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  • It's Never Too Late: Study Finds Beginning PA Later in Life Reduces Mortality Risk Nearly as Much as Remaining Active From Adolescence

    You've probably experienced it before: your 40-something patient thinks that after 4 decades of relative physical inactivity, there's no point in starting now.

    Tell your patient to think again. A recent study that tracked leisure time physical activity (LTPA) levels of more than 300,000 adults for as long as 46 years concludes that middle-aged adults who take up LTPA for the first time reduce risk of all-cause mortality by nearly as much as adults who've remained active since adolescence. And that risk reduction extends to deaths related to cardiovascular disease (CVD) and cancer.

    The study analyzed data from an AARP-sponsored diet and health survey conducted from 1995 to 1996 in relation to mortality information from the National Death Index. The survey, administered to participants aged 50–71, asked respondents to identify levels of regular moderate-to-vigorous LTPA at various points in their lives—at age 15-18, 19-29, 35-39, and during the previous 10 years. A little more than 20 years later (2017-2018), researchers paired respondents with mortality reports to gauge the effects of LTPA on risk of death. Results were published in JAMA Network Open.

    Authors of the study had a sensible-sounding hypothesis—that participants who reported more LTPA in adolescence, and then maintained higher levels of LTPA throughout adulthood, would be found to have lower risk of all-cause, CVD, and cancer-related mortality. They were right—but there was more to the story.

    As they predicted, researchers found that compared with a control group that reported low levels of LTPA during their lifetimes (fewer than 60 minutes per week), participants maintaining moderate to high amounts of LTPA (2-8 hours per week) from age 15 to 40 or older lowered their risk of death, reducing all-cause mortality risk by 29% to 36%, and dropping CVD and cancer-related death risk by an average of 38% and 18%, respectively.

    To the researchers' surprise, however, adults who reported low levels of LTPA in adolescence but increased those levels after age 30 generated comparable reductions in risk of death compared with control—a drop of 35% for all-cause mortality, and reductions in CVD and cancer-related mortality of 43% and 16%, respectively.

    "We anticipated that participants who maintained the highest levels of activity throughout adulthood would be at lowest risk and were thus surprised to find that increasing activity early or late in adulthood was associated with comparable benefits," authors write. "These benefits held similarly for men and women…and were independent of changes in BMI over time."

    Researchers also found that respondents who reported high levels of LTPA in early adulthood but lower levels at 40 or older "appeared to have little all-cause or CVD-related mortality protection in midlife."

    Authors say their study supports earlier research into the benefits of PA in midlife, but they believe theirs is the first to look at LTPA over a longer period of time and to track increased or decreased levels of LTPA at multiple points. The results echo those of another recent study linking higher rates of PA midlife to lowered risk of Alzheimer's disease and other dementia in later years.

    [Editor's note: Visit APTA's prevention and wellness webpage for resources on how physical therapists and physical therapist assistants can help individuals become more physically active, and share the latest PA information from APTA's consumer-focused MoveForwardPT.com with your patients, clients, and others interested in the benefits of exercise and movement. Want to connect with others interested in physical therapy's role in improving health? Join APTA's Council on Prevention, Health Promotion, and Wellness. The association is also an organizational partner in the National Physical Activity Plan Alliance, and has a seat on its board of directors.]

    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.

    Too Much Focus on Productivity Increases Risk of Unethical Behavior, Say Researchers

    Employers that overemphasize productivity goals over evidence-based practice (EBP) may inadvertently set the stage for unethical behaviors by physical therapists (PTs) and physical therapist assistants (PTAs), say authors of an unedited new study published ahead of print in Archives of Rehabilitation Research and Clinical Translation. Organizational culture, say authors, is "the most easily changeable" factor in promoting ethical behavior.

    In an email survey, researchers asked licensed PTs and PTAs in the state of Texas about their practice settings, their employers' use of productivity goals, and observed unethical behaviors, such as inappropriately discharging patients or falsifying or changing documentation.

    The majority of the 3,446 respondents were women (70.5%) and had been practicing an average of 15 years. One-third of respondents were PTAs. The most-represented practice settings were skilled nursing facilities (SNFs) (23.1%) and private outpatient clinics (17.7%).

    Their findings include:

    The majority of employers set formal productivity goals. Of the respondents, 73.9% said their employers set productivity goals for them. Of that group, 85.1% indicated that the goal was based on billable units per hour. However, 54.5% said they had no input into the goal-setting process.

    The use of productivity goals varied by setting. SNF clinicians were most likely (97.1%) to report having productivity goals, while school system PTs and PTAs were least likely (13.2%). [Editor's note: an accompanying table in the unedited article includes different percentages.]

    As the rate of expected productivity increased, so did the rate of observed unethical behaviors. Of all respondents, 53.3% indicated their productivity goals were difficult or very difficult to meet, and 60.2% felt they were high or much too high. Most clinicians said that productivity goals influenced their clinical decision making.

    SNFs had the highest prevalence of observed unethical behavior as well as the highest frequency of each behavior. PTs and PTAs in SNFs were 4 times more likely as those in other settings to report having observed unethical behavior.

    Overall, unethical behavior is not widespread. While a majority of respondents had observed unethical behavior, 68.6% reported observing it "rarely" or "never."

    However, workplace cultures emphasizing ethics are not common, either. Only 38.9% of respondents said their organization's culture emphasized ethical practice, far below the business average of 66%.

    Focusing on ethics and evidence-based practice may discourage unethical behaviors. The degrees to which an organization emphasizes ethical and evidence-based practice were negatively associated with observed unethical behavior. Employees whose organizations emphasized productivity over EBP and ethical practice were, respectively, 6 times and 3.39 times more likely to have observed unethical behaviors.

    One of the contributing factors to unethical care is a payment environment that results in patients and clinicians being "disconnected from negative consequences" over overutilization, say authors. They write, "Historically, utilization of rehabilitation has been highly influenced by financial incentives, with significant variances in factors unrelated to caseload such as geographic location and payer source."

    Authors explain that business pressures toward overutilization often are accompanied by a gradual shift in the attitudes of clinicians, who "justify overutilization of rehabilitation services by portraying it as meeting their patients' desires or sustaining their own livelihood." This "moral re-construal" in turn paves the way for unethical behavior, with clinicians and patients seldom experiencing the results of overutilization, given the typical health care system with its long gaps between service delivery and payment.

    Given the ways business decisions can set the stage for unethical behavior, change must take place at the organizational level, which also happens to be "the most easily changeable component," researchers write. Among their recommendations: Survey employees about the ethical climate and organizational behavior; avoid the use of productivity standards based on billable units; and involve clinicians in developing productivity goals.

    "Use of productivity standards measured solely by the quantity of billable units is not advised," authors write. "We recommend that clinicians are involved in the setting of productivity standards."

    APTA members Justin Tammany, PT, DPT, MBA, ScD; and Janelle O'Connell, PT, DPT, PhD, were among the authors of the study.

    The issue of productivity pressures is at the heart of a "Consensus Statement on Clinical Judgment in Health Care Settings (.pdf)" collaboratively created by APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association. For more on productivity, check out "Measuring by Value, Not Volume," in PT in Motion magazine.

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

    Study: Light Physical Activity Could Help to Lower Risk of Coronary and Cardiovascular Problems

    No one doubts the positive health effects of regular moderate-to-vigorous physical activity (MVPA), but now researchers are finding that even light physical activity can reduce the risk of coronary heart disease and cardiovascular disease. The latest findings, focused on women age 65 and older, echo revised US Department of Health and Human Services (HHS) activity guidelines strongly supported by APTA.

    The recent study, published in JAMA Network Open, asked 5,861 women with an average age of 78.5 years to wear a hip accelerometer for a week to establish PA rates, and then tracked rates of later coronary heart disease (CHD) and cardiovascular disease (CVD) for nearly 5 years. Researchers were particularly interested in the effect of light physical activity (PA)—between 1.6 and 2.9 metabolic equivalent tasks (METs)—on the risk of experiencing CVD and CHD.

    Researchers divided the participants into 4 groups based on the average amount of time spent per day in light PA: 36-236 minutes, 235-285 minutes, 286-333 minutes, and 334-617 minutes. They also tracked rates of MVPA, as well as demographic, educational, and health information including the presence of chronic conditions, alcohol consumption, smoker or nonsmoker status, and use of antihypertensive and antilipidemic medications. The population studied was a mix of white (48%), black (33.5%), and Hispanic (17.6%) women.

    They found that during the study period, participants in the highest light PA quartile (about 5-10 hours of light PA per day) reduced their risk of both CVD and CHD by significant percentages compared with the lowest light PA quartile (about 30 minutes to 4 hours per day)—by 42% for CVD and 22% for CHD, adjusted for demographic and health variables. The reduction was dose-dependent, with every additional hour of light PA correlating to a 20% reduction in CHD risk and a 10% reduction in risk for CVD.

    When researchers factored in rates of MVPA (METs of 3 and above), they found risk reductions beginning with the second-lowest quartile (27 minutes or more per day). Compared with women in the lowest MVPA quartile, women in the highest MVPA quartile (a difference of 42 minutes per day) reduced risk of CHD by 46% and lowered CVD risk by 31%. Those results, so similar to the light PA risk reductions, told researchers that light PA could play a more important role in long-term health than previously thought.

    Authors acknowledge that women with the highest levels of light PA tended to have healthier levels of HDL-C, triglycerides, and glucose, as well as on-average lower BMI to begin with—factors possibly tied to genetics—but they still believe light PA itself has an important role to play.

    HHS agrees. Its latest revision to national physical activity guidelines emphasizes that "some physical activity is better than none," even while promoting the familiar goals of at least 150 minutes of moderate intensity PA or 75 minutes or more of vigorous PA per week for adults. What's different is that the new guidelines no longer include statements saying that PA must occur for at least 10 minutes to be effective, stressing instead the anything-is-better-than-nothing approach.

    "This study is encouraging, as well as another confirmation of what the new HHS guidelines tell us—that any amount of physical activity can positively affect health," said Hadiya Green Guerrero, PT, DPT, a senior staff specialist in the APTA practice department and a certified sports physical therapy specialist. "What's encouraging here is the emphasis on light physical activity, something that's attainable by adults who are older. It's important to have evidence that further supports the idea that PTs are doing well by their patients when they promote movement through usual and enjoyable physical activities like walking, gardening, dancing, stretching exercises, or playing with grandchildren."

    In an editorial that accompanies the JAMA Network Open article, author Gregory W. Heath, DHSc, MPH, characterizes the study as a "clarion call" for physicians, other health care providers, and health care systems to promote the HHS guidelines. "To temporize such action is to jeopardize the future health and well-being of older women," Health writes.

    Green Guerrero, who represents APTA on the board of directors for the National Coalition for Promoting Physical Activity, and who led APTA's recent collaborative efforts with the National Institutes of Health's "Go4Life" exercise campaign, says that APTA couldn't agree more.

    "APTA supports efforts that look to keep America healthy and level the health disparities playing field rather than continuing to spiral down the exponentially expensive sick care from which only a select few benefit," Green-Guerrero said. "As movement experts PTs intimately understand that blood flowing through arteries, to the brain, and to and from the heart are crucial to function and movement. It only makes sense that movement—any movement—will help things keep churning and, in the case of the evidence presented in this study, significantly reduce risk of preventable cardiovascular disease processes."

    [Editor's note: Visit APTA's prevention and wellness webpage for resources on how physical therapists and physical therapist assistants can help individuals become more physically active, and share the latest PA information from APTA's consumer-focused MoveForwardPT.com with your patients, clients, and others interested in the benefits of exercise and movement. Want to connect with others interested in physical therapy's role in improving health? Join APTA's Council on Prevention, Health Promotion, and Wellness. The association is also an organizational partner in the National Physical Activity Plan Alliance and has a seat on its board of directors.]

    Authors of the JAMA study say that while more clinical trials could help to better define the relationship between light PA and risk reduction, there's no reason to wait on promoting this type of PA.

    "The magnitude of these associations for light PA and their consistency across strata of CVD risk, physical functioning, and MVPA suggest that light PA could have much to offer older women in the prevention of CVD whether or not they can or choose to engage in MVPA," authors write. "Given the low risks of light PA and the abundance of light movements that are part of everyday life, even in the absence of trial data it may be prudent to encourage older women to increase light PA to improve their CVD health and reduce the occurrence of CVD events."

    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.

    Researchers Find 'Only Positive Effects' From PTs in Primary Care Role

    Get thee to a physical therapist (PT): according to a new study from Sweden, patients seeking primary care for musculoskeletal disorders (MSDs) who are triaged to a PT fare just as well—and in some respects, better—than those who are seen by a physician general practitioner (GP). It's a finding consistent with APTA's own investigations into the PT's role in primary care settings.

    Authors of the study, published in Therapeutic Advances in Musculoskeletal Disease, concede that, at 55 participants, their study was small. But they assert that their findings indicate that directing patients to PTs for primary assessment in primary care results in slightly better patient-reported outcomes related to pain, disability, and health-related quality of life (HRQoL) at follow-up, from 2 weeks to a year after initial visit. "Only positive effects were notable, and no adverse events regarding the triaging process were reported," they write.

    Researchers worked with 3 primary care health centers (PHCCs) in Gothenberg, Sweden, each serving a slightly different socioeconomic population (one serving patients experiencing generally lower socioeconomic conditions; one in a more affluent area; and one serving a more mixed population). PHCCs are the usual route taken by patients in Sweden seeking primary care, where patients are first assessed by a nurse, who determines a treatment pathway—including which provider the patient sees next.

    [Editor's note: want to learn more about how PTs are deepening their footprint in primary care? This 2018 article from PT in Motion magazine explores how the landscape is changing and offers links to APTA resources on issues related to primary care.]

    For the study, it wasn't a question of whether PTs should be delivering primary care—they were already doing that at the 3 participating PHCCs—but of how PT primary care affected outcomes. To make this assessment, researchers worked with nurses to randomly assign patients who normally would be referred to a PT to a control group that received "treatment as usual" (TAU) from a GP. The researchers then compared patient-reported outcomes from the PT and TAU groups at various points.

    Patients participating in the study were "working age" (16-67 years old) individuals seeking help for a new musculoskeletal condition; patients were excluded from the study if they required home visits, were receiving ongoing treatment for the current MSD, were seeking help for a chronic condition unchanged for 3 months or more, or possessed insufficient English or Swedish language skills to complete patient questionnaires.

    Both groups were asked to complete patient questionnaires on pain (0-10 rating scale), disability (Disability Rating Index), HRQoL (EuroQol 5), and risk for developing chronic musculoskeletal pain (Orebro Musculoskeletal Pain Questionnaire). Researchers also sought to determine whether the PT patient group developed different attitudes about responsibility for their MSDs, shifting more of that sense of responsibility to the patient and away from employers and/or medical professionals. Researchers asked patients to complete the questionnaires at initial consultation and 2, 12, 26, and 52 weeks later.

    Analysis revealed that while all patients improved at roughly similar rates, the PT group reported consistently better—albeit just slightly better—outcomes. The exception to that trend was in HRQoL scores, which improved for the PT group over the TAU group by a statistically significant margin.

    As for patient attitudes about responsibility for MSDs, the PT group tended to reduce what authors call "externalization" of the condition to health care providers, but a slight drift to greater externalization focused on employers after 1 year. However, researchers found that the changes in attitudes were slight.

    "This study indicates that early contact with both GPs and [PTs] can reduce the risk for patients developing chronic conditions with subsequent need for more comprehensive treatment," authors write. "As the effects of [PT] treatment were at least as good as TAU, it is clearly feasible to impose management modifications which can free medical competence for other patient groups. It is important to take care of even the group of patients with short-term or low-intensive musculoskeletal conditions to prevent development of chronic disorders."

    The researchers acknowledge that besides the small study population, the project also experienced patient dropout over time—particularly among younger patients in the PT group. Still, they contend, the findings support the role of PTs in primary care.

    "While it cannot be irrevocably concluded that initiation treatment by a [PT] is better for all patients with [MSDs] than [is] medical advice and treatment by a GP, there is nothing to indicate that this triage model for managing patients with [MSDs] in primary care is, in any way, detrimental to the patient health or worse than standard care," they write. "Triaging to [PTs] for primary assessment in primary care seems to lead to at least as positive health effects as primary assessment by GPs and can be recommended as an alternative management pathway for patients with MSDs."

    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.

    Researchers: Aquatic Exercise Offers Similar Results With Less Pain for Patients With Chronic LBP

    Aquatic exercise, a common physical therapist intervention for patients with chronic low back pain (CLBP), shouldn't be viewed as "less strenuous or less effective" than land-based exercise, according to authors of a recent study in PTJ (Physical Therapy). In fact, they write, water-based exercise can be beneficial for people whose movement is limited by pain.

    Researchers recruited 40 men aged 18 to 45 with a healthy body mass index. Half of participants had experienced CLBP for greater than 12 weeks; the control group experienced no back pain. Both groups performed 15 aquatic exercises and 15 land-based exercises with movement patterns similar to the aquatic exercises. Fourteen of the exercises included upper extremity dynamic movements, and 16 focused on the lower extremities.

    The authors measured heart rate, rate of perceived exertion, and pain. They also used video motion analysis and wireless, waterproof EMG sensors to measure bilateral activation of the erector spinae, multifidus, gluteus maximus, gluteus medius, rectus abdominis, external oblique, and internal oblique muscles.

    Among their findings:

    There were few significant differences between the CLBP and control groups. Heart rate (HR), rate of perceived exertion (RPE), pain, and muscle activation for both land and water-based exercises were similar for both groups. Patients with CLBP had greater mean left erector spinae activations in one exercise and higher RPE in another.

    Differences were seen when comparing results for exercises performed in water versus land. Muscle activation was greater on land in 29% of cases and in water in 5% of cases. Heart rate was higher on land with all exercises, but RPE was not consistently higher or lower in either environment.

    Pain was reported more than twice as frequently when subjects exercised on land. However, pain levels were generally low in both environments.

    While the study was small, and the researchers say it was the first to examine this data set for aquatic exercises, the fact that results were similar for both groups suggested to them that "exercising in the water can be beneficial for rehabilitation and strengthening by allowing people with CLBP to perform the exercises and activate muscles without their condition adversely affecting them."

    [Editor's note: interested in aquatic physical therapy? Check out the APTA Academy of Aquatic Physical Therapy.]

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

    Can Cognitive and Physical Activity in Midlife Reduce the Risk of Dementia in Later Years? Researchers Say Yes

    Staying intellectually engaged and physically active is an important part of a healthy lifestyle at any age, but now authors of a new study from Sweden say that cognitive and physical activity in midlife can pay off years later by reducing the risk of some forms of dementia. The results of the study showed that individuals who were cognitively active in midlife reduced their risk for Alzheimer's disease (AD) by as much as 46%, while those who were physically active reduced the risk of later dementia and stroke by 53%.

    The study, e-published ahead of print in Neurology, followed 800 women from 1968 to 2012, noting levels of cognitive and physical activity at baseline, and analyzing rates of various types of dementia as the women aged. Baseline activity ratings were taken when the women were 38-54 years old (average age, 47) as part of the Prospective Population Study of Women.

    Cognitive activity was assessed on 0-2 point scale based on each woman's level of involvement in 5 areas of activity: intellectual, artistic, manual, club, and religious. Activity in each category could range from no/low (0) to high (2). Information was obtained via "semi-structured psychiatric interviews."

    Physical activity (PA) was assessed using the Saltin-Grimb Physical Activity Level Scale, which assigns PA levels on a 4-point scale: 1 - completely inactive; 2 - light PA for at least 4 hours a week; 3 - regular physical training such as running or swimming for at least 2-3 hours a week; and 4 - regular intense physical training such as running or swimming several times a week or participating in competitive sports.

    After the initial assessments in 1968-69, participants were reexamined for cognitive and neurophysiologic function in 1974-75, 1980-81, 1992-93, 2000-03, 2005-06, and 2009-10. The last 4 follow-ups included "close informant interviews" that provided additional, third-party information on behavioral changes, activities of daily living, and, if it had occurred, the participant's age at onset of dementia. Information on potential confounders—education, socioeconomic status, hypertension, smoking, diabetes, angina, psychological stress, and depression—was also gathered.

    Between 1998 and 2012, 194 women—nearly 25%--developed dementia over an average 31.5-year timespan. Average age of dementia onset in the group was 79.8 years, and the overall average age at death was 80 years. In addition to total dementia rates, researchers looked at rates of AD, vascular dementia (VaD), "mixed dementia" (both AD and cerebrovascular disease [CVD]), and "dementia with CVD,” which encompassed individuals with any type of dementia and stroke.

    When researchers began analyzing rates of dementia in terms of baseline levels of cognitive and physical activity, they discovered a connection between that activity and lower risk of dementia, albeit in different areas: cognitive activity was associated with a 46% risk reduction for Alzheimer's disease, while PA was associated with a 37% risk reduction for mixed dementia and a 53% drop in risk for dementia with CVD. Both types of activity reduced overall dementia risk by about 33%. The reduced risk rates remained even when researchers factored in the potential confounders. Neither type of activity seemed to reduce the risk for VaD alone.

    Authors write that a possible explanation for the reduced risk has to do with the ways in which cognitive and physical activity increase "cognitive reserve," or "how flexible and efficiently one can make use of available brain reserve," even when measurable factors such as brain size and neuronal count are lower. It's a concept echoed in a study that appeared in Neurology earlier this year, in which researchers reported that higher levels of PA and motor skills not only lowered the odds of dementia, but seemed to buffer its severity if it did occur.

    Authors of the Swedish study acknowledge some significant limitations in their study, including its focus on a fairly demographically homogenous group, and the lack of any data on whether the women active in midlife remained so as they aged. Also "impossible to rule out," according to the researchers: the possibility that the lower cognitive and physical activity levels reported by some of the women were "manifestations of very early pathologic processes in dementia disorders."

    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.

    CPG: Avoid Surgery for Atraumatic Shoulder Pain

    Authors of a new clinical practice guideline (CPG) on treatment of shoulder pain took a hard look at the advisability of surgery and came to a conclusion that can be boiled down to 3 words: don't do it.

    Published in BMJ, the CPG focuses on adults with atraumatic shoulder pain lasting for 3 months or more (diagnosed as subacromial pain syndrome, or SAPS), and zeroes in on the effectiveness of arthroscopic decompression surgery versus nonsurgical approaches including exercise therapy, analgesics, and injections. The CPG development group, which included patients who had experienced SAPS, analyzed results of 2 systematic reviews—one on what constitutes a "minimally critically important difference" (MCID) in patient-reported outcomes, and another on the benefits and harms of decompression surgery. The systematic reviews included 7 trials involving 1, 014 patients.

    In reviewing the systematic review of MCIDs for SAPS, the CPG group identified, with confidence, 2 changes that patients value: a difference in pain of at least 1.5 points on a visual 1-10 scale, and a difference in function of at least 8.3 units on a 100-point scale. In both areas, decompression surgery resulted in no significant differences from other approaches—including placebo surgery. The lack of difference remained at 6-month, 2-year, and 5-year follow ups.

    Authors of the CPG also looked at 6 trials that compared surgery with exercise therapy, and although all were at high risk of bias due to lack of blinding, the results indicated that surgery demonstrated no advantages over exercise therapy in terms of pain, function, quality of life, perceived effect, and return to work.

    Armed with the conclusion that decompression surgery isn't any more effective than sham surgery or other treatment approaches, the CPG authors next analyzed the benefits and harms of the procedure. Again, surgery didn't fare well.

    After the guideline panel found that "potential harms from surgery were incompletely reported in the trials," the group requested that the systematic review be expanded to include observational studies that evaluated harm after the procedure. They found 4 sets of results from a large US study that found a roughly 0.55% risk of complications after 30 days. The harms included bleeding, infections, peripheral nerve injury, anesthetic complications, and venous thromboembolism.

    Given the procedure's risks and apparent lack of superiority in terms of effectiveness, "the panel concluded that almost all well informed patients would decline surgery and therefore made a strong recommendation against subacromial decompression surgery," authors write. "Clinicians should not offer patients subacromial decompression surgery unprompted, and others should make efforts to educate the public regarding the ineffectiveness of surgery."

    As for the alternatives to surgery, authors state that "the whole area of best management of SAPS is uncertain," including exercise therapy, manual therapy, and electrotherapies. Current evidence on these approaches show "uncertain benefit to patients compared with watchful waiting, and guidelines vary in their recommendations," they write.

    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 PTJ: PT, PTA Injuries Related to Patient Handling Still Common in LTC Settings

    Despite efforts by APTA and others to emphasize safety and the use of lifting devices, physical therapists (PTs) and physical therapist assistants (PTAs) working in long-term care (LTC) facilities continue to experience musculoskeletal disorders (MSDs) linked to patient handling incidents, say authors of a new study. Areas of injury most frequently cited by PTs, PTAs, and other "therapy personnel"—occupational therapists (OTs) and occupational therapy assistants (OTAs)—were the lower back, shoulder, and neck.

    For the study, published in the February issue of PTJ (Physical Therapy), researchers looked at a year's worth of workers compensation claims (WCCs) from a long-term care company with 202 skilled nursing facilities and 20 assisted living facilities, and compared those data with the results of confidential surveys completed by 2,642 employees of the company. While the primary aim of the study was to get a sense of the magnitude of musculoskeletal injuries experienced by employees, authors also were interested in how those injuries correlate to workers' perceptions of their job demands and whether they routinely used resident-lifting equipment.

    For the analysis, the authors divided the WCC claims into 4 categories related to the cause of injury: ergonomic (manual or patient handling, bodily reaction, repetition), workplace violence, acute incident (fall, slips, trips, being struck by an object), and other. The nature of the injury—acute, subacute, nonspecific, nonmusculoskeletal—and body region affected also were grouped into major areas. Employees were grouped into larger categories: therapy personnel, nursing aide, licensed practical nurse (LPN), registered nurse (RN), social/speech/respiratory service, technician, housekeeping/dietary maintenance, and office/administrative service.

    Among the findings:

    • According to WCC data, the most commonly injured body regions among all employees were upper extremities (37%), lower back/back and trunk (20%), and lower extremities (17%).
    • Therapy personnel had the lowest rate of claims for acute injury, at 2 claims per 1,000, but their average per-claim cost were the highest.
    • In terms of ergonomic injury among clinical staff, nursing aides reported the highest rate of injury, at 36 claims per 1,000. Therapy personnel were next, at 16 per 1,000—a rate similar to those of LPNs and RNs.
    • About 43% of subacute injuries (defined by the authors as "sprains, spasms, muscle contusions, carpal tunnel, tendinitis, disc hernias, and similar injuries") were related to patient handling incidents across all jobs, with nursing aides once again reporting the highest claims rate, at 58 per 1,000. Therapy personnel were next highest at 15 per 1,000.
    • Therapy personnel, RNs, and nursing aides reported low back pain at a similar rate—48.1%, 44%, and 47.5%, respectively. Therapy personnel registered higher rates of neck pain (24.4%) and shoulder pain (34.6%) than nursing personnel (14%-22% for neck pain and 25%-30% for shoulder pain).
    • In analyzing survey results among employee categories, researchers found that therapy personnel recorded the third highest "psychological demand score" (5.87 on a 2- to 8-point scale, behind RNs and LPNs), and the highest "physical demand score"(14.6 on a 5- to 20-point scale), followed by nursing aides (12.6).
    • Just over half of therapy personnel—53%—reported that they "never" or "rarely" use resident-lifting equipment. When asked to explain the use rates, "a majority of therapy personnel stated that treatment did not involve lifting because the goal was to make residents independent," authors write.

    "It is concerning that MSD symptoms and costs…for therapy personnel were higher than for nurses," the authors write. "Our finding on the low use of resident-handling equipment by therapy staff, and the rationale that equipment use interferes with therapy goals, are consistent with prior studies." This use pattern is common despite evidence of similar patient outcomes with and without the use of patient-handling equipment and safe patient-handling protocols, they add.

    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.

    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.

    Check Your QPP Status (Again)

    Beginning this year, Medicare's Quality Payment Program (QPP) applies to qualifying physical therapists (PTs). Does that mean you?

    The US Centers for Medicare and Medicaid Services (CMS) has recently updated its QPP participation lookup resource to reflect the rules for 2019. APTA recommends that even if you've checked on your participation status before, you should revisit the site to see if anything has changed.

    The QPP and its Merit-based Incentive Payment System (MIPS) represent some of the most sweeping changes to PT reporting and payment in years—and all indications are that the models will likely include more PTs in the future. Get up to speed with this major shift through resources available at APTA's QPP webpage.

    Researchers: Physical Therapy-Related Cochrane Reviews Largely Inconclusive

    The Cochrane Database of Systematic Reviews is widely considered the “gold standard” for health care professionals who want to know what current, high-quality research says about the efficacy of various interventions. But when it comes to physical therapy, a “researcher or clinician would not necessarily be able to turn to [Cochrane reviews] for a definitive answer” on a treatment strategy, write authors of an article in the International Journal of Rehabilitation Research (abstract only available for free).

    Reviewers for the Cochrane Collaboration—an international network of subject-matter groups that produces evidence-based resources—are known for their systematic analysis of evidence obtained from randomized clinical trials and provide recommendations for specific interventions. Like any systematic review, Cochrane reviews (CRs) are based on the existing research, and randomized controlled trials vary in quality.

    For the Rehabilitation Research study, a multidisciplinary group of researchers in Japan turned to physical therapy to find out what CRs had to say about various interventions. They examined 283 CRs to evaluate just how conclusive the evidence is with regard to physical therapy, as well as what factors influence the degree of conclusiveness.

    Authors classified a CR as “conclusive” if it identified a particular intervention as “superior to another” or found that interventions are “equivalent.” Inconclusive reviews concluded that “no decision can be made.”

    While the authors acknowledge that CRs “often show a lack of strong evidence for the efficacy of a particular treatment or strategy,” they found that an overwhelming majority of reviews related to physical therapy—94.3%—were inconclusive and recommended further study, a rate higher than in many other areas of study. Reviews that evaluated a larger number of trials or included greater total numbers of patients were more likely to list conclusive results; still, even among CRs with conclusive results, 68.8% recommended further study.

    According to the authors, many factors were associated with recommendations for further research, including low-quality study design, small sample sizes, too few available studies, and not enough data on participant subgroups or on adverse effects.

    “The low proportion of conclusive studies may be attributable to the poor quality of evidence” in physical therapy, the authors write, noting, however, that, unlike other areas of study, blinded randomized controlled trials are “often hard to achieve” in physical therapy research.

    Authors emphasized that although inconclusive reviews cannot assist in clinical decision making, “high-quality inconclusive reviews…are of great value” to identify gaps in the literature and areas for further study.

    And while there's much work to be done to increase the number of physical therapy-related CRs with conclusive recommendations, authors think the effort is worthwhile—and timely.

    “Trials in physiotherapy are worth conducting, as the field is positioned as a new frontier and is receiving much attention," they write. "Future research in physiotherapy and further development of the [Cochrane Collaboration] are eagerly awaited.”

    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.