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  • 2019 APTA Honors and Awards Nominations Now Open

    Members of the physical therapy profession do amazing things for people every day, and not just inside the walls of a clinic. And with National Physical Therapy Month upon us, now's the perfect time to honor those contributions by nominating an APTA member for national recognition through the APTA Honors & Awards program.

    The APTA Honors & Awards program is now accepting nominations for the 2020 awards cycle, an annual effort aimed at celebrating members' outstanding achievements in the areas of education, practice and service, publications, research, and academic excellence. In 2017 the awards program was expanded to include humanitarian work and societal impact, and this year's awards program features 2 new opportunities: outstanding physical therapist fellow and outstanding physical therapist resident.

    The program also includes the Catherine Worthingham Fellows of APTA, the Mary McMillan Lecture Award, and the John H.P. Maley Lecture Award.

    Detailed award descriptions, eligibility information, and nomination instructions for these and the many other awards and honors in the program are available on the APTA Honors & Awards webpage. Deadline for nominations is December 1.

    Award winners will be recognized at the 2020 NEXT Conference and Exhibition, set for June 3-6 in Phoenix. For more information, email Alissa Patanarut.

    CMS Releases a Burden Reduction Rule That Affects a Wide Range of Facilities, Settings

    In this review: Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction; Fire Safety Requirements for Certain Dialysis Facilities; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care (final rule)
    Effective date: November 29, 2019, for most provisions; March 30, 2020, for implementation of hospital and critical-access hospital (CAH) antibiotic programs; March 30, 2021, for changes to Quality Assessment and Performance Improvement Programs in critical access hospitals
    CMS Press Release
    CMS Fact Sheet

    The big picture: An omnibus rule that could ease some regulatory burdens
    The US Centers for Medicare and Medicaid Services (CMS) has released a final rule aimed at reducing Medicare- and Medicaid-related regulatory burdens in a range of settings, from hospitals to home health care. And for the most part, the rule hits its target.

    The final rule includes provisions related to outpatient rehabilitation facilities, home health agencies, ambulatory surgical centers, hospitals, CAHs, psychiatric hospitals, transplant centers, X-rays, community mental health clinics, hospice care, and more. For the most part, the changes either lift or relax requirements, giving facilities more leeway in meeting reporting and other duties. CMS estimates the changes will save providers 4.4 million hours of paperwork time and result in $800 million in savings annually.

    Most provisions in the rule go into effect November 29, 2019.

    Notable in the final rule

    • Relaxed emergency preparedness requirements for most settings—except long-term care facilities (LTCs). The new rule changes a mandate for an annual self-review of a provider's or supplier's emergency program to every other year, except for LTCs, which will still have to submit reviews every year. The move to biennial requirements is also applied to training and testing around emergency preparedness (again, with the exception of LTCs), and allows providers to choose the type of test they administer—either a community-based full-scale test, or a facility-based exercise.

    CMS will also lift a requirement that Medicare and Medicaid providers and suppliers must document efforts to contact local, tribal, regional, state, and federal emergency preparedness officials, as well as document participation in "collaborative and cooperative planning efforts."

    • Less burdensome evaluation rules for home health aides, and more limited requirements around notifying home health patients of their rights. The final rule also gives home health agencies (HHAs) more latitude in how they assess the competencies of aides to allow for a "simulation" on a patient or "pseudo patient." In addition, aides who are found to be deficient in certain skills will need to undergo retraining and revaluation only on those particular skills, and be subject to a comprehensive process.

    HHAs will also be operating under less rigid rules about notification of patient rights: instead of requiring verbal notification of all patient rights, providers will be required to provide notification only of rights related to Medicare, Medicaid, or other federal programs, as well as potential patient liabilities as described in the Social Security Act.

    Comprehensive outpatient rehab facilities get a break on utilization review plans. The new rule reduces the frequency of utilization reviews from quarterly to annually.

    • More flexible requirements for hospitals around the use of comprehensive medical histories and physical examinations (H&P) presurgery/preprocedure. Instead of requiring H&P, hospitals will be permitted to use a presurgery/preprocedure assessment if, in the hospital's opinion, that's the appropriate way to go. The assessment option must be well-documented, and hospitals must consider the patient's age, diagnoses, type and number of procedures to be performed, standards of practice related to specific patients and procedures, and all relevant state and local laws.
    • Fewer requirements for hospitals and CAHs that provide swing beds, and easier reporting requirements for CAHs. The new rule changes requirements for swing bed providers—hospitals and CAHs that designate some of their beds for skilled nursing facility care—in a few ways: CMS is removing requirements that the facilities offer patients opportunities to "perform services for the facilities" if they choose, as well as requirements mandating ongoing activity programs, a full-time social worker for facilities with more than 120 beds, and the provision of 24-hour emergency dental care.

    CAHs will see some lessened reporting burdens as well—they will no longer be required to disclose the names of people with a financial interest in a CAH, and a current annual requirement to conduct a policy and procedures review will be changed to every other year.

    APTA's efforts, and the possibility of more to come
    The new rule is part of CMS' broad "patients over paperwork" initiative that continues to explore ways to decrease the regulatory burden on facilities and individual providers, and APTA has seized every opportunity to provide input to CMS on the topic. The latest rule reflects only some of the areas addressed by the association, according to Kara Gainer, APTA's director of regulatory affairs.

    "As we've done in nearly every call for comment on administrative burden, APTA and individual PTs have highlighted multiple areas that we think are in need of change," Gainer said. "This rule is a step in the right direction, but there are many more steps that should be taken if CMS truly wants to fulfill its commitment to putting patients over paperwork."

    APTA will provide information on how to comply with the new requirements as it becomes available.

    Want to find out more about the new rule? CMS is holding a national stakeholder call on the burden reduction rule on Thursday, October 3, 2019, from 1:00 pm-2:00pm ET. To join in, call 1-888-455-1397 and use conference ID 4114189. TTY Communications Relay Services are available for the hearing or speech- impaired. For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.

    APTA to CMS: Proposed 8% Cut is 'Arbitrary' and Puts Patients at Risk

    The big picture: APTA is fighting a "nonsensical" and "arbitrary" plan to cut physical therapy reimbursement by 8% in 2021.
    The US Centers for Medicare and Medicaid Services' (CMS) proposed physician fee schedule (PFS) rule for 2020 is, as always, a wide-ranging plan that affects multiple types of providers. But this year, physical therapists (PTs), physical therapist assistants (PTAs), and the patients they serve are facing a particularly pointed threat: a cut to the reimbursement codes most often used in physical therapy. Combined, these reductions would reduce reimbursement by an estimated 8% in 2021. APTA's comment letter to CMS lays out how the cut could dramatically reduce patient access to effective care, forcing many PTs and other rehabilitation providers to leave Medicare or shutter their doors entirely.

    The comment letter also addressed numerous other provisions in the proposed rule, including changes to the Merit-based Incentive Payment System (MIPS), remote physiologic monitoring, digital evaluation, dry needling codes, and telehealth. Additionally, APTA reiterated many of its concerns regarding CMS’ proposal for determining when therapy services are delivered "in whole or in part" by a PTA or occupational therapy assistant. Those concerns were communicated to CMS in detail in August in a comment letter that described the plan as "fundamentally flawed." APTA and 2 of its members, along with 3 other associations, met in-person with the CMS Administrator earlier this month, echoing the same concerns.

    The proposed cut, and why it's a bad idea
    The cuts are associated with a CMS plan to adopt the American Medical Association-recommended increases in values for office/outpatient evaluation and management (E/M) codes, an increase that APTA sees as generally positive. The problem is in CMS' approach to paying for the increase.

    In order to adopt those increases and maintain budget neutrality, CMS proposes cuts to other codes to make up the difference. We believe there are other, more valid ways to respond: seeking additional funding for the increase; applying negative adjustments uniformly across all services; not excluding any specialties, procedures, or service codes; increasing the conversion factor; and phasing in any proposed reductions would be "appropriate and necessary" actions to take, as stated in our letter. Instead, CMS attempts to keep the E/M increase budget neutral through a seemingly haphazard approach that lowers reimbursement for non-E/M codes, resulting in the most drastic cuts to reimbursement for providers who don't bill E/M. That list of providers isn't limited to PTs and occupational therapists—it also includes audiologists, clinical social workers, clinical psychologists, ophthalmologists, optometrists, chiropractors, and more.

    In our comment letter to CMS, we point to 5 major areas of concern:

    1. The plan is an arbitrary, across-the-board cut that doesn't account for reimbursement decreases in other areas.
    We argue that PTs have been the target for cuts through other policies such as the multiple procedure payment reduction (MPPR), sequestration, Correct Coding Initiative edits, and by way of a 2018 revaluation of current procedural terminology (CPT) codes, particularly to the practice expense (PE) of certain codes. When those reductions are combined with the proposed 8% cut, on top of the pending 15% reduction in payment for services furnished by PTAs and OTAs in 2022, the reductions for many PTs could be closer to 23% in 2022. We call that an "unrealistic" plan that will lead to a "significant decline in beneficiary access" to physical therapy.

    2. The cut runs counter to CMS' efforts to provide patient access to better care.
    Both the US Congress and the Department of Health and Human Services emphasize the importance of a Medicare system that supports integrated team-based care, chronic disease management, and reducing hospital admission and readmission rates—concepts that are central to PT practice. Given this emphasis, we write, it's "nonsensical" to cut reimbursement to the very professionals who play key roles in achieving these aims by decreasing functional limitations and increasing strength and flexibility deficits.

    3. In the midst of an opioid crisis and a national conversation on pain management, CMS should be promoting physical therapy, not decreasing patient access to it.
    Research makes the case over and over again: physical therapy lowers overall costs of care, and is an effective pathway for management of many types of chronic pain. We ask CMS to explain how the proposed 8% cut supports those ideas, and argue that if Medicare beneficiaries are in need of access to effective nonpharmacological pain management treatments, "there must be adequate payment and coverage."

    4. There was little transparency and a seeming lack of responsible analysis in the development of this proposal.
    The Regulatory Flexibility Act requires CMS to conduct a regulatory analysis of changes, such as the 8% cut, including the ways it would affect small businesses and possible options for achieving its goals that reduce economic impact. If such an analysis was conducted, it doesn't seem to be reflected in the plan, which clearly puts PTs and many other providers at risk. We write that CMS' nontransparent approach and lack of dialogue with providers may have led to "many flawed assumptions regarding practice."

    5. The cut includes unfair reductions to practice expense (PE).
    PTs have seen reimbursement for PE—costs incurred in renting office space, purchasing supplies and equipment, hiring nonphysician and administrative staff, and more—decreasing since 2011, when CMS started introducing cuts through MPPR. APTA has always held that applying MPPR to PTs was inappropriate in the first place, and often results in underpayments. The proposed cut includes a PE reimbursement decrease of at least 3%. We write that it's a plan that puts "expediency ahead of quality." Instead, we argue for the removal of the proposed cuts to the PE values of codes used by physical therapists and that CMS recoup that money by looking to those codes used by providers "who do not have as demonstrable costs for equipment and supplies as physical therapy providers."

    What's next?
    The comments are one part of a multifaceted approach to advocacy against the proposed cuts. APTA members, patients, and other stakeholders have joined a grassroots effort opposing the plan, and the association has joined with the American Chiropractic Association, the American Psychological Association, the American Occupational Therapy Association, the American Speech-Language-Hearing Association, and 5 other professional associations in a letter opposing the cuts and requesting additional dialogue. APTA will continue to work with CMS to educate them on the negative consequences on patient health if this reduction is implemented. APTA and our members will also have a second formal opportunity to fight any proposed cut in the 2021 proposed fee schedule rule that will be released in July 2020.

    After the deadline for comments closes at 11:59 pm on September 27, CMS will begin its review process. The final rule is expected to be released in early November.

    Reading this before 11:59 pm on September 27? There's still time to add your voice to the effort. Visit APTA's "Regulatory Take Action" webpage to access a customizable template letters on both the proposed 8% cut and the PTA/OTA modifier proposal. It's easy—and crucial.

    APTA Co-Sponsored Study: Seeing a PT First for LBP Lowers Odds of Early and Long-Term Opioid Use

    In this review: Observational retrospective study of the association of initial health care provider for new-onset low back pain with early and long-term opioid use
    (BMJ Open, September, 2019)

    The message
    An analysis of more than 200,000 commercial and Medicare Advantage insurance beneficiaries has revealed what researchers describe as a "significant" pattern: among patients seeking treatment for low back pain (LBP), those whose initial visit was with a physical therapist (PT), chiropractor, or acupuncturist decreased their odds of early opioid use by between 85% and 91%, and lowered their odds of long-term opioid use by 73% to 78% compared with those whose index visit was with a primary care physician (PCP).

    The study
    Researchers reviewed insurance claims from 216,504 adults with new-onset LBP between 2008 and 2013 to explore the relationship between the type of provider seen at the initial (index) visit and subsequent opioid use. The study looked at opioid use in terms of both "early" use, defined as a filled opioid prescription within 30 days of the index visit, and "long-term" use—a filled opioid prescription within 60 days of the index visit and either an opioid supply of 120 days or more over 12 months or a supply of 90 days and 10 or more opioid prescriptions over 12 months. The analysis included claims for patient visits, inpatient and outpatient treatment with initial providers, and pharmacy services.

    Authors of the study were also interested in gauging the impact of varying levels of direct access to PT visits as allowed in state laws, and evaluated rates of initial physical therapy use in states with access laws they defined as "limited," "provisional," and "unrestricted."

    The de-identified data, provided by OptumLabs®, included both commercial insurance and Medicare Advantage claims, and are described by authors as "representing a diverse mix of ages, ethnicities, and geographical regions across the USA." The study itself was sponsored by the American Physical Therapy Association (APTA) and UnitedHealthcare®, and included APTA members Christine McDonough, PT, PhD, and Julie Fritz, PT, PhD, FAPTA, among the authors.

    Findings

    • Of the patients who met inclusion criteria for new-onset LBP (no previous LBP diagnosis, no previous back procedures for at least 12 months before the index event, and insurance enrollment for at least 12 months before and after the index date), 53% initially met with a PCP. Among what authors call "conservative providers"—PTs, chiropractors, and acupuncturists—chiropractors were the most frequently seen, drawing 23.1% of patients, followed by PTs (1.6%), and acupuncturists (0.8%).
    • About 18% of patients filled an opioid prescription within 3 days of the index visit, and 22% received a fill within the first 30 days. Only 1.2% of patients met the researchers' criteria for long-term use.
    • In terms of early opioid use, patients who saw a PT first had 85% decreased odds of receiving an opioid fill within the first 30 days after the index visit compared with patients who saw a PCP first. Patients whose index visit was with an acupuncturist were associated with 91% decreased odds compared with PCPs, and those who saw a chiropractor first were correlated with 90% decreased odds.
    • The decreased odds of opioid use with conservative treatment also carried over to long-term use, with 73% decreased odds associated with a PT index visit, 74% decreased odds for acupuncturists, and 78% decreased odds for chiropractors compared with patients whose index visit was with a PCP.
    • Compared with states in which direct access to PTs is limited, patients in states with provisional access to PTs—for example, states that impose time or visit limits—had 21% increased odds of seeing a PT at index. Those odds increased to 67% in states with unrestricted direct access.
    • Compared with patients whose index visit was with a PCP, patients who saw other types of physicians, such as orthopedic surgeons and neurosurgeons, tended to have lower odds of early opioid use—but those lower odds disappeared when it came to long-term use.

    Why it matters
    This large-scale retrospective study—authors believe it's one of a very few to look at opioid use patterns across multiple providers—adds to the evidence that conservative approaches to LBP can significantly lower the odds of opioid use, an important consideration as the country continues to struggle with its opioid crisis.

    The bottom line, according to authors is that "early engagement of conservative therapists may decrease initial opioid prescriptions in association with MD visits by providing the opportunity to incorporate evidence-based nonpharmacological approaches."

    More from the study
    Authors believe several factors might be at work when it comes to lower opioid use among patients whose index visit was with a conservative care provider:

    • These providers can't prescribe opioids, which may lower short-term use rates.
    • Patients who seek out conservative care providers may be doing so because they don't want to take opioids.
    • Conservative therapies tend to decrease LBP, lowering the need to seek other treatment.

    Related APTA resources
    The study's results are consistent with the policy recommendations in a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches. In addition, APTA offers a wide range of consumer-focused resources on pain and pain management at its ChoosePT.com website.

    Keep in mind…
    Because the study was based on claims data only, researchers couldn't account for the severity of the LBP being experienced by patients, a factor that could influence the decision about which type of provider to see first. Researchers were also unable to dive more deeply into patient preferences and behavioral factors that might influence index visits and opioid use.

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

    [Editor's note: McDonough and Fritz are also the recipients of grants from the Foundation for Physical Therapy Research: McDonough received a Magistro Family Foundation Research Grant in 2015 as well as a New Investigator Fellowship Training Initiative in Health Services Research grant in 2009; Fritz was awarded an Orthopaedic Research Grant in 2002.]

    APTA Student-Led 'Flash Action' on Federal Loan Repayment Program Sets Record

    Capitol Hill now has 14,000 additional reasons to increase access to physical therapists (PTs) in rural and underserved areas—and to provide student debt relief to some PTs along the way—as the result of one of the most successful APTA "flash action" events to date. And the profession's students can claim much of the credit.

    This year's Flash Action Strategy (FAS) event, held September 18 and 19, focused on advocacy around the Physical Therapist Workforce and Patient Access Act (HR 2802/S 970), a proposal that would include PTs in the National Health Services Corps (NHSC) and its loan repayment program. Participants in NHSC can receive repayment for up to $50,000 in outstanding student loans when they agree to work for at least 2 years in a designated Health Professional Shortage Area. This increased access to physical therapy instead of opioids for pain management could help reduce consumption of the drugs in some areas of the country hardest-hit by the opioid crisis.

    In the midst of already-packed semesters, students from multiple PT and physical therapist assistant (PTA) programs took time to participate in the nationwide effort, primarily using social media to concentrate their efforts during a 48-hour window of intense messaging. The students were joined by PTs, PTAs, and other stakeholders to generate a total of 14,148 communications advocating for passage of the legislation—the most ever delivered during an APTA FAS since its beginnings in 2013.

    "FAS is an opportunity for our voices to be amplified because of our unity, but it's also a reminder that each voice matters," said Kate Zenkder, SPT, member of APTA Student Assembly Board of Directors. "We hope the FAS is really just the beginning of a conversation with our representatives that should take place all year round about how we can all work to transform society. We can be a part of real change and transformation, but we need to join that conversation."

    PT and PTA students will bring their energy and excitement to the upcoming APTA National Student Conclave, set for October 31 to November 2 in Albuquerque, New Mexico.

    Kate's right: advocacy for the profession never stops. Find out how to add your voice to the conversation around the NHSC legislation and a host of other important legislative and regulatory issues by visiting APTA's "Take Action" webpage.

    PTs in Pain: Study Finds Relationships Between PTs Who Experience MSK Pain and Hours Worked, Patient Volume, and Years of Experience

    In this review: Professional experience, work setting, work posture, and workload influence the risk for musculoskeletal pain among physical therapists: a cross-sectional study
    (International Archives of Occupational and Environmental Health, August, 2019)
    Abstract

    The message
    A survey of physical therapists (PTs) in Spain revealed that about half of all respondents had experienced moderate-to-high levels of low back pain in the last 30 days, and nearly 3 in 5 had experienced neck pain in the same time frame. Researchers analyzed those and other areas of pain in relation to work conditions and demographic variables, and found several elements that they believe increase—and sometimes decrease—the odds of experiencing musculoskeletal pain (MP). Among the connections: larger patient loads, more hours worked per week, and more frequent use of machines and manual therapy raised the odds of some types of MSK pain, while more years of experience in the field tended to have the opposite effect.

    The study
    Members of Spain's physical therapy professional association were invited to participate in an online survey that asked them about any MP they may have experienced in the past 30 days, including the pain site as well as the severity of the pain on a 0-10 scale. For purposes of the study, researchers focused on pain episodes with ratings of 3 and above, and limited pain sites to neck, shoulders, upper back, low back, elbow/forearm, and hand/wrist.

    The pain episodes were then compared with self-reported work-related factors including years of experience, work in the public vs private sector, hours worked per week, number of patients per week, prevalence of treating multiple patients at a time, primary patient type, and primary type of treatment used. A total of 981 questionnaires were analyzed. The study population had an average age of 34.3 years, with females making up 70.6% of respondents.

    Findings

    • Overall, 57% of respondents reported experiencing moderate-to-significant neck pain within the past 30 days, and 49.4% reported low back pain (LBP). Upper back pain was the third most reported site at 36.1%, followed by shoulders (33.8%), hand/wrist (32.7%), and elbow/forearm (16.7%)
    • Higher odds of experiencing LBP were associated with treating more than 1 patient at the same time (2.14 times as likely than treating individual patients), working more than 45 hours per week (1.73 times as likely compared with working fewer than 35 hours per week), and working in a seated position (2.04 times as likely compared with standing work).
    • PTs who reported using exercise interventions as their primary type of treatment tended to have lower rates of neck pain compared with PTs whose primary approach was manual therapy. PTs who primarily used machines "consistently reported higher rates of upper back pain," compared with the use of manual or exercise therapy, according to the study's authors.
    • In addition to its correlation to LBP, working more than 45 hours per week was also associated with higher prevalence of upper back pain compared with PTs who worked fewer than 35 hours per week.
    • Patient load was found to have a weak-to-moderate effect on increased rates of shoulder pain, with PTs who treated 30 or more patients per week reporting a higher prevalence than those who treated fewer than 30 patients per week.
    • PTs with 6 to 15 years of experience were found to have lower odds of experiencing shoulder, low back, and elbow/forearm pain compared with PTs reporting 5 or fewer years of experience. PTs with more than 15 years' experience were found to have lower odds of experiencing pain in those same areas, as well as lower odds of neck pain, compared with the 0-5 year group.

    Why it matters
    While MP is common among health care providers, PTs tend to be at higher risk, with a recent systematic review predicting that as many as 91% of PTs will experience MP in their lifetimes. Authors of this study hope that their findings could help in the development of clinical guidelines and interventions "to prevent work-related MP and better working conditions among PTs."

    More from the study
    Authors were particularly interested in the reasons why more experienced PTs reported a lower prevalence of MP. They suggested 4 possible explanations:

    • Better patient management skills and "the dearth of practice about how to reduce the risk of MP"
    • Better injury prevention strategies among more experienced PTs such as "modification of treatment techniques or increasing the use of support staff"
    • Attrition as PTs who experience MP early in their careers leave those careers sooner (the "healthy workforce effect")
    • The possibility that "more experienced PTs developed a higher pain threshold due to higher work volume"

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

    Keep in mind...
    The study, based on survey results, looked at exposure and outcomes simultaneously, which can influence the ways associations are established. Additionally, researchers didn't know how many PTs received the initial survey, so they couldn't determine a response rate—data that could also color the findings.

    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.

    Leaders from Wyoming, Ohio, Minnesota, and Indiana Honored for State Advocacy Efforts

    Recognition of the importance of direct access to physical therapy for consumers, updating decades-old practice acts, and making it easier for patients to obtain handicapped parking plates and placards were among the accomplishments of this year's APTA State Legislative Leadership Award winners, The awardees were recognized at the association's recent State Policy and Payment Forum in Arlington, Virginia, hosted by the Virginia Chapter of APTA.

    This year, 4 members were honored for their service to the profession at the state level:

    Jamie Childs Everett, PT, DPT, was awarded an APTA State Legislative Leadership Award for her efforts to bring unrestricted direct access to Wyoming. As chapter president, Childs led the Wyoming Chapter in a legislative effort to remove the state's limitations on access, among the most restrictive in the country. The chapter's efforts were successful due in large part to her leadership around educating legislators on the need for change. The final bill, which was signed into law and took effect July 1, allows for unrestricted direct access in the state.

    Alan Howell, PT, ATC, received an APTA State Legislative Leadership Award in recognition of more than 7 years of service to the Ohio Chapter as state legislative chair. During his tenure, Howell led a 5-year effort to update the state physical therapy practice act’s definition of physical therapy to include diagnosis. To accomplish this, he led chapter efforts to improve grassroots involvement, PAC fundraising, and building stakeholder alliances, all of which significantly elevated the chapter’s profile in the legislature during that time. The expanded definition was signed into law in December 2018.

    Anne Johnson, PT, DPT, was recognized with an APTA State Legislative Leadership Award for more than a decade of outstanding efforts on behalf of the Minnesota Chapter. Johnson began her service by participating in the chapter’s Government Affairs Committee when she was still a student, and quickly expanded her involvement to include chairing various work groups and serving as committee co-chair since 2013. During that time, she grew the active membership of the committee, implemented a key contact program for state representatives and senators, and initiated the use of the Take Action App for the chapter’s lobby day. Johnson's leadership was integral in a recent chapter victory: the addition of physical therapists to the list of providers who may provide certification of disability for purposes of parking placards and plates. The new law became effective August 1, 2019.

    Emily Slaven, PT, PhD, received an APTA Legislative Leadership Award for her contributions to a multiyear effort in Indiana that resulted in a comprehensive update to the state's outdated physical therapy practice act. Slaven coordinated the chapter’s efforts to communicate with members about the chapter’s plans, led the organization of successful and well-attended lobby days in 2018 and 2019, and personally engaged in negotiations with several stakeholder groups to resolve their opposition to the chapter’s bill. The law, signed May 1, 2019, establishes an independent board of physical therapy, expands direct access from 24 to 42 days, includes a contemporary definition of the practice of physical therapy, adds new term and title protection provisions, and much more.

    Media Tour Takes APTA's 'ChoosePT' Message Nationwide

    Pain is complicated, and effectively addressing it requires open communication and a true partnership between providers and patients. Sarah Wenger, PT, DPT, believes that physical therapy can support just that type of relationship, and she took that message to TV and radio stations across the United States as part of a recent APTA satellite media tour.

    The "tour" involved linking up with TV and radio stations across the country to arrange for short remote interviews with Wenger, a clinician and educator with extensive experience in working with patients living with chronic pain. The daylong event was held during Pain Awareness month, and provided an opportunity to promote the association's retooled ChoosePT.com consumer site (formerly MoveForwardPT.com), as well as a more broad use of the "ChoosePT" call to action to include a wide range of conditions including pain.

    By the beginning of the tour day on September 18, 28 interviews were booked—17 for television and 11 for radio. The interviews tended to focus on how to address the opioid crisis through better approaches to pain management that involve interprofessional teams, a patient-centered approach, and honest discussions between patients and providers. Wenger emphasized how physical therapy can play an important role in the process. Most of the interviews were broadcast live, but some were recorded for later playback—meaning there's a chance you could hear an interview in the coming days and weeks. Check out this video of a live interview from WTMJ-TV 4, in Milwaukee, for an example.

    The day also included a lengthier interview with Jaqueline Andriakos, health director for Women's Health magazine. That interview, presented as a Facebook Live broadcast, allowed Andriakos and Wenger to discuss at length the more personal, patient-centered relationships physical therapists and physical therapist assistants try to build with their patients.

    In the Women's Health interview, Wenger talked about the importance of receiving a range of care for pain, including physical and mental health care, and how physical therapy's focus on movement fits into the picture.

    "When you're in pain moving is hard, and you end up in this bad relationship with pain where you're scared to move…and you end up doing less and less, and as you do less and less, you can do less," Wenger said. "You get less and less and less healthy, and movement is how you get yourself back to being healthy."

    19 - 09 - 20 ChoosePT Facebook Interview
    Sarah Wenger, PT, DPT, discussed pain management and role of physical therapy with Women's Health magazine in a recent Facebook Live event.

    ChoosePT: 5 Ways to Participate in National Physical Therapy Month in October

    National Physical Therapy Month (NPTM) is just around the corner. Are you ready?

    October is the profession's opportunity to amplify and promote the benefits of physical therapy, and APTA is here to help you get the message out. This year, #ChoosePT has expanded to include all the benefits of physical therapy, how it is effective for a wide range of conditions including chronic pain, and that connecting with a physical therapist (PT) can be as easy as visiting APTA's Find a PT directory.

    Getting involved in NPTM is easy. Here are 5 ways to share the ChoosePT message:

    1. Help consumers choose you.
    The best way to promote the profession is by increasing the public's engagement and positive experiences with physical therapy—in other words, by doing what you do best. But before you can make that very personal case, the public has to know you're out there and ready to help. APTA's Find a PT directory, a physical therapist member benefit accessible through our consumer website, ChoosePT.com, makes it easy for consumers and other providers to filter results by practice focus or specialization. Take the time to sign up—or if you're signed up already, make sure your information is up-to-date. You can even add a headshot to enhance your profile.

    2. Let the public know about ChoosePT.com.
    APTA's consumer website has a new name and a new look. ChoosePT.com includes the Find a PT directory, symptoms and conditions guides, health tips, podcasts, and more. Get the word out on what the site has to offer—it's easy to navigate and full of resources designed to help the nonclinician understand the value of physical therapy.

    3. Get social.
    This one's easy: use #ChoosePT in your social media posts, and be sure to follow us on Twitter and Facebook.

    4. Spread the word with handouts and flyers (and look awesome doing it).
    APTA’s updated ChoosePT toolkit offers downloadable handouts and graphics that help you get the word out. And because it just wouldn't be a celebratory month without swag, we're also offering new ChoosePT t-shirts that allow you to keep the message close to your heart (scroll to the bottom of the toolkit page to order).

    5. Celebrate Global PT Day of Service on October 12 by helping out in your community.
    PTs, physical therapist assistants, and students have a strong track record for being community-minded all year long, but October 12 is a special day set aside for letting the profession's dedication to community service really shine. Visit APTA's PT Day of Service webpage to find out more, participate in challenges, and find local projects to join.

    Questions? Contact APTA's public and media relations staff.

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

    He'll always be our PT Ninja Warrior: Conor Galvin, SPT, made it to the national finals of NBC's "American Ninja Warriors" competition. (Riverhead, New York, News-Review)

    Stiff is for upper lips only: Katie Sun Worrall, PT, DPT, offers advice on how adults can remain flexible as they age. (Wellandgood.com)

    Tiny homes for vets: Tim Terrio, PT, DPT, ATC, MS, is the originator of a plan to build 12 tiny homes to provide permanent housing for homeless veterans. (Bakersfield.com)

    Too much too soon: Nancy Robnett Durban, PT, DPT, MS, shares the kinds of injuries that are common among young athletes who focus intensely on a single sport. (Boston Globe)

    A much-kneeded guideline: Richard Willy, PT, PhD, explains the findings from the recently published clinical practice guideline on runner's knee that he helped to author. (abcFOX Montana)

    Getting back into the workout groove: Karen Litzy, PT, DPT, MS, emphasizes the importance of an evaluation by a physician or PT before getting back into an exercise habit after a long hiaitus. (Time)

    The #ChoosePT message: Matt Kudron, PT, DPT, helps viewers understand the benefits of physical therapy for a variety of conditions. (Fox21 News, Colorado Springs, Colorado)

    Virtually effective: Danielle Levac, PT, PhD, discusses the potential for virtual reality to aid in rehabilitation. (US News and World Report)

    Outrunning injury: Robert Gillanders, PT, DPT, offers advice on how to avoid common running-related injuries. (NBC News)

    Taking aim at injury prevention: Jeff Samyn, PT, provides tips to hunters on getting in shape for the fall hunting season. (Petosky, Michigan, News-Review)

    The view from Kilimanjaro: Scott Winkler, PT, DPT, recounts climbing Mount Kilimanjaro with his son Eric. (Murray, Kentucky, Ledger-Times)

    Getting past pain: Alan Meade, PT, BSPT, DScPT, outlines how physical therapy can help to manage pain. (WJHL News11, Johnson City, Tennessee)

    Don't be a slouch at aging: Eric Robertson, PT, DPT, adds his perspective on how older adults can improve their posture. (AARP magazine)

    #ouch: Collin Kudrna, PT, DPT, discusses the dangers of "text neck" and how to counter the condition. (KXNet.com News, Bismarck, North Dakota)

    Living active with arthritis: Karl Gilliam, PT, DPT, stresses the importance of movement—and physical therapy—to help individuals with arthritis stay active. (NBC2 News, Fort Meyers, Florida)

    Changing the game for lung cancer patients: Nicole Stout, PT, DPT, FAPTA, and Megan Anne Burkart, PT, DPT, discuss the importance of prehab and rehab to keep patients healthy during and after treatment for lung cancer. (Everyday Health)

    Quotable: "If medication requires a $10 copay and physical therapy requires a $50 copay, that's not equitable." – American Medical Association President Patrice Harris on the need to rethink copays as a way to increase patient access to medication-assisted treatment for opioid addiction. (Medpage Today)

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

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    5 Ways to Get Ready for Falls Prevention Awareness Day

    An estimated 1 in 4 adults 65 and older experiences a fall each year, and according to a recent study, falls-related deaths among adults 75 and older are on the rise, all of which makes falls prevention more relevant than ever.

    With Falls Prevention Awareness Day coming September 23, now is a great time to check out a few falls-related resources from APTA and its components. Here are a few ways to make the next few days a little more fall-focused.

    1. Check out the tests and measures at PTNow.
    In addition to being your source for clinical summaries, clinical practice guidelines, and research, APTA's evidence-based practice resource also includes a host of tests and measures—including many related to balance. Members can download information on the 360-degree turn stand, the balance error scoring system, the elderly mobility scale, and the falls risk assessment tool, to name a few. Some of the resources even come with accompanying videos. And don't forget other falls-related resources at PTNow, such as this clinical summary on fall risk in community-dwelling elders.

    2. Learn about (and share) the research that supports physical therapy's value in reducing fall risk.
    This 2-page pdf document compiles summaries of recent studies that underscore the important role physical therapists (PTs) and physical therapist assistants (PTAs) can play in falls prevention. It's easy to print out and share.

    3. Get involved with a SIG—or 3.
    SIG stands for an APTA "special interest group," a place where you can connect with other providers who share your passion for a particular subject. When it comes to falls, you have options: the APTA Academy of Geriatric Physical Therapy's Balance and Falls Special Interest Group, the Balance and Falls SIG sponsored by the APTA Academy of Neurologic Physical Therapy, and the APTA Academy of Oncologic Physical Therapy's Oncologic Balance and Falls SIG. You'll need to be a member of the respective academies first, but belonging to any of them has its own merits.

    4. Stay informed.
    APTA's Learning Center makes it easy to grow your knowledge around falls prevention by way of timely (and convenient) continuing education offerings offered at a discount to APTA members. Two relevant and relatively recent examples: "Physical Therapy and the Aging Adult: Management of Falls and Falls Prevention in Older Adults," a 0.4 CEU online learning course, and "Management of Balance Impairments and Fall Risks for Adult Cancer Survivors," a 0.7-CEU online course that explores a perspective surveillance model to decrease fall risk in this population.

    5. Help your patients and clients understand the importance of falls prevention.
    The risk of falls can't be reduced if patients aren't actively engaged—and that engagement begins with education. APTA's consumer focused ChoosePT.com website is designed to do just that, making it easy for nonclinicians to learn about a wide range of conditions and what PTs and PTAs can do to help. ChoosePT.com resources include a Physical Therapist's Guide to Falls that lays out the basics, an overview of how physical therapy can aid in falls prevention, a podcast on falls and falls prevention, and a short video on how balance can be improved—and falls avoided—through physical therapy

     Want more? Check out APTA's Balance and Falls webpage. Resources include tips on developing consumer events on falls and links to other organizations.

    Time to Act: CMS Proposes Significant 8% Cut to Physical Therapy in 2021

    [Editor’s Note: Response to CMS about the proposed PFS has been strong, and the more comments CMS receives the more likely they are to consider our recommendations. Use this prewritten template letter to add your voice by the September 27 deadline and strengthen our message even more.]

    In this review: APTA's response to a CMS plan to cut Medicare physician fee schedule (PFS) reimbursement for physical therapy providers by 8% beginning in 2021. The reduction for 2021 is included in the proposed 2020 PFS.
    Proposed 2020 Physician Fee Schedule (see table 111, p 1187)
    CMS Fact Sheet
    CMS press release

    The big picture: a proposed 8% cut in Medicare reimbursement for physical therapy providers in 2021
    Deep within the proposed 2020 PFS, CMS reveals a plan that puts Medicare beneficiary access to physical therapy at risk by way of an estimated 8% cut to fee schedule reimbursement in 2021. CMS says the reductions, which affect multiple providers to different extents, are driven by changes to reimbursement formulas for evaluation and management (E/M) services furnished by physicians and some other providers.

    APTA's message to CMS: significant cuts to fee schedule reimbursement for physical therapy providers will put challenging and likely unsustainable financial pressures on physical therapists (PTs), particularly in rural and underserved areas where access is already limited. As more PTs feel this pressure and opt out of treating Medicare beneficiaries—or close their doors altogether—patient access to care will suffer.

    "The changes to reimbursement for office/outpatient E/M codes itself are positive ones and we fully support access to primary care services, but the idea that these changes must be accompanied by deep cuts to other crucial services is outrageous," said Kara Gainer, APTA's director of regulatory affairs. "At a time when our aging population is in need of greater access to physical therapy, with its proven benefits and track record for reducing overall costs, CMS has instead decided to turn its back on the facts and put patients at risk."

    What we're doing—and what you can do (before September 27)
    We're preparing a formal comment letter to CMS, but that's just a part of APTA's efforts. Because the proposal affects multiple providers, from PTs and occupational therapists to clinical social workers, clinical psychologists, ophthalmologists, optometrists, and chiropractors, we're circulating a provider organization sign-on letter objecting to the cuts, and we're working with the American Occupational Therapy Association to develop an additional sign-on letter to be circulated among members of Congress.

    Even more important, we're urging APTA members to bring their individual voices to bear on this issue. We've created a customizable template letter that makes it easy to let CMS know how these proposed cuts will pose a real danger to Medicare beneficiaries and negatively impact PTs' ability to practice under Medicare. Make sure you get your comments to CMS by the September 27 deadline (the template letter includes instructions on how to submit to CMS).

    Tip: this letter is the second template letter we've created in response to the 2020 PFS. The first addresses the problematic physical therapist assistant/occupational therapy assistant coding modifier plan, and is still available for download. If you haven't yet completed and submitted that letter, you can combine it with the letter on the reimbursement cuts.

    What's next
    Deadline for comments is September 27, and the final rule will likely be issued by November 1. In addition to the sign-on letters described above, APTA and several other provider associations will meet with CMS officials in mid-September to share concerns and provide recommendations on a range of issues related to the PFS.

    APTA Launches New ‘Find a PT’ and ‘ChoosePT.com’ Website to Support Consumer Awareness

    Every day, people choose physical therapy for a multitude of reasons, from managing pain to building healthy lifestyle habits. Now APTA's consumer-focused website has a new name—and a new look—to support that reality and help connect patients with physical therapists (PTs) through an enhanced "Find a PT" feature.

    This week, APTA unveiled ChoosePT.com, a consumer website that replaces MoveForwardPT.com, now retired after 10 years. The new site is a best-of-both-worlds combination of 2 of the association's most high-profile and far-reaching initiatives—APTA's popular online source for consumer-oriented health information, now operating under a name that leverages the power of the association's award-winning opioid awareness campaign. The ChoosePT site is expected to receive more than 4 million visitors in 2019, with anticipated increases in the coming years.

    The transition to ChoosePT does not significantly change the content on the former MoveForwardPT site, which still includes information on symptoms and conditions, prevention, and pain management, as well as access to podcasts and videos that deliver powerful messages about the difference physical therapy can make in people’s lives.

    But not everything's the same: The changeover has allowed APTA to make improvements to the site's "Find a PT" directory, an APTA member benefit for physical therapists, that makes it easier for consumers and other providers to filter results by practice focus or specialization.

    The upgraded feature is an opportunity that members shouldn't miss, according to Jason Bellamy, APTA's executive vice president of strategic communications.

    “Millions of people will visit ChoosePT.com this year, and one of their most common destinations will be Find a PT," Bellamy said. "APTA members should ensure their information is up-to-date, and add a headshot to make their profile more appealing. Our message to members is, 'do everything you can to help consumers choose you.'"

    ChoosePT.com is also enhanced by geolocation technologies that, with a user's permission, create an online experience customized to the user's physical location. APTA state chapters that have an active geolocation page—49 to date—can add state-specific information to the ChoosePT site, providing visitors with an additional depth of relevant information.

    Bellamy believes the change to ChoosePT.com is the right move at the right time, with more exciting changes coming around the corner.

    “When we launched our opioid awareness campaign we knew our #ChoosePT message was dynamic enough to extend beyond the safe management of chronic pain,” Bellamy said. “With APTA’s centennial approaching in 2021, and the public awareness opportunities that will provide, this was the perfect time to make that our primary call to action.”

    Want t-shirts with the new ChoosePT logo? They're available here.

    New Rule Allows CMS to Deny Enrollment to Providers 'Affiliated' With Sanctioned Entities

    In this review: US Centers for Medicare & Medicaid Services (CMS) Medicare, Medicaid, and Children's Health Insurance programs; Program Integrity Enhancements to the Provider Process (final rule)
    Effective date: November 4, 2019
    CMS Press Release

    The big picture: a new level of authority for CMS
    CMS has released a final rule that gives it the power to revoke Medicare, Medicaid, and Children's Health Insurance Program (CHIP) enrollments of providers or suppliers who have an "affiliation" with previously sanctioned entities, even if those providers and suppliers aren't directly violating any existing rules themselves. CMS says the new authority will help to "stop fraud before it happens."

    While APTA supports efforts to reduce waste, fraud, and abuse in all areas of health care, we believe this rule may create more problems than it solves, particularly given an overly broad definition of what constitutes an "affiliation." The likely result: undue administrative burden for providers and suppliers who have been compliant from the start.

    The rule goes into effect November 4.

    Notable in the final rule

    • "Affiliations" authority. Under the new rule, all Medicare, Medicaid, and CHIP providers must disclose current or past affiliations with any organization that has uncollected debt, has had a payment suspension under a federal health care program, has been excluded from a federal health care program, or has had billing privileges denied or rescinded. If they don't disclose, CMS reserves the right to prevent them from participating in Medicare, Medicaid, and CHIP. These affiliations must be reported even if the other organization was not enrolled in Medicare, Medicaid, or CHIP at the time of the relationship.

    What's an "affiliation"? CMS provides 5 definitions:

    1. Direct or indirect ownership of 5% or more in another organization
    2. A general or limited partnership interest, regardless of the percentage
    3. An interest in which an individual or entity "exercises operational or managerial control over, or directly conducts" the daily operations of another organization, "either under direct contract or through some other arrangement"
    4. When an individual is acting as an officer or director of a corporation
    5. Any reassignment relationship
    • Expanded authority to revoke Medicare enrollment for other reasons. The final rule also gives CMS more power to revoke or deny Medicare participation for providers or suppliers who do any of the following:
    • Try to come back into the Medicare program under a different name.
    • Bill for services or items from noncompliant locations
    • "Exhibit a pattern or practice of abusive ordering or certifying of Medicare Part A or Part B items, services or drugs."
    • Owe CMS money from an overpayment referred to the US Treasury Department.

    Concerns
    When the rule was first proposed in 2016, we voiced our concerns in a comment letter that characterized the plan as an overly burdensome one that would prove costly for providers and, ultimately, decrease patient access to care as providers downscaled or ended their participation in Medicare. Not much has changed since then

    Between the extremely low 5% ownership threshold that triggers disclosure (APTA proposed a 25% bar), the requirements that providers disclose relationships with affiliates who weren't enrolled in Medicare at the time, and a poorly defined "lookback" requirement that puts a 5-year limit on how far back a provider must scour its records for bad-actor affiliates but no similar timeframe on how long ago that affiliate's violations may have occurred, the new rule is burdensome to say the least.

    Under the rule, we wrote, "providers and suppliers will be forced to become private investigators to determine whether an affiliate ever had its enrollment denied, revoked, or terminated. We believe this is simply not feasible and will divert time that physical therapists could spend on improving the quality of patient care rather than on regulatory requirements that will not make the Medicare program appreciably safer."

    Where things stand
    According to Kate Gilliard, APTA senior regulatory affairs specialist, now that the rule is final, the emphasis should be on monitoring for impacts and reporting problems to strengthen APTA's advocacy for changes in future versions.

    "It's clearly important for CMS and the physical therapy profession to make every reasonable effort to eliminate fraud in health care, and APTA will continue to work toward that goal," Gilliard said. "But this rule threatens to sacrifice patient access to care for the sake of a shotgun approach to the problem, adding further unnecessary burden to providers who already follow the rules. That's the message we will continue to bring to CMS."

    The new rule goes into effect November 4. APTA will provide information on how to comply with the new requirements as it becomes available.

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    Posture and Movement Coordination, Sensorimotor Integration May Affect Motor Skills in Children With Autism

    In this review: Postural Control and Interceptive Skills in Children With Autism Spectrum Disorder
    (PTJ, August 2019)

    The message

    In children with autism spectrum disorder (ASD), problems with sensorimotor integration and difficulty in coordinating posture and arm motions may result in impaired motor planning and control. These children also exhibited fewer anticipatory postural adjustments and demonstrated more corrective control during arm movements. Compared with typically developing peers, children with ASD were less likely to use visual cues to plan for motions required to catch an item, such as a ball.

    The study

    To examine the interplay of sensory cues, postural demands, and arm movement during ball-catching, researchers in Taiwan asked children with and without ASD to catch a ball rolling down a ramp toward them. Of the children, 15 had ASD and 15 were typically developing age- and sex-matched peers.

    During the task, each child was asked to catch a foam ball rolling down 3 stationary tubular ramps inclined at 4 degrees. The first ramp was placed directly in front of the child, while 2 others each were placed 35 degrees to the left and right. The first 59-centimeter section of each ramp was enclosed so that the child could not see the ball. A sensor within the tube activated a beep as the ball passed through, and, to test catching with and without visual cues, a second sensor lit up an arrow sign during half of the catching attempts.

    A real-time motion-capture system measured the children's arm movements while catching the ball. The authors measured center of pressure (COP) displacements using a computerized pressure plate and recorded ball-catching on video, both synchronized with the motion capture system.

    Findings

    • Children who were typically developing had a significantly higher success rate for all 3 ramps than did their peers with ASD.
    • Children with ASD were more successful in catching on the left side and right side ramps than they were in catching on the center ramp.
    • Visual pre-cues had no effect on rates of ball catching. However, children with ASD used visual information to plan their arm movements significantly less often than did their typically developing peers.
    • Overall, children adjusted their posture before moving their arms in nearly half of catching attempts. While children with ASD had a lower rate of postural adjustment for lateral ramps compared with their peers, all of the children were more likely to adjust their posture for lateral directions than they were for the middle ramp. Children with ASD made anticipatory postural adjustments later than did children who were typically developing, and all children adjusted their posture earlier when presented with visual pre-cues.
    • Amplitude of shoulder excursion was greater in children with ASD, and was higher overall when visual pre-cues occurred. In contrast, elbow displacements were larger when no visual pre-cues were present. Visual pre-cues were associated with slower arm movements for lateral catches. In general, children with ASD moved their arms faster than did their peers.
    • During lateral catches, both groups demonstrated larger COP displacements and greater COP velocity, but visual pre-cues resulted in slower COP velocity.
    • Children with ASD demonstrated more corrective control during arm movements than did their typically developing peers.

    Why it matters

    Physical therapist interventions for children with ASD, the researchers write, "could focus on the integration between perception and motor components as well as motor adaptability of the motor skills."

    Related APTA resources

    The association offers a Cochrane systematic review and several clinical practice guidelines through the PTNow resource area. Individuals who want to learn more about physical therapist treatment for autism spectrum disorder can visit APTA's consumer-friendly guide at MoveForwardPT.com, the American Physical Therapy Association's consumer website.

    Keep in mind…

    The study excluded children with intellectual disability and attention deficit and hyperactivity disorders, which might reduce generalizability to the entire ASD population. Also, the small sample size limited the authors' ability to analyze the effect of any comorbidities.

    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, where's you'll also find a clinical summary on Autism Spectrum Disorder in Children.

    New Clinical Guidelines Find Strong Evidence Supporting Exercise Therapy for Knee Pain

    In this review: Patellofemoral Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association
    (The Journal of Orthopaedic and Sports Physical Therapy, September 2019)

    The message    
    It's all about movement: In its first-ever comprehensive clinical practice guideline (CPG) on patellofemoral pain (PFP), APTA's Academy of Orthopaedic Physical Therapy (Academy) lays out a set of recommendations that stress exercise therapy as the best approach to improve functional performance in the short, medium, and long term. But that's just 1 facet of the guidelines, which also include recommendations on diagnosis, classification, and examination.

    The study
    A panel of content experts from the Academy conducted an extensive review of scientific articles associated with PFP from 1960 to 2018, evaluating each for its evidence related to physical therapist (PT) clinical decision-making around the condition. From an initial field of 4,691 articles, reviewers winnowed the studies down to 271 that addressed diagnosis and classification (120), examination (56), and interventions (95). The panel then analyzed the overall strength of evidence, and shared a draft of its recommendations with members of the Academy and, later, with a panel of consumer representatives and other stakeholders that included claims reviewers, coding experts, researchers, and academic and clinical educators.

    Recommendations were assigned letters according to the strength of the evidence evaluated: A-"strong," B-"moderate," C-"weak," D-"conflicting," E-"theroretical/foundational," and F-"expert opinion."  

    Among the Recommendations
    Recommendations within the following CPG categories include:

    • Interventions. CPG authors found strong evidence supporting exercise therapy with combined hip- and knee-targeted exercises to reduce pain and improve outcomes, stressing that a combination of hip and knee exercises is better than a focus on knee exercises alone.
      The guidelines also find strong evidence that dry needling shouldn't be used for PFP, and moderate evidence that clinicians should stay away from the use of "biophysical agents" including ultrasound, cryotherapy, electrical stimulation, and laser treatments.
      Taping was supported by moderate-level evidence. The guidelines state that clinicians should combine physical therapist interventions such as foot orthoses, taping, mobilizations, and stretching when appropriate, but that "exercise therapy is the critical component and should be the focus in any combined intervention approach."
    • Diagnosis. Use of diagnostic tests that reproduce retropatellar or peripatellar pain during squatting received an A-level recommendation as a diagnostic tool, as did "performance or other function activities that load the patellofemoral joint in a flexed position, such as stair climbing or descent."
    • Examination. Strong evidence supports the Anterior Knee Pain Scale, the patellofemoral pain and osteoarthritis sub¬scale of the Knee Injury and Osteoarthritis Outcome Score (KOOS-PF), and the visual analog scale (VAS) for activity or the Eng and Pierrynowski Questionnaire (EPQ) as ways to measure pain and function. Moderate-level evidence supports the use of "clinical or field tests" that reproduce pain and allow for assessment of movement. Authors write that "these tests can assess a patient's baseline status relative to pain, function, and disability; global knee function; and changes in status throughout the course of treatment."
    • Classification. The guideline panel found no "previously established valid classification system" for PFP, so it developed one. The system is based on impairment and function-based categories that include overuse/overload, muscle performance deficits, movement coordination deficits, and mobility impairments.


    Why the CPG Matters
    PFP is estimated to affect 1 in 4 adults every year, with women reporting knee pain twice as often as men do. Authors of the CPG write that while the recommendations shouldn't be considered a standard of care that guarantees a successful outcome for every patient, they are a reflection of the best-available evidence around the condition. They add that "significant departures" from the CPG "should be documented in the patient's medical records."

    APTA's Role
    The association provided funding and technical support during development of the CPG. This support is part of an ongoing APTA initiative to work with its sections and academies to produce a range of guidelines that highlight the evidence base for physical therapy in treatment of a variety of conditions. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    3D Technology: All That's Fit to Print?

    When it comes to 3D printing and physical therapy, the future is now—well, almost now.

    In the September issue of PT in Motion magazine: "A New Dimension to Physical Therapy," a feature article that explores the current use of 3D as well as its challenges and possibilities, as seen through the eyes of physical therapists (PTs), a physical therapist assistant (PTA), and a professor of visual arts who heads the University of North Georgia's 3D printing efforts.

    The APTA members interviewed for the story say that in many ways 3D printing has arrived in physical therapy—and already is allowing for the creation of customized equipment and devices, many of which can be produced relatively quickly, and some at a fraction of the cost of their non-3D printed counterparts. The possibilities for orthotics and adaptive equipment for pediatric patients are just some of the reasons the interviewees are excited about the technology's future.

    "Future," however, is the key word: While 3D technology has improved dramatically since its debut in the 1990s, refinements still are needed. And the cost of the devices—particularly those capable of manufacturing with multiple materials—must come down before they become standard equipment in a physical therapy clinic.

    The challenges aren't just technological—a clinic has legal and regulatory considerations should it decide to go all-in on 3D printing now or in the future. Patient safety is an issue, of course, but so is the line between a clinic that produces the occasional customized orthotic and an equipment manufacturer, and the attendant regulatory oversight that entails.

    Still, those challenges shouldn't overshadow 3D printing's potential in physical therapy, and they certainly shouldn't cause physical therapy education programs to shy away from incorporating 3D printing concepts into their curricula.

    Robert Latz, PT, DPT, who was interviewed for the article, says there's good reason for practicing PTs and physical therapy students to keep up with the technology and not wait until it's perfected.

    "We need to learn the technology and apply the development process to this new technology," Latz says in the article. "If we do not do this, someone else will. I guarantee that the technology of 3D printing is only going to continue to improve and that the cost to create with this technology will continue to decrease."

    "A New Dimension to Physical Therapy" is featured in the September 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: highlights from the 2019 APTA NEXT Conference and Exhibition.