Alivia Stehlik, PT, DPT, testified to congress about the contributions made to national defense by her and other transgender individuals in the military. (NBC News)

    When discomfort takes off: Blake Dircksen PT,DPT, offers tips on the best way to sit on a long flight. (lifehacker.com)

    Get some rest: Alika Antone, PT, DPT, discusses the importance of adequate sleep to good health. (South Sound Magazine)

    Don't stand for sitting: Kasey Kruse PT, DPT, outlines the risks of too much sitting, and what can be done to address them. (CBS News11/21, Dallas-Fort Worth, Texas)

    Quotable: "We physical therapists hope that people will begin to see physical therapy as a necessary and tremendously helpful part of maintaining a healthy lifestyle. Eventually, we hope people will come to physical therapy for an annual check up, so that we can spot dysfunction before it becomes painful and problematic." –Rena Eleazar, PT, DPT, on helping people to understand when they should see a PT. (Self)

    Helping heroes regain independence: Whitney Anderson, PT, DPT, shares her pride in being part of a rehab team that helped a wounded warrior gain independence through use of an exoskeleton. (KFOR News 4, Oklahoma City, Oklahoma)

    Easing plantar fasciitis pain: Chris Wilson, PT, outlines ways to manage plantar fasciitis at home. (Frontiersman)

    Got the (tummy) time? Tricia Catalino, PT, DSc, and Jill Heathcock, PT, MPT, PhD, discuss the importance of "tummy time" for infants. (New York Times)

    Worth the weight: Keaton Ray PT, DPT, ATC, provides pointers on how to start weight training the right way. (nextavenue.org)

    The Lakers' PT advantage: Judy Seto, PT, DPT, has been named director of sports performance for the Los Angeles Lakers. (lakersnation.com)

    The keys to more years in the driver's seat: Heidi Piccione PT, DPT, recommends movements that can build flexibility to help older adults keep driving. (Tampa Bay, Florida, Times)

    Journal-publishing how-tos: Christopher Kevin Wong PT, PhD, and Jean Fitzpatrick Timmerberg PT, MHS, PhD, share what they've learned about starting up an academic journal (they're cofounders of the Journal of Clinical Education in Physical Therapy). (Columbia University Medical Center newsletter)

    Let's dance: Michelle Reilly PT, DPT, explains how dancing can be an effective alternative to the gym when it comes to staying physically fit and active. (Omaha, Nebraska, World-Herald)

    Quotable: “There are times where somebody else has the knowledge that a physician doesn’t have to be the leader. A good example would be if physical therapy or some other modality is more important to the patient progressing. In those instances, the physician shouldn’t be necessarily calling the shots.” – Jason Higginson, MD, chief of pediatrics at eh Brody School of Medicine at East Carolina University, and co-author of JAMA module on working in interprofessional teams. (American Medical Association newsletter)

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

    News From NEXT: Oxford Debaters Argue: Is Social Media Hazardous?

    The verdict is in: social media is hazardous to the physical therapy profession. At least some of the time.

    That was the outcome of the 12th annual Oxford Debate, during APTA's NEXT Conference and Exposition in Chicago, which in traditional style-over-substance fashion included the pro team wearing hazmat suits while the con team adopted a Blues Brothers theme.

    "Our job isn't to say that social media is good or evil but that it's hazardous," Karen Litzy, PT, DPT, said in her opening remarks for the pro team. "People [complain], sell pseudoscience, and attack others. This is where social media becomes hazardous."

    Litzy was joined on the pro team by Jimmy McKay, PT, DPT (team captain), and Jarod Hall, PT, DPT. Taking the opposing position were Ben Fung, PT, DPT, MBA (team captain), Jodi Pfeiffer, PTA, and Rich Severin, PT, DPT. (Positions in the Oxford Debate are assigned, and may not reflect the personal opinions of the participants.)

    News From NEXT: Debaters Argue: Is Social Media Hazardous?


    Pfeiffer, dressed as Sister Mary Stigmata, led off for the con team, arguing, "Social media is vital. It's how we communicate with each other. Some people disseminate misinformation on social media. How do we correct it? On social media! We will use it to get rid of the misinformation."

    Hall responded, "One study said that, across social media, young professionals spend 116 minutes a day. Social media thrives on the misfortunes of others." Borrowing the concept of schadenfreude—defined as pleasures derived from the misfortunes of others—Hall referred to schandenFacebook. "It's where you relate the great things you said to Mrs Jones and ignore the stupid things you said to 50 others. Sometimes the grass looks greener (on the other side) because it's fake."

    Fung insisted that social media does more good than harm, asking, "Which is more hazardous to our profession: that questions are being asked or that we're not part of the conversations? One study found that only 1 in 10 people who need physical therapy will receive physical therapy. If you want to get the average person away from the screen, you have to be part of the conversation. The greater question is that when people ask questions, we're not there [on social media] in their time of need."

    Audience participation followed, with a near-even split of 7 for the pro position and 6 for the con. Among the comments:

    • Anything can be hazardous. If we're not using social media, we're missing an opportunity.
    • How many people at NEXT have met people on social media?
    • How many people have sat next to someone at NEXT who isn't paying attention because they're on social media?
    • Maybe we shouldn't be looking for evidence and research on social media.

    The attendees also made their views known by using clappers, running from one side of the room to the other as a debater made a persuasive point, and enthusiastically cheering.

    Severin summarized for the con team: "PTs are the movement experts. But people have an outdated image of physical therapy. #ChoosePT changed many views about physical therapy. The PT Day of Service, under the brand of physical therapy, has helped. Social media is key to that movement. Illinois and Texas recently adopted direct access legislation, and social media was vital in that effort. Social media has removed hazards to the profession. It's where we create communities. In addition, it's where patients and the next generation of PTs are going. We need to engage with our communities on social media."

    McKay summarized for the pro team: "My job isn't to show that social media is good or bad, just that it's hazardous. Social media leads you to do things you'd never do in person. … Social media is how the anti-vax science goes viral. This is how flat earth society thought goes around the world. Social media filters and distorts information. That's hazardous. But social media is not going away. So we must be safe when using it."

    After weighing the arguments and presentations, moderator Charles Ciccone, PT, PhD, FAPTA, found in favor of the pro team 29-23.

    Labels: None

    News From NEXT: For Optimal Outcomes, Look Beyond Compensation Patterns, Maley Lecturer Says

    "Any movement-related profession—personal trainers, athletic trainers, dance therapists, yoga instructors—who can observe impairments such as a weak muscle can try to fix it," said Beth Fisher, PT, PhD, FAPTA, in delivering the 24th John H. P. Maley Lecture on June 14 at Combined Sections Meeting. However, too often the "fix" involves the patient compensating with movement patterns that interfere with the ability of an affected limb to improve to its true potential. Fisher argued that with their level of education and skill, physical therapists (PTs) can and should identify and help the patient recover that capability.

    During her presentation "Beyond Limits: Unmasking Potential Through Movement Discovery,"

    Fisher said that in earlier clinician practice with patients with stroke and brain injury she continually hit ends points with her patients, but she realized "these were my endpoints and not the patient's, [because] at least 1 aspect of the movement abnormalities…were the results of compensation." Given the brain's ability to continuously alter its structure and function, and the body's ability to achieve movement goals in more than 1 way, people with an impairment tend to progress toward the movement pattern that is most efficient—achieves a goal using the least amount of energy and the fewest body parts. And while a compensatory solution may get the job done overall, this easy route that comes naturally may not lead to optimal improvement, thus denying the patient the best possible outcome. In fact, "the compensations [patients] choose may be the source of the problem—may actually predispose the problem to occur," Fisher said, by keeping the patient from exploring better ways to achieve their movement goals.

    She asked: Is this really the best we can do? "If we want to reach someone's full capacity, then we need to go beyond this limited choice that patients come up with on their own without a physical therapist," Fisher said. However, she argued, PTs have been academically trained to view movement from an impairment-driven perspective—the assumption that a patient's compensatory movement pattern results from an impairment that is masking his or her capability. And so both PT and patient expect that compensation will provide the best—or only—results.

    "If I have minimal expectations," Fisher asked, "how is that going to impact my patient's expectations? What is that going to do for recovery potential?" Instead, as professionals with the expertise to look beyond compensation approaches, PTs must encourage potentially riskier, more-difficult solutions. "With what we know about brain plasticity, it is our job to help patients realize that they have more options," she said.

    By modifying that implicit choice, the PT can help patients discover a capability they may not have even realized they have. "The most rewarding moments I have had in my career have come when I hear ‘I didn't know my leg (or arm) could do that,'" Fisher said.

    She noted that PTs can't ignore impairment, "but if we are only viewing the problem from that perspective then we and our patients will reach a plateau-minimizing capacity."

    Instead, every student and every therapist should include the perspective of looking at how a movement choice can mask capacity. "We need to start from the bottom up," Fisher said, "and teach students to observe movement and hypothesize how implicit choices—not just impairments—may be driving movement faults." Otherwise, "we have limited patients and their potential to discover other options for movement by a perspective that does not consider the choices they make."

    News From NEXT: McMillan Lecturer Outlines Keys to Excellence in the Physical Therapy Profession

    Tom McPoil, PT, PhD, FAPTA, said he intentionally structured the title of the 50th McMillan Lecture—"Is Excellence in the Cards?" as a question "to raise an element of doubt or uncertainty in our quest to achieve excellence." After all, he said during his delivery of the lecture on June 13 as part of the APTA NEXT Conference and Exposition in Chicago, he has several concerns regarding the profession's ability to achieve excellence.

    Before describing the reasons for his uncertainty, McPoil did recognize some of the profession's remarkable accomplishments since he began his career in 1973. "We no longer serve as a subservient technician in the health care system, our students now obtain an exceptional education and are granted a doctoral degree, we can practice in a variety of specialty areas in multiple practice environments, and we have achieved the ability to practice autonomously with patients having direct access to our services," he noted.

    But he said there still is room for improvement from both clinical and academic perspectives, and the remainder of his lecture outlined those perspectives. From the clinical standpoint, he described 3 areas.

    First, McPoil questioned continued acceptance of examination and management methods that may have been proven to have no evidence to support their use. As an example, he identified what is known as the podiatric model, which classifies foot types based on the concept of subtalar joint neutral position. McPoil said that subsequent studies—including those he and colleagues conducted—showed that "subtalar joint neutral position had no relevance to the typical pattern of rearfoot motion. In short, our results challenged the validity of the podiatric model." Yet, he continued, many physical therapist education programs and postprofessional continuing education courses still teach the model. McPoil expressed his hope that the profession will continue to stress the importance of using methods that have been validated with basic science and clinical evidence, especially at entry-level and in education programs, "as it is our new doctor of physical therapy graduates who must serve as our profession's change agents."

    Second, McPoil expressed concern over a lack of acknowledgment of historical research studies that provide evidence for a practice's continue use. He quoted a 2009 article by Mary Halefi ("Forget This Article: On Scholarly Oblivion, Institutional Amnesia, and Erasure of Research History," Studies in Art Education) that "recurring themes, issues, and concerns are part of any field" and failing to cite them along with more contemporary studies risks the loss of past scholarly endeavors upon which current research may be based. "Hopefully," McPoil said, "our professional journals will always perform their due diligence" to retain the contributions of past scholars and researchers in the profession.

    Inconsistence in the level of care was McPoil's third area of needed improvement. He noted some probable causes for inadequate care, such as limited patient time resulting from low payment rates, some highly specialized areas of practice that not all PTs are familiar with, and lack of clinical practice guidelines (CPGs) that address needed services. As for specialized areas of practice, he said that physical therapist-to-physical therapist referral was "rare," and the need for intraprofessional referral needs more emphasis during entry-level education. Concerning CPGs, McPoil argued that while important, they cannot always guide the clinician to an appropriate decision and "cannot replace the need for clinical reasoning and practice knowledge." He continued that such knowledge "can be achieved only through residency or fellowship training."

    To that end, McPoil said that it may no longer be feasible to train a generalist at the entry-level, and the profession must consider allowing specialization to begin before graduation. He identified challenges to developing residency and fellowship programs, such as student loan debt, salaries not commensurate with advanced clinical specialization, and a lack of federally funded support. He expressed his hope that the profession will prioritize development of these programs, as needed funding for them won't occur until they are the expected route following professional graduation. "Our pathway to excellence demands no less!" he said.

    McPoil followed up with his thoughts on achieving academic excellence, specifically the need for every faculty member to have "a personal agenda for scholarship that includes publication."



    News From NEXT: Building Wellness Programs in the Least Likely Places

    Sometimes, basic assumptions beg to be questioned. Just ask physical therapists (PTs) in the oncology rehabilitation department of Froedtert Hospital and Medical College of Wisconsin, who wondered why prevention and wellness couldn't be a part of the patient experience from the moment they entered the facility's doors.

    That questioning led to the development of an innovative group exercise program for patients checked in to the hospital for chemotherapy and other treatments primarily related to blood cancers—and so far, the program seems to be allowing many patients to leave as mobile, if not more so, than when they arrived. On June 13, the PTs shared their story of how they established and grew the program, known as the "Strength in Numbers" exercise class, as part of APTA's NEXT Conference and Exhibition in Chicago.

    The idea behind the program was based on a reality check of the typical path of an oncology patient visiting the hospital for treatment, explained Kelly Colgrove, PT. Unlike patients who arrive with other conditions such as congestive heart failure, "our patients walk in strong and independently." During the course of treatment, however, they often experience decreased muscle strength, challenging PTs to play catch-up before the patient is discharged.

    The Froedert PTs wanted to "Strength in Numbers" change that. As it now operates, the program—known as "SIN" to the amusement of patients—offers a 1-hour group circuit training class 2 times a week. Colgrove describe SIN as "a fun environment based on camaraderie and music, but all within the acute care setting."

    Patients are selected for the voluntary program based on their health at the time of check-in, Colgrove explained. Those whose condition is more fragile receive more typical 1-on-1 physical therapy. But the patients who qualify for SIN are assessed, given goals, and scheduled to participate in the group. Once the SIN group, patients still can choose to return to the more traditional therapy program.

    Besides the direct physical benefits to patients, the SIN program has helped to reinforce what the presenters call a "culture of mobility" at the hospital.

    The presenters led attendees through their process of developing and maintaining the program, encouraging audience members to think about similar possibilities in their own practice settings. They explained the importance of a solid basis in research, careful consideration of stakeholder concerns, evaluation of current and needed resources, and program metrics to evaluate outcomes, among other areas.

    Through their recaps, the presenters demonstrated how flexibility and creativity are key elements in all areas of development, implementation, and evaluation. "Being able to adapt and evolve is going to be key," explained Alyssa Kelsey, PT, DPT. For the SIN program, that means seeking ongoing input from patients and staff, as well as monthly check-in meetings to monitor operations and identify future goals.

    That flexibility should also include the capacity to question your own assumptions and evaluative measures, explained Colgrove. "Sometimes, the questions you think you want to answer at the beginning of the program may not be the questions you want to answer after a year," she said.

    One question has been consistent throughout the SIN program: Does it work? So far, the answer seems to be yes. Outcome measures for patients with a length of stay longer than 20 days and more than 50% participation in SIN found that 72% maintained or improved their 5-time sit-to-stand scores, 64% maintained or improved on Functional Gait Assessment, and 53% maintained or bettered their scores related to self-perceived deficits at discharge.

    And if patient enthusiasm for the program is any measure, the SIN program also seems to be doing well: according to the presenters, patients frequently have the same criticism of the offering—that the classes only occur 2 days a week.

    News From NEXT: How One Hospital Implemented Direct Access

    A panel of PTs from the Hospital for Special Surgery (HSS) in New York explained how that institution implemented direct access (DA) to physical therapist services during a June 13 session at APTA's 2019 NEXT Conference and Exposition. They then advised attendees how to operationalize DA at their own institutions.

    Presenters from HSS were Carol Page, PT, DPT; Mary Murray-Weir, PT, MBA; Robert Turner, PT, DPT; and Jaime Edelstein, PT, DScPT. Also presenting was Aaron Keil, PT, DPT, from the University of Illinois at Chicago.

    Keil noted that DA was achieved in all 50 states and the District of Columbia in 2015, but only 18 states have unrestricted access. The others include limiting or restrictive provisions, meaning there still are barriers to DA.

    He cited a 2015 APTA survey for which nearly 65% of respondents said the major administrative barrier to DA implementation was "My supervisor/facility requires all patients to have a referral." Keil noted that this is especially true in hospital-based inpatient and outpatient facilities, as hospitals tend to be more risk averse and "may be more restrictive than state law."

    Page said that an essential first step to achieving DA was getting buy-in. One key group was physicians—particularly surgeons—who were concerned that their patient levels would drop. Page explained, "We showed that direct access would 'widen the funnel' and actually provide them more patients," while at the same time screening to avoid sending inappropriate patients to the surgeons.

    Administrative staff was taught how to screen patients and schedule them with appropriate PTs. They also were made responsible for tracking timing and number of permissible visits for adherence to state provisions, building on an HSS foundation of training and competency programs it conducts for all staff.

    The hospital established criteria for DA PTs that were more stringent than required by the state. For example, while New York requires 3 years of clinical experience, HSS required that experience to be at outpatient facilities. It also required CEUs in certain areas, such as spine, manual therapy, and differential diagnosis.

    Turner described the development of a written exam for aspiring DA PTs. Questions were developed following the same item-writing guidelines used by the American Board of Physical Therapy Specialties. A score of 80% is required to pass the test.

    HSS also developed a practical examination involving an actual patient. The primary question to be answered is: "Can you take this patient and treat him or her? Or do you refer to a physician?"

    The program was made voluntary for PTs since some didn't initially feel comfortable with it. "Not everyone fits the mold," Turner said.

    Page addressed operationalizing DA, which she divided into 4 categories. The first was resources. She said, "APTA has amazing resources." She advised those in the audience to search APTA's website for "direct access" and browse the resources. The second category is billing, which she made clear "is different in a hospital setting" from a private practice and requires a hospital-wide effort. The team leading the DA program at HSS made a conscious decision not to contact insurance companies in advance and announce their intentions. "We did a soft launch with a small number of patients. We let them know that their interventions might or might not be covered," Page said, but he found that most insurers did cover the services, and HSS now contacts insurers in advance.

    The other elements of operationalizing DA were documentation and marketing. These included developing specific policies and procedures, providing notice of advice for patients, identifying common ICD-10 codes, and developing tip sheets for patients and physicians.

    The panel listed a series of lessons learned—things to do and things not to do. For example, don't:

    • Assume people understand what DA is.
    • Give up.
    • Be mean, defense, argumentative, or otherwise difficult to deal with.

    On the other hand, do:

    • Assume some people will think DA is illegal and/or unsafe.
    • Highlight improved patient access and patient care.

    Ask "How can we?" rather than "Can we?"

    News From NEXT: A Moving Account of a Journey Out of Pain and Addiction—And a PT's Crucial Role

    "I failed my marriage. I failed as a father. I failed my career. And I didn't even know it was happening."

    That's how Justin Minyard describes the lowest point in his life, when, after experiencing 2 spine fractures and receiving multiple surgeries, he became addicted to the opioids prescribed to him. He found himself consumed by his pain and his meds—how many he had on hand, when he could take the next one, where he needed to go to get refills. His addiction led to a suicide attempt and 2 accidental overdoses. But most devastating for Minyard was that his addiction hurt the people he loved the most.

    "I let them down," Minyard said. "You didn't want to be around me at that time."

    Now things are different. With the help of an interdisciplinary care team that included a physical therapist (PT), Minyard said he learned how to "make pain a footnote, not the header" of his life and defeat his addiction. He'll be 8 years' clean in July.

    Minyard's moving story was delivered as the keynote address at the opening event for APTA's NEXT Conference and Exposition, held June 12-15 in Chicago. The retired Army Master Sergeant recounted the injuries he received—first during a rescue attempt at the Pentagon during the 9-11 attacks and then while on a mission in Afghanistan—but focused more on what happened afterward: the multiple fusion and other surgeries, the intense pain, and his eventual slide into addiction.

    "I didn't wake up one day and say, 'this sounds great,'" Minyard said of his use of opioids; however, he believes his passive approach to exploring treatment options played a role in his use of drugs.

    "I was not an educated patient; I didn't ask questions," he told the audience.

    After more than 2 years of attempting to manage his pain through opioids and other medications—and becoming addicted along the way—Minyard began to see options for change.

    His last fusion surgery kept him in the hospital for 3 months. Then a physician who called Minyard a "hot mess" offered him another avenue: a pain management program that involved 9 different professionals including a psychologist, psychiatrist, a pharmacologist—and a PT. Minyard took him up on the offer, and moved from what he describes as a "pain-centric to a patient-centric model of care."

    Minyard credits his PT as helping him to accept the idea that, yes, he may be in pain for the rest of his life, but he could work to find ways to manage the pain to make it "more of a footnote, less of a header." Now Minyard says that on most days his pain level is moderate but manageable, around a 3 on the pain scale.

    Minyard also feels that it wasn't just about the physical therapy itself. He thinks his relationship with his PT was also a major factor in his recovery.

    "She wasn't just my PT, but my psychologist, my sounding board, my marriage counselor, my educator of my options, and my kick in the ass," Minyard said. "She was all of those things."

    That recovery included taking his PT up on a suggestion that he try handcycling. He liked it—so much so that he wound up medaling in traditional upright cycling at the Invictus games.

    Even more important for Minyard is how the changed approach to pain management gave him back his life with his family.

    "I am my 11-year-old daughter's soccer coach," Minyard said. "I get to be her coach. I don't know a damn thing about soccer, but I get to be her coach. But I almost lost that. I was this close, multiple times."

    While Minyard credits a single PT with a major role in his own recovery, he told the NEXT audience that the entire profession should be proud of the life-changing work they do.

    "You're going to continue to make such a tremendous impact on countless other patients," Minyard said. "Choose PT."

    Vision in Action: 2019 House of Delegates Sees Important Role for APTA in Host of Professional, Societal Issues

    APTA's outward-facing, forward-leaning vision continues to guide APTA’s House of Delegates. The policy-making body considered 70 motions during the 75th House session addressing a wide range of issues, yet 1 overarching theme was clear: the House believes APTA has the potential to be a change agent for the profession and society at large.

    APTA as Advocate
    Delegates approved multiple motions aimed at positioning the association as an advocate for a more diverse, equitable, and inclusive profession, beginning with a general statement that APTA "supports efforts to increase diversity, equity, and inclusion to better serve the association, profession, and society." The House also unanimously adopted stronger language around the association's commitment to nondiscrimination on the basis of race, creed, color, sex, gender, gender identity, gender expression, age, national or ethnic origin, sexual orientation, disability, or health status; as well as a charge directing APTA to work with stakeholders to advance diversity, equity, and inclusion in all areas of physical therapy, including clinical, educational, and research settings.

    The House also voted to add language to the Code of Ethics for the Physical Therapist (PT) and Standards of Ethical Conduct for the Physical Therapist Assistant (PTA) that more clearly describes the duty of PTs and PTAs to report verbal, physical, emotional, or sexual harassment. In addition, delegates approved revisions to the Standards of Practice for Physical Therapy that better align the document with the APTA vision statement and more explicitly reflect the role of PTs in population health and community engagement. In addition, the House created a single set of core values for both the PT and PTA to replace separate versions for each, noting in discussion that core values are common to PTs and PTAs but discrete from behaviors, which continue to be appropriately described in the separate ethics documents.

    Other profession-focused House actions included unanimous approval of the definition of the movement system as "the integration of body systems that generate and maintain movement at all levels of bodily function," further describing human movement as "a complex behavior within a specific context…influenced by social, environmental, and personal factors." The definition will further strengthen APTA's efforts to promote the movement system as a critical component of the physical therapy profession's identity.

    Societal Issues and population health
    The House passed multiple motions related to the ways both the association and individual PTs and PTAs are connected to larger societal issues. In addition to updating positions on the association's role in advocacy for prevention, fitness, wellness, health promotion, and population health, delegates voted to broaden APTA's ability to respond to health and social issues. The House provided examples of what those broader efforts will entail, approving motions that support taking a public health approach to gun violence, promoting public participation in vaccination schedules, improving health literacy, and supporting the availability in physical therapy settings of the drug naloxone to reverse the effects of an opiate overdose.

    A new area of specialization: wound management physical therapy
    Making it the 10th area of physical therapist clinical specialization, delegates approved the creation of a wound management specialty area for certification by the American Board of Physical Therapy Specialties, a proposal developed by the APTA Academy of Clinical Electrophysiology and Wound Management.

    Finally, in keeping with APTA’s ongoing efforts to follow best practices in governance, the motions deliberated at the House included the second phase of a complete review of all House-generated documents. The review, conducted by a special committee of the House over the course of 2 years, focused on updating, consolidating, and sometimes rescinding documents, resulting in recommendations for changes to more than 100 House policies, positions, directives, and other guidance.

    APTA Board Member Sheila Nicholson Dies

    Sheila Nicholson, PT, DPT, JD, MBA, MA, a member of the APTA Board of Directors and passionate advocate for the physical therapy profession, died on June 12, after a more than 2-year battle with cancer. She was 57.

    A physical therapist (PT) for more than 30 years, Nicholson dedicated herself to serving the physical therapy profession and its patients. After working solely as a PT for more than a decade, she earned a law degree and a master's degree in business administration and worked as a health care defense attorney while continuing to see physical therapy patients on weekends. She authored a book, The Physical Therapist's Business Practice and Legal Guide, and wrote multiple articles on risk management and medical malpractice.

    Nicholson joined APTA in 1982 and devoted herself to service in the association. She was elected to the APTA Board of Directors (Board) in 2014, after serving as president of APTA's Florida Chapter since 2009. Her long history of service also included APTA's Scope of Practice Task Force and participation in the APTA House of Delegates. Most recently, she was the Board lead on the effort to develop APTA's strategic plan for 2019-2021.

    "Sheila was a mentor, an educator, an advocate, and, above all, a friend to her family, colleagues, and APTA," said APTA President Sharon Dunn, PT, DPT, board-certified orthopaedic clinical specialist. "She was tenacious, thoughtful, and heartfelt, with an indomitable spirit that allowed her to be an active member of our Board until the end of her life.

    "Along with the rest of my Board colleagues, I am devastated by her loss and overwhelmed with gratitude for the opportunity to serve with her. Sheila has helped lay a firm foundation on which future generations will stand. Our condolences go out to Sheila's family—including the so many members of Sheila's APTA family whose lives she enriched.

    "And given her love for all things 'Bama, this LSU girl says from the bottom of her heart: Roll Tide!"

    Throughout her fight with cancer, Nicholson continued to advocate for the physical therapy profession and to stay involved with the work of APTA.

    In a prerecorded video shared with the APTA House of Delegates on June 10, Nicholson said, "I can't express how proud I am to have served with the people who are so dedicated to advancing our profession and making the world a better place. I am grateful for the opportunities I have had and for all of you, my colleagues and APTA family. Thank you for all you have given me. Most importantly, thank you for caring for our profession. I encourage you to make an impact that will outlast us all."

    Nicholson is survived by her parents, 2 brothers, and several nieces and nephews.

    APTA has posted a statement of tribute that allows readers to share their thoughts and memories. That page will be updated with memorial service and donation details when available.

    Can't-Miss Special Edition of PTJ Focuses on Intersection of Pediatric Physical Therapy and Developmental Science

    The June edition of PTJ (Physical Therapy) is something special: an entire issue devoted to the ways pediatric physical therapy and developmental science are informing each other—all to the benefit of children and their families.

    The issue shouldn't be missed, say Alyssa Fiss, PT, PhD, and Anjana Bhat, PT, PhD, both of whom are board-certified pediatric clinical specialists. PT in Motion News asked Fiss, a physical therapy professor at Mercer College, and Bhat, who teaches at the University of Delaware, to share their personal highlight of the issue. Here's what they had to say:

    Alyssa Fiss: "Michele Lobo and colleagues' ‘Wearables for Pediatric Rehabilitation: How to Optimally Design and Use Products to Meet the Needs of Users’ was a favorite of mine among many very strong articles. This article provides an excellent overview of the broad spectrum of wearable clothing and devices that support pediatric rehabilitation. Specific examples of wearables, with benefits and considerations for each, provide for interesting, thought-provoking reading about the variety of options available for children. When I read it, I was inspired to think of ways to creatively and intentionally use or design wearables to support children in active engagement and participation in daily life."

    Anjana Bhat: "I think 'Feasiblity and Effectiveness of Intervention With the Playskin Lift Exoskeletal Garment for Infants at Risk' by Iryna Babik and colleagues is one of the standouts of the issue. This is a beautifully written paper describing changes in reaching and cognitive performance over a 4-month period as well as a 1-month follow-up in infants born preterm or with birth injury, or both. This paper is unique in its use of a Playskin Lift garment to improve reaching and object exploration skills of young infants. Clinicians who work with challenging and highly diverse populations will gain a lot from this paper, including some new ideas on how to broaden their therapeutic toolbox. Parents should also be encouraged to explore what Babik and her coauthors have to say."

    But wait, there's more: in addition to the articles highlighted above, the special issue includes perspectives and original research on topics ranging from the ways motor skills development is connected to social skill development, to neonatal abstinence syndrome, as well as a case study on the use of electrical stimulation in gait training of adolescents with cerebral palsy. In all, 17 articles are included in the special issue.

    "Pediatric physical therapy and developmental science share a fundamental concern—the optimization of developmental outcome," write special issue coeditors Jill Heathcock, PT, PhD, and psychologist Jeffrey Lockman, PhD. "We believe this issue contains 'something for everyone'—practical information for clinicians in the trenches and intriguing trends in research for investigators."

    Attending the 2019 APTA NEXT Conference and Exposition? Stop by the PTJ booth in the APTA pavilion to find out more about the special issue and all of the other resources available at the journal's website.

    What's New at PTNow?

    PTNow, the association's flagship site for evidence-based practice resources, continues to expand in ways that help PTs and PTAs easily access the evidence they need in just a few clicks. If you haven't visited the site lately, check it out soon. Here's a quick take on the latest additions to the site. [Editor's note: member login required to access the resources listed here.]

    Recently added clinical practice guidelines

    Exercise and Physical Activity


    Neurological conditions

    Recently added Cochrane Systematic Reviews
    Cochrane reviews provide some of the most reliable information on evidence-based health care—thoroughly researched, carefully evaluated, and presented in a way that makes it easy to understand the effects of interventions on rehabilitation, treatment, and prevention.

    Recently, PTNow added the following 15 Cochrane systematic reviews to the more than 600 reviews already posted:

    Pelvic health



    Other Cochrane systematic reviews

    Recently Added CPG+ resources
    APTA's CPG+ program brings in identified member experts in research methodology to review selected CPGs and grade them based on the AGREE II tool. The result? A quality ranking of the guideline with highlights, plus a “Check Your Practice” list describing how you can incorporate the guideline into your clinical care.

    Latest CPG+ additions:

    Recently Added Tests and Measures
    Although many tests and measures are easy to administer, few are easy to find in their published formats. PTNow offers members licensed access to some 270 instruments for use in the clinic, with another dozen postings in development.The following tests and measures are recommended for use within the Physical Therapy Outcomes Registry. The Registry’s Scientific Advisory Panel has reviewed these tests and measures for appropriateness in terms of reliability, validity, feasibility of use, and adoption by physical therapists or other health care providers. Final results from these tests and measures can be manually entered into the Registry or synced from an electronic health record:

    Patient-Reported Outcomes Measurement Information System (PROMIS)

    Other tests and measures

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    What's New at PTNow? More Guidelines and Systematic Reviews Enrich an Already-Robust Resource(1)

    PTNow, the association's flagship site for evidence-based practice resources, continues to expand in ways that help PTs and PTAs easily access the evidence they need in just a few clicks. If you haven't visited the site lately, check it out soon. Here's a quick take on the latest additions to the site.

    Recently added clinical practice guidelines (member login required)

    Canadian Guidelines for Physical Activity Throughout Pregnancy

    Non-specific Low Back Pain

    Clinical Guideline and Recommendations on Pre-operative Exercise Trainng in Patients

    Awaiting Major Non-Cardiac Surgery

    Non-pharmacological Management of Persistent Headaches Association with Neck Pain: A Clinical Practice Guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa)


    Cerebral Palsy in Adults

    Rheumatoid Arthritis in Adults: Management

    Dementia: Assessment, Management, and Support for People Living With Dementia and Their Careers

    Practice Guideline Update Recommendations Summary: Disorders of Consciousness

    Recently added Cochrane Systematic Reviews

    Cochrane reviews provide some of the most reliable information on evidence-based health care—thoroughly researched, carefully evaluated, and presented in a way that makes it easy to understand the effects of interventions on rehabilitation, treatment, and prevention.

    Recently, PTNow added the following 15 Cochrane systematic reviews to the more than 600 reviews already posted:

    Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews

    School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review

    Interventions to promote patient utilisation of cardiac rehabilitation

    Interventions for treating urinary incontinence after stroke in adults

    Exercise for preventing falls in older people living in the community

    Aerobic physical exercise for adult patients with hematological malignancies

    Exercise training for advanced lung cancer

    Exercise-based cardiac rehabilitation for adult patients with an implantable cardioverter defibrillator

    Interventions for treating wrist fractures in children

    Yoga for treating urinary incontinence in women

    Positive end-expiratory pressure for preterm infants requiring conventional mechanical ventilation for respiratory distress syndrome or bronchopulmonary dysplasia

    Physical exercise training for type 3 spinal muscular atrophy

    Non-invasive positive pressure ventilation for prevention of complications after pulmonary resection in lung cancer patients

    Interventions to support return to work for people with coronary heart disease

    Constraint-induced movement therapy in children with unilateral cerebral palsy

    Recently Added CPG+

    APTA's CPG+ program brings in identified member experts in research methodology to review selected CPGs and grade them based on the AGREE II tool. The result? A quality ranking of the guideline with highlights, plus a "Check Your Practice" list describing how you can incorporate the guideline into your clinical care.

    Latest CPG+ additions (member login required):

    Recently Added Tests and Measures

    Although many tests and measures are easy to administer, few are easy to find in their published formats. PTNow offers members licensed access to some 270 instruments for use in the clinic, with another dozen postings in development.

    The following tests and measures are recommended for use within the Physical Therapy Outcomes Registry. The Registry’s Scientific Advisory Panel has reviewed these tests and measures for appropriateness in terms of reliability, validity, feasibility of use, and adoption by physical therapists or other health care providers. Final results from these tests and measures can be manually entered into the Registry or synced from an electronic health record (member login required):

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    APTA 2019 House of Delegates Election Results Announced

    The following members were elected to APTA's Board of Directors and Nominating Committee on Monday, June 10, at the 2019 House of Delegates in Chicago.

    Kip Schick, PT, DPT, MBA, was elected secretary.

    Kyle Covington, PT, DPT, PhD, was elected vice speaker of the House of Delegates.

    Deirdre "Dee" Daley, PT, DPT, MSHPE, Heather Jennings, PT, DPT, Board-Certified Clinical Specialist in Neurologic Physical Therapy, and Carmen Cooper-Oguz, PT, DPT, MBA, were elected director.

    Carole "Carrie" Cunningham, PT, Board-Certified Clinical Specialist in Orthopaedic Physical Therapy, and V. Kai Kennedy, PT, DPT, were elected to the Nominating Committee.

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

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    APTA Reveals Future National Logo as Part of Association Branding Project


    APTA is an association on the move, and soon it will have a logo to match.

    Monday night, the association unveiled its future national logo, which it will begin using in the summer of 2020, coinciding with the launch of a new APTA.org.

    The future logo can be seen at the end of a video that APTA CEO Justin Moore, PT, DPT, shared during his address to the 2019 APTA House of Delegates in Chicago. The logo's general shape pays tribute to multiple previous association logos—particularly in the use of a triangle shape, which can be traced back to the association's first logo from 1921.However, the mark also features contemporary design that evokes movement and hints at a more open, outward-facing association.

    The future logo inspired applause from delegates—and over the next few years there will be more reasons to celebrate as APTA implements other elements of its association branding project. APTA plans to rename several of its products, services, and events, and it is providing chapters and sections with the opportunity to align within the new brand system.

    The logo is one small but important piece of that.

    "The brand project is about ensuring that our collective value is greater than the sum of our parts," Moore said. "It's also about committing to a higher level of excellence across all our programs, products, and member experiences."

    The new association brand will be implemented in several phases, with most visual changes slated to coincide with the association's centennial in 2021.

    APTA's existing national logo has been in use since 1998. APTA also has dozens of unique product, service, and event logos—and that adds up to a disconnected and complex association experience, said APTA President Sharon Dunn, PT, DPT, Board-Certified Orthopaedic Clinical Specialist.

    "It's time to embrace change and imagine something different," Dunn said when discussing the brand in her annual address to the House. "Aligning our dozens of brands won't be easy, but the result will be a more accessible association. A unified brand strategy makes it easier for our community to engage, and it strengthens our collective voice. It's yet another chance to be better together."

    APTA's 3-year strategic plan includes an objective to "embody the APTA mission and vision through an integrated brand strategy," in order to help deliver on the goal to "maximize stakeholder awareness of the value of physical therapy."

    'Where Might We Be Now?' APTA Congressional Briefing Makes a Personal Case for Pain Treatment Alternatives

    The plan was set: on May 21, APTA would hold a congressional briefing on the importance of increasing patient access to nonpharmacological approaches to pain treatment. The event would be highlighted by the story of Cindy Whyde and her son Elliott, who became addicted to prescription opioids, and eventually heroin, after receiving an opioid prescription to treat a high school football injury 9 years ago. Elliott's road to recovery has not been easy.

    But the briefing didn't go as planned. Days before the Whydes were to travel to Washington, DC, Elliott relapsed into addiction and disappeared. Cindy came to the event alone, determined to do whatever she could to effect change. At the time of the event Elliott had been missing for 3 days.

    "That is one of the worst fears any parent should have to go through, not knowing where their child is and what's going on with them," Whyde said.

    And like any parent, Whyde couldn't help thinking about how things might've been different.

    "It runs through my mind all the time—if someone had given us an option other than pain meds when he was 17 years old, where might we be right now?" Whyde asked. "Elliott might be here right now sitting where you are. Instead I don't know where he is."

    The APTA-hosted event consisted of 2 separate-but-nearly-identical briefings, one for US House of Representatives staff, sponsored by Rep Rosa DeLauro (CT), and another for the Senate, sponsored by Sen Charles Grassley (IA). Essentially, the briefings were a set of object lessons in the ways health care policy affects lives in real and direct ways, with attendees receiving a clear overall message: changes, such as those suggested in APTA's white paper "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health (.pdf)" need to happen, and soon. [Editor's note: scroll down in this story to view a video of the entire House briefing.]

    Whyde was joined by Jen Bambrough, PT, DPT, and Sarah Wenger, PT, DPT, who provided personal perspectives on the need for better pain treatment options. Bambrough described the increasingly debilitating injury she received after a car accident in high school, and how, after multiple physicians, opioid prescriptions, imaging, and a visit to a neurologist, nothing was getting better. Finally, just as insurance company lawyers were beginning to question "whether I just wanted attention," Bambrough began seeing a physical therapist (PT). She worked with multiple PTs after that—some better than others—but eventually found a path to full health. Her experience inspired her to pursue a career in physical therapy, and she graduated with her DPT this year.

    The years of opioid-led treatments "made me very hopeless," Bambrough said. "I just wanted to tell them, 'I want to work, I want to go back to coaching, I want my life.'"

    Wenger, a clinician, educator at Drexel University, and volunteer at Drexel's 11th Street Family Health Services clinic, emphasized the importance of interdisciplinary collaboration and genuine conversations with patients.

    "I've heard that story a thousand times," Wenger said of Bambaugh's disjointed treatment experience.

    It doesn't have to be that way, she pointed out, relating the story of an 11th Street patient who arrived in pain from a sprained ankle. She was fearful of the injury for several reasons, including the possible ramifications from a less-than-empathetic employer, that were making the pain experience worse and pushing her down a path toward chronic pain. Finally with the help of an art therapist, the patient was able to express her fears, providing Wenger and other clinicians on her team with insight and allowing them to provide the person-centered treatment she needed to fully recover.

    Unfortunately, a few years later the patient experienced a neck injury from a car crash, Wenger said. Instead of receiving coordinated care for her pain, she followed a path directed to her by her attorney that involved multiple disparate providers and procedures. When she finally returned to Wenger's clinic, she was experiencing chronic pain.

    But it was Whyde's experiences that brought the current problems in pain treatment policy into starkest relief.

    Elliott, "my red-headed fireball," as Whyde sometimes refers to him, was a dedicated high school football player with prospects for playing in college. During his senior year, he experienced a shoulder injury but was determined to return to play as soon as possible. According to Whyde, the physician they saw said that the injury would continue to bother Elliott, and prescribed opioids to help him get back on the field.

    The rest of Elliott's story is, in many ways, too familiar.

    When his prescription ran out, a teammate gave Elliott leftover opioids from his prescription. After football season ended, Elliott continued taking the pills, and when the pills became impossible to find, he began using heroin. His addiction continued into the late summer. When he arrived at his college team's football camp, he stopped using and experienced withdrawal symptoms. Except neither he nor his mother understood that's what was going on.

    Eventually, the addiction won out. "By the end of that semester he was a full-blown addict and dropped out of school," Whyde said. "It was 'off to the races' at that point."

    Over the ensuring years, Elliott was in and out of treatment, staying clean for sometimes-lengthy periods of time but eventually succumbing to his addiction. At one point, Cindy had to administer 2 doses of naloxone to save her son from an overdose in their home.

    Things began looking better more recently. Elliott stopped using, thanks to treatment, and began working for the treatment center that helped him. Then he relapsed again, disappearing days before he was to tell his story on Capitol Hill.

    Whyde, a high school teacher, sees education—especially prevention education—as the key to disrupting the devastating pattern she witnessed. And she believes that education must include more information on alternatives to opioids in the treatment of pain.

    "We do the best that we can with the knowledge that we have. I know I would do anything I could to make life good for my children," Whyde said. But despite these intentions, an inadequate understanding of the dangers of opioids and a lack of information on the potential for other approaches to pain can lead to devastating results.

    "[Elliott] didn't want to become an addict—nobody wakes up and says 'I want to be an addict,'" Whyde said. "There are so many other things that should be done rather than go immediately to a pharmacological method of treating pain."

    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 (.pdf) that makes it easy for patients to assess the severity and impact of the pain they're experiencing.


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    Get Involved With APTA: 5 'Light Lift' (and Fun) Opportunities

    Maybe you've been thinking about getting more involved with APTA, but worry about the time commitment. Maybe committee service just isn't your thing. Maybe you have a story you've been dying to share with members. Maybe you just want to dip your toe in the involvement pool before diving in later.

    APTA's got you covered.

    Earlier this year the association launched APTA Engage, a comprehensive volunteer portal that makes it easy to find and apply for a wide range of volunteer opportunities—including some "light lift" options.

    Here are 5 suggestions for easy (and fun) participation in APTA.

    PT in Motion Asks…
    In July, PT in Motion magazine rolls out a new feature called "PT in Motion Asks…" that highlights member responses to various questions—why not submit yours?

    Share Your Volunteer Story
    Maybe you've volunteered with APTA in the past—so share your thoughts! The APTA Engage webpage includes a rotating "Volunteer Spotlight" that focuses on members' experiences with the association—all based on their answers to a few questions.

    Tell Your APTA Love Story
    The easiest volunteer opportunity yet. Tell APTA about the moment you fell in love with your association in 300 words or fewer, along with a photo of yourself making one of those 2-handed heart shapes (you know what we're talking about), and your love story could be posted in the APTA social media feed. Can you feel the love?

    Shoes4Kids (limited time offer!)
    If the shoe fits, donate it: the community service initiative, led by Brad Thuringer, PTA, that provides new athletic shoes and socks to local kids during APTA national meetings. Check out the APTA Engage description of the program to find out how easy it is to contribute (Shoes4Kids accepts money, as well as actual shoes and socks, btw), but hurry: the current initiative wraps up at the 2019 APTA NEXT Conference and Exposition in Chicago, June 12-15. (Tip: you don't have to attend NEXT to participate.)

    APTA Student Pulse blog
    This one's a little more involved, but a great opportunity for physical therapy students and new graduates to share insights: APTA's Student Pulse blog series is one of the association's most dynamic and popular offerings, and is always on the lookout for potential contributors. Add "published author" to your list of accomplishments.

    Ready for more?
    APTA Engage isn't just a place for short-term opportunities—it's also your connection to longer-term involvement in your profession at national and component levels. And those opportunities aren't limited to groups within the association, because APTA also nominates individuals to serve on the committees and advisory panels of federal agencies. Find out more at the APTA Engage pages on Federal Committees and Advisory Panels and the Medicare Payment Advisory Commission.

    VA Rolls Out New Community Care Program

    The US Department of Veterans Affairs (VA) released final rules related to a completely retooled program that allows veterans more choice in health care providers, but some of the provisions will apply only to certain regions (for now), and other interpretations of the new rule—including whether physical therapists (PTs) will be considered primary care providers—will be made as needs arise.

    The final rules released this week are related to implementation of the VA Mission Act of 2018, which consolidates VA’s community care programs into a new community care program known as the Veterans Community Care Program. Among programs being consolidated is VA Choice, the program created in 2014 to increase access and reduce wait times for VA patients by allowing greater use of non-VA providers. The VA Choice Program will continue to provide care to veterans until the new program is fully operational.

    Community Care Eligibility Criteria
    The Veterans Community Care Program final rule provides the nuts-and-bolts guidance on the operation of the new Community Care Network, the centerpiece of the Mission Act, and specifically on 2 of the central features of the Mission Act: how and when veterans might qualify for receiving covered non-VA care, and who can provide it. The new community care provisions will apply only to certain regions of the country upon rollout and will expand incrementally.

    When it comes to which veterans would qualify for non-VA care, the rule includes a long list of criteria, including the inability of a VA facility to provide the type of care the veteran requires, as well as factors including treatment frequency, geographical proximity of an appropriate VA facility, the veteran's ability to travel, and a "compelling reason" for the veteran to receive non-VA services, among others.

    Entities who want to be included as eligible non-VA providers will need to enter into a contract with VA, and either not be a part of (or employee of) VA or not provide the same services provided within the VA. The provider must also be accessible to the veteran, which includes a reasonable wait time to receive services. The rule also states that VA will announce quality standards through a separate document but predicts that "quality comparisons will generally be based on care that is locally available and not on national averages." In its comments on the proposed rule, APTA asked VA to clarify how it would define types of care, including primary and specialty care, and whether physical therapy would be considered primary care. The VA responded by taking a wait-and-see approach, writing that "we believe in a majority of cases that it will be clear what standard should be applied to what care."

    For now, the new system is being rolled out in states in Regions 1, 2, and 3 of VA’s new Community Care Network, which includes mid-Atlantic, southern, and Midwestern states: Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Iowa, Kansas Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, US Virgin Islands, Vermont, Virginia, Washington DC, West Virginia, and Wisconsin. The program isn’t expected to be operational everywhere until the end of 2019 at the earliest.

    Urgent care
    In another rule, VA clarified policies and procedures around covering veteran access to urgent care from non-VA providers without prior approval from VA. Qualifying facilities would include urgent care and walk-in retail health clinics.

    As in the community care rule, qualifying non-VA providers would need to enter into a contract or agreement with VA. Veterans could in turn go to those facilities to seek a range of urgent care, including flu shots, vaccines, certain screenings, and other services, so long as the care isn't emergent or based on care over an extended period of time. In the rule, VA states it will provide veterans with information on participating urgent care providers.

    In its comments on the proposed rule, APTA asked VA about whether follow-up care related to a covered urgent care visit would need separate VA authorization. VA responded by stating that follow-up care must be coordinated by VA.

    APTA regulatory affairs staff continues to monitor the implementation of the Mission Act and will post resources and information on its Veterans Affairs and TRICARE webpage.

    OSHA Responds to APTA by Affirming the PT's Role in First Aid

    When it comes to workplace injury, soft tissue massage is considered first aid for recordkeeping purposes, regardless of whether the health professional providing the treatment holds a certification in Active Release Techniques (ART): that's the bottom-line message from the US Department of Labor Occupational Safety and Health Administration (OSHA) in response to APTA’s request for OSHA clarification on the subject. The OSHA response definitively establishes physical therapists (PTs) among the providers able to perform soft tissue interventions that constitute first aid in work settings.

    The OSHA clarification is a response from a February 2019 meeting secured by APTA government affairs staff in partnership with the APTA Academy of Orthopaedic Physical Therapy’s Occupational Health Special Interest Group and the APTA Private Practice Section. It clears up a previously foggy area of agency regulation involving what is and isn't considered "medical treatment beyond first aid" in the workplace—an important distinction for OSHA, as any treatment beyond first aid must be reported as a work-related injury or illness.

    While the regulations state that "using massages" is considered first aid, APTA pointed out that previous OSHA guidance recognizing ART as a soft tissue intervention led some employers to mistakenly believe that only ART-certified individuals could provide “massage.” APTA asked OSHA to confirm in writing that soft tissue management is considered first aid when it is performed by individuals who do not have ART certification—including non-ART-certified PTs.

    OSHA did just that.

    "OSHA considers the treatments listed in…the regulation to be first aid regardless of the professional status of the person providing the treatment," writes Amanda Edens, director of OSHA's Directorate of Technical Support and Emergency Management. "Even when these treatments are provided by a physician or other licensed health care professional, they are still considered first aid for purposes of [the regulation in question]." Edens went on to state, “Accordingly, soft tissue massage is first aid whether or not such treatment is performed by individuals with ART certification.”

    The letter from OSHA also made it clear that the approach to recording soft tissue injuries and illnesses is the same as any other type of injury or illness, meaning that work-related injuries and illnesses "involving muscles, nerves, tendons, ligaments, joints, cartilage, and spinal discs" do in fact meet the general recording criteria if they involve medical treatment beyond first aid, days away from work, transfer, or restricted work.

    "Although this may seem like a minor clarification, it's a great win for PTs," said Kara Gainer, APTA director of regulatory affairs. "It's another affirmation that PTs play a valuable role in workplace health and safety, and can be an important part of employer prevention and wellness teams."

    Want more on the potential for PTs to contribute to population health in the workplace? Check out APTA's webpage "The PT's Role in Promoting a Productive and Healthy Workforce."

    Study: Burnout Comes at a (Literal) Cost to Organizations

    A recent PT in Motion magazine story that looked at burnout among physical therapists (PTs) and physical therapist assistants (PTAs) highlighted the ways the condition can impact the lives of individual providers, and characterized burnout as an "area of concern" for the profession. Now a study of physicians adds another dimension to the concern: burnout also comes with a hefty price tag.

    Authors of the study were well aware of the relationship between burnout and negative clinical outcomes, decreased patient satisfaction, and medical errors. What they wanted to uncover was burnout's economic impact—particularly in terms of the ways turnover and reductions in clinical hours reduced revenue for facilities. Their estimate: about $4.6 billion annually, or $7,600 per employed physician.

    The $4.6 billion cost figure was an average. Depending on the models they used, researchers estimated burnout-attributable costs ranging from $2.2 billion to $6.7 billion annually. Likewise, the individual physician cost ranged from $3,700 to $11,000 depending on the analysis used. Estimated turnover costs tended to represent the lion's share of the expenses, exceeding the costs of reduced productivity.

    To get this snapshot, researchers used results from physician surveys and other studies on physician turnover, and combined those with studies related to the value of hours worked and the cost of physician replacement including expenses related to search, hiring, and onboarding. Results were published in the Annals of Internal Medicine (abstract only available for free).

    APTA's focus on burnout—particularly on the ways undue administrative burden contributes to it—has led to several gains for the profession, including the elimination of functional limitation reporting under Medicare, an end to the functional independence measure in inpatient rehabilitation facilities (effective October 1 of this year), and reduction in the number of required assessments in skilled nursing facilities (also effective October 1). Other contributing factors, such as student debt burden, are also being addressed by the association, which offers an online financial solutions center to boost financial literacy and offer options for loan refinancing.

    Authors of the Annals study agree that "burnout is a problem that extends beyond physicians" to other health care providers, and they urge further research to uncover the costs involved, hinting that among some policymakers, an analysis of the bottom line may be key to helping them sit up and take notice of the problem.

    "Traditionally, the case for ameliorating physician burnout has been made primarily on ethical grounds," authors write. "Our results suggest that a strong financial basis exists for organizations to invest in remediating physician burnout."

    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: The Power of Adaptive Sports

    Adaptive sports are on the move as a popular way for individuals with physical disabilities to reclaim—and, sometimes discover—their love for physical activity. Do physical therapists (PTs) and physical therapist assistants (PTAs) need to catch up?

    In "The Competitive Edge of Adaptive Sports," featured in the June issue of PT in Motion magazine, Associate Editor Eric Ries examines the ways participation in the modified sports has changed the lives of several individuals—some of whom are PTs—who believed their injuries would forever prevent them from taking part in their favorite activities, such as basketball, cycling, and surfing. When they discovered the possibilities available through adaptive sports programs and leagues, a world they thought was closed to them was reopened.

    However, despite the growing prominence of adaptive sports, many feel that PTs and PTAs are behind the curve when it comes to having sufficient experience and understanding to help patients participate in the programs, according to the article.

    "Still in its infancy" is how Katie Lucas, PT, DPT, chair of the APTA Academy of Sports Physical Therapy's Adaptive Sports Special Interest Group, describes the profession's role in adaptive sports to PT in Motion. "There's a lot of room for growth in research and in terms of identifying and taking advantage of all the ways in which adaptive sports fit into physical therapist practice, enhance wellness, and expand opportunities for patients."

    The article plumbs the possible reasons behind the general lack of awareness, with PTs familiar with adaptive sports offering ideas for changes in physical therapy education programs that would familiarize students with the potential value of the programs. Some of those changes could be as simple as merely exposing students to an adaptive sporting event, they say, but the payoff could be significant for patients and providers.

    Maria Thomassie, PT, DPT, can attest to the benefits of understanding adaptive sports. She tells PT in Motion that being involved in adaptive sports has shed light on "how far we've come in creating an accessible world but how much further we have to go," adding that "there are insights to be gained by PTs and PTAs regardless of practice area."

    "The Competitive Edge of Adaptive Sports" 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 1 of the benefits of belonging to APTA. Also open to all: "Let Her Roll," a look at how PTs help roller derby athletes compete in the rink.