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  • European Psychiatrists Recommend Physical Activity in the Treatment of Severe Mental Illness

    Could the effect of physical activity (PA) on the brain extend beyond a general sense of well-being? The European Psychiatric Association (EPA) thinks so and has issued guidance that recommends supervised PA as potentially effective treatment for individuals with severe mental illnesses (SMIs) such as schizophrenia and major depression. The recommendations are supported by the International Organization of Physical Therapists in Mental Health.

    The recommendations, appearing in European Psychiatry (abstract only available for free), are based on a review of 20 meta-analyses and systematic reviews gathered through January 2018. Researchers began with a pool of more than 2,000 studies but narrowed their review to studies of randomized controlled trials that specifically addressed exercise interventions for individuals with schizophrenia, major depressive disorder (MDD), and bipolar disorder (BP).

    Authors of the recently released guidelines were interested in the role of PA among the population of individuals with SMI not only in relation to its ability to lessen symptoms, but also as an intervention that could extend lifespans in that population. According to the researchers, individuals with SMI face an increased risk of early mortality by as much as 10 to 20 years, with physical disorders accounting for as much as 70% of those early deaths.

    The type of PA analyzed was focused on aerobic exercise, high-intensity exercise, resistance exercise, and mixes of aerobic and high-intensity exercise. Researchers excluded mind-body PA such as yoga and tai-chi, "since these activities are presumed to exert beneficial effects on mental health through additional factors distinct from the [PA] itself."

    In the end, authors found good evidence to support PA as a treatment for both schizophrenia and MDD, particularly when supervised by an exercise professional such as a physical therapist. For MDD, authors recommend 45- to 60-minute sessions of supervised aerobic training or aerobic and resistance training at moderate intensity 2-3 times per week. Research on optimal PA frequency, duration, and intensity for individuals with schizophrenia was harder to find, but authors make a general recommendation for 150 minutes per week of aerobic exercise to improve symptoms, cognition, and quality of life. Authors were unable to find sufficient research to reach a conclusion on the effects of PA among individuals with BP.

    Additionally, the researchers issued a recommendation, based on "some evidence," that PA should be used to improve the physical health of individuals with SMI—a recommendation that was limited by what authors describe as the "paucity of studies that have targeted this important topic." The set of guidelines also includes a recommendation, "based on expert opinion," that individuals with SMI should be routinely screened for PA habits in both primary and secondary care.

    Authors also include a set of 6 recommendations to address what they believe are the current gaps in research around PA and SMI. Recommended areas for research are investigation into the effects of PA in the early stages of SMI, the development of "pragmatic, scalable methods" for PA in the SMI population, establishment of optimal dose-response relationship between PA and SMI, exploration of interventions to reduce sedentary behaviors, identification of the underlying neurobiological mechanisms at work, and an analysis of the long-term cost-effectiveness of PA as a treatment for SMI.

    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.

    Survey Finds 'Considerable Variation' in Postsurgery ACL Rehab

    Authors of a new study say that while guidelines exist for rehabilitation after anterior cruciate ligament (ACL) reconstruction, there remains "a large degree of variation in rehabilitation progression" among physical therapists (PTs), particularly when it comes to timing of the progression, strength assessment, and use of patient-reported outcome measures

    Those conclusions, published in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free) were based on results of an online survey of 1, 074 members of APTA’s Academy of Orthopaedic Physical Therapy, American Academy of Sports Physical Therapy, and Private Practice Section. Authors believe that this is the first time PTs' private practice patterns in this area have been studied.

    As for the respondent pool, the majority of PTs treated patients in a private practice or hospital-based outpatient facility. Just over half (52.5%) held American Board of Physical Therapy Specialties certifications in either orthopaedic or sports physical therapy, and 92.5% were APTA members. Authors of the study also classified respondents by the volume of post anterior cruciate ligament repair (ACLR) patients they treated annually, with 32.3% falling into the "low volume" category of 1 to 5 per year, 28.8% grouped into a "medium volume" category of 6 to 10 patients per year, and 37.9% categorized as "high volume," with 11 or more post-ACLR patients per year. Researchers also tracked respondents by years in practice.

    Here's what they found:

    • Overall 56% of respondents reported the duration of supervised physical therapy at 5 or fewer months.
    • Regarding the length of time PTs would wait before recommending a patient initiate sports activity, 58% said 3-4 months for jogging, 50% said 4-5 months for modified sports activity, and 40% said 9-12 months for unrestricted sports participation. Given that most respondents reported treatment periods of 5 months or less, the number of PTs who don't recommend unrestricted participation until after 9 months postsurgery "imply that there may be a long gap between the discontinuation of supervised rehabilitation and return to activity," authors write.
    • Over 80% of respondents used strength and functional measures to assess patients during rehabilitation. Most PTs used manual muscle testing (MMT) to assess strength before progressing patients to jogging (80.6%) or modified sports (74.3%). Of those, 56% relied solely on MMT as a mode of assessment—a potential concern, according to authors, because MMT "may lack the sensitivity to detect residual strength deficits that may be present at this phase of recovery, leading to poorly informed decision making." The tendency to rely solely on MMT was more prevalent among low-volume providers and uncertified PTs.
    • Before progressing patients to jogging or modified sports, most respondents assessed knee strength, function and balance, knee range of motion, and degree of knee effusion. However, there was significant variation among PTs regarding limb strength criteria for functional advancement. Authors speculate this may be due to a lack of clear evidence.
    • Only 45.3% of respondents reported using patient-reported outcome measures to quantify functional deficits. The most common measure was the Lower Extremity Functional Scale, used by 39.2% of respondents, with fewer than 10% of respondents reporting use of measures related to fear or athletic confidence. Authors describe the lower usage rates of patient-reported outcomes as "regrettable," writing that "it has become clear that physical recovery alone is not sufficient to ensure successful return to sports, and many authors have emphasized the importance of assess¬ing psychological readiness and fear of reinjury." The lack of attention to patient-reported fear and readiness "[neglects] the holistic framework highlighted within the biopsychosocial approach to patient management," they add.

    According to authors, across the survey areas reviewed, 1 consistent element emerged: PTs who treated a large volume of post-ACLR patients, more recent graduates, and those with specialty certifications were more likely to report practice patterns "that were more consistent with current best evidence."

    Authors caution that the results should be understood within the limitations of the study itself. Among those limitations: the survey instrument was not validated before dissemination, there were no questions that addressed the possible influence of payment systems on treatment patterns, and the respondents were overwhelmingly APTA members—a fact that authors believe may hide even greater variability among the entire PT population.

    Overall, however, authors call the results "surprising," and note that "one of the most noticeable findings was the degree of variability in clinical testing and decision making, particularly within the later phases of rehabilitation, during the transition back to sports activity." The variation, they write, points to the possibility that at least when it comes to on-the-ground PT practice, "there is no consensus about the ideal postoperative rehabilitation program."

    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.

    JAMA Study Supports Physical Therapy as First-Line Approach to Meniscal Tears

    A new study has turned the debate over physical therapy-versus-surgery for meniscal tears on its head—and even from that angle, the results again point to the validity of physical therapy as first-line option for treatment.

    In an article published in JAMA (abstract only available for free), researchers from the Netherlands analyzed outcomes for adults aged 45-70 with nonobstructive meniscal tears, not by trying to find out whether physical therapy is better than surgery but by evaluating whether physical therapy is "noninferior" to surgery. The logic behind the approach is fairly simple: given that arthroscopic partial meniscectomy (APM) is 1 of the most frequently performed orthopedic surgeries, given that it comes with a hefty price tag ($4 billion annually in 2006), and given that it's, well, surgery, it would make sense that physical therapy would simply need to be no worse than surgery to qualify for consideration as a first-line treatment.

    The study assigned 321 participants with nonobstructive meniscal tears to 1 of 2 groups: one that underwent APM, and another that participated in 16 30-minute sessions of physical therapy over 8 weeks that included "cardiovascular, coordination/balance, and closed kinetic chain strength exercises." Individuals who experienced locking of the knee, instability caused by an anterior or posterior cruciate ligament rupture, or severe osteoarthritis were not included in the study. Additionally, patients who had received prior knee surgery or whose BMI was higher than 35 were excluded.

    To gauge improvement, researchers monitored outcomes from the International Knee Documentation Committee Subjective Knee Form (IKDC) a self-assessment measure that uses a 0-100 scale to rate knee function, symptoms, and ability to engage in physical activities. Assessments were taken at baseline, 3 months, 6 months, 12 months, and 24 months after randomization. As for the participants, both groups were similar, with a mean age of 58, 56% women, and comparable baseline knee function and pain during weight-bearing. Here's what researchers found:

    • Overall, the physical therapy group IKDC scores demonstrated noninferiority—defined by authors as average IKDC scores no more than 8 points apart—compared with the APM group. During the 24-month study period, knee function improved from 44.8 points to 71.5 points for the APM group, and from 46.5 points to 67.7 points for the physical therapy group.
    • While the score differences between physical therapy and APM showed physical therapy as noninferior at 3 months and 6 months, the gap widened at 12 months and 24 months. But those differences weren't enough to move physical therapy from an overall "noninferior" rating.
    • Participants who were obese tended to report higher improvement scores related to pain during weight-bearing than did their physical therapy counterparts. Other factors—location of the tear, education level of the participant, osteoarthritis severity, mechanical complaints, sex, and age—did not seem to significantly affect treatment outcomes.

    "The results of this trial support the recommendations from the current guidelines that [physical therapy] may be considered an appropriate alternative to APMs as first-line therapy for patients with meniscal tears," authors write, adding that their study echoes the consensus that "APM should not be the first treatment in middle-aged and older patients with meniscal tears."

    Authors of an accompanying editorial cast the results as yet another affirmation of physical therapy's effectiveness as a treatment for meniscal tears but wonder why "the orthopedic community [has been] slow to reduce APM."

    The editorial authors speculate on several possible explanations, including "community norms" around the expected treatment, surgeons simply doing what they've always done, and the power of a volume-based health care environment that incentivizes more procedures. Change may only come, they write, when payers take a more informed approach to what is and isn't authorized—but even that change may be slow to happen until everyone can agree on treatment guidelines.

    "To change clinical practice, it may be necessary to establish a consortium of all groups involved in the management of this knee condition—orthopedic surgeons, physiatrists, physical therapists, professional organizations, and insurance companies—to develop evidence-based treatment guidelines that each group can support," editorial authors write. "The guidelines should be focused on the best interests of the patients, rather than the clinicians, therapists, and other groups or entities who may gain from the different treatments."

    [Editor's note: check out APTA's PTNow online resource for a clinical practice guideline on meniscal and articular cartilage lesions, updated earlier this year.]

    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.

    Physical Activity May Decrease Mortality Risk in Frail Older Adults, Say Researchers

    While previous research has found that physical exercise decreases fall risk and improves mobility, researchers at the Universidad Autónoma de Madrid (UAM) in Spain wondered whether physical activity could reduce frailty-associated mortality risk. In their study, published in the Journal of the American Geriatrics Society, authors found that physical activity decreased mortality rates for healthy, prefrail, and frail adults over age 60.

    Authors used data from a nationally representative sample of 3,896 community-dwelling individuals to explore any “separate and joint associations between physical activity and frailty” and all-cause and cardiovascular disease (CVD) mortality rates.

    At baseline, in 2000–2001, researchers interviewed participants at home about their “leisure-time” physical activity: inactive, occasional, several times a month, or several times a week. They administered both the Fatigue, Resistance, Ambulation, Illness, and weight Loss (FRAIL) scale and 3 items from the 36-item Short-Form Health Survey (SF-36) to measure frailty, fatigue, resistance, ambulation, and weight loss. Participants also were asked whether they had been diagnosed with pneumonia, asthma or chronic bronchitis, hypertension, coronary heart disease, stroke, osteoarthritis or rheumatism, diabetes mellitus, depression under drug treatment, hip fracture, Parkinson disease, or cancer.

    Based on their answers, participants were categorized as “robust,” “prefrail,” or “more frail.”

    In 2014, authors determined that 1,801 total deaths had occurred, including 672 from cardiovascular disease.

    After adjusting for sex, age, education, alcohol use, smoking, BMI, waist circumference, and mental status, researchers found:

    • Prefrail individuals were 26% more likely as robust individuals to die of any cause, with frail individuals more than twice as likely to die of any cause compared with robust individuals.
    • Prefrail individuals were 40% more likely and frail individuals 2.32 times as likely as robust participants to die of CVD.
    • Fatigue, low resistance, limitations in ambulation, and weight loss were significantly correlated with higher all-cause and CVD mortality rates.
    • Being physically active decreased all-cause mortality by 18% in robust, 28% in prefrail, and 39% in frail individuals.
    • Participants who were frail and inactive were 2.45 as likely as robust, physically active individuals to die of any cause.
    • Risk of all-cause and CVD mortality in frail, physically active individuals was similar to that of prefrail, inactive participants.
    • Prefrail, active individuals had all-cause and CVD mortality similar to robust, inactive participants.

    This study, authors write, is the first to examine the effects of physical activity on mortality risk in frail and prefrail older adults. Authors speculate that physical activity contributes to longevity by helping to reduce chronic disease and falls and increase balance, strength, agility, and gait speed. This, they conclude, highlights the importance of future research on “the effectiveness of mobility programs to reduce mortality in frail older adults.”

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

    USBJI Young Investigators Program Accepting Applications for 2019 Program

    Physical therapist investigators have an opportunity to receive guidance in getting their research funded and "other survival skills required for pursuing an academic career" through a program that connects them with experienced researcher-mentors.

    The United States Bone and Joint Initiative (USBJI) and Bone and Joint Canada are now accepting applications for the Young Investigator Initiative, a career development and grant mentoring program. Investigators chosen for the program will attend 2 workshops 12 to 18 months apart and work with faculty between workshops to develop grant applications.

    This grant mentoring workshop series is open to promising junior faculty, senior fellows, or postdoctoral researchers nominated by their department or division chairs. It also is open to senior fellows or residents who are doing research and have a faculty appointment in place or confirmed and have a commitment to protected time for research. Basic and clinical investigators, with or without training awards, are invited to apply.

    Application requirements and more details can be found at the USBJI website. Deadline is January 15, 2019, to participate in the next workshop, April 26-28, 2019, in Rosemont, Illinois.

    APTA is a founding member of USBJI.

    CSM Delivers: Students and Early-Career PTs and PTAs

    You don't have to look very far to find an article that lists "physical therapy" as a hot, in-demand career. That's good news for students and newly minted physical therapists (PTs) and physical therapist assistants (PTAs), but it's also a challenge to the profession to ensure that those joining its ranks are prepared for and energized about their futures.

    The 2019 APTA Combined Sections Meeting, set for January 23-26 in downtown Washington, DC, will offer several sessions of particular interest to students, educators, and others interested in preparing the next generation of professionals. Here are a few suggestions.

    Future Momentum: Pushing Limits on Simulation to Maximize Student Preparation
    What's the state of simulation-based education in preparing PT and PTA students for the dynamic, fast-paced arena of acute and critical care physical therapy? How can faculty and clinicians leverage this technology to maximize its potential? Experience lively discussion from an expert panel of acute care physical therapist academic faculty as they debate and challenge our existing evidence base regarding simulation-based education to prepare the next generation of PTs and PTAs. Friday, January 25, 8:00 am–10:00 am.

    Competency-Based Education: Exploring Opportunities for Our Future
    How well do our professional curricula and educational methods prepare our learners to meet current and future needs of patients, communities, and society? Competency-based education (CBE) theories have existed for decades but have only recently been applied to medical education, including the use of competencies, milestones, and entrustable professional activities, with a de-emphasis on the time required to demonstrate competence. This session will center on evaluation of ongoing development of CBE in medicine and its potential application to physical therapy. Friday, January 25, 11:00 am – 1:00 pm.

    From Lightly Salted to Seasoned: Implementing Early Professional Development
    The shift from student to PT or PTA can be dramatic for some. What can be done to maintain and even increase engagement in the profession during this critical time? Join panelists involved with the Florida Physical Therapy Association's Early Professional Special-Interest Group (SIG) to discuss their efforts to maintain membership engagement and facilitate the transition from new graduates to early-career professionals and further into association leadership. Thursday, January 24, 3:00 pm–5:00 pm.

    Register for CSM by October 24 to grab early bird discounts and your chance to win a roundtrip ticket to the conference.

    Study: Many Gaps Still Exist in Insurer Coverage of Nondrug Treatments for LBP

    According to authors of a new study, physical therapy and occupational therapy to treat low back pain (LBP) frequently may be included in public and private insurer plans, but there's a lack of consistency in factors such as copays, referral requirements, prior authorization, and treatment limits. Coupled with a general lack of attention to many other nonpharmacological approaches to LBP, the inconsistencies create coverage gaps at a time when increased emphasis is being placed on nonopioid pain treatment, they write.

    The study, published in JAMA Network Open, looked at 2017 data from 15 commercial, 15 Medicaid, and 15 Medicare Advantage (MA) health plans in 16 states selected to provide a cross section of relative wealth, geographic location, and other factors. In addition to the insurers studied—a sample that authors claim represents insurers of more than half of the nation's populace—researchers also interviewed 43 "senior medical and pharmacy health plan executives" to get their take on the use of, and barriers to, nonpharmacological treatments for LBP.

    Researchers were interested in the degree to which insurers were covering nonpharmacological treatments for LBP and, if so, what restrictions they were placing on that use. It's an area in need of study, they say, given the current opioid crisis, the link between later opioid abuse and initial prescriptions of opioids to treat pain, and recommendations from the US Centers for Disease Control and Prevention (CDC) and others pushing for nonopioid approaches as first-line treatment for chronic noncancer pain.

    The study focused on 5 nonpharmacological therapies for LBP across all plans: physical therapy, occupational therapy, chiropractic care, acupuncture, and therapeutic massage. Additionally, because the information was readily available through Medicaid, researchers added 6 more approaches to their review of Medicaid plans: transcutaneous electrical nerve stimulation (TENS), psychological interventions, steroid injections, facet injections, laminectomy, and discectomy. Here's what they found:

    Physical therapy and occupational therapy fared well in terms of medical necessity.
    Among both commercial insurers and MA, physical therapy and occupational therapy were almost always deemed a "medical necessity" and thus subject to coverage. Of the commercial insurer coverage policies reviewed, all included physical therapy, and all but 1 included occupational therapy.

    But exactly how that physical therapy is covered? That's another matter.
    Researchers found that when it comes to utilization management issues, not all plans are equal. Among the 15 commercial insurers studied, researchers found 1 instance of prior authorization requirements, 10 instances of limits put on visits to a physical therapist (PT), and 1 instance of a referral requirement. The prior authorization (PA) situation in MA is worse (a fact that APTA is working with other groups to change), with 5 of the 15 plans studied requiring PA, and 1 requiring a referral.

    Copays can vary, too—sometimes by a lot.
    In the MA plans studied, patient copays for physical therapy for LBP ranged from $32.50 to $40 per session; the range was $15 to $50 per session among the commercial payers.

    Coverage for other nonpharmacological treatments for LBP is spotty.
    Of the commercial plans studied, only a few conferred "medical necessity" status on acupuncture (3 providers), TENS (3 providers), steroid injections (3 providers), and facet injections (3 providers). The MA system consdiered TENS, steroid injections, and facet injections medically necessary.

    Medicaid reflected the same general coverage patterns.
    As in the commercial and MA study group, the Medicaid plans included in the research largely covered physical therapy and occupational therapy (14 of 15, with the remaining plan being "unclear or not found"). All other treatments were in the single digits, with the exception of TENS (10 plans covered) and chiropractic care (12 plans covered).

    Are health plan execs on board with making it easier to access nonpharmacological pain treatments? Not exactly.
    In their interviews with health plan executives, authors of the study found that "overall, informants indicated a low level of integration between coverage decision making for nonpharmacologic and pharmacologic therapies." Researchers noted that when the interviewees did mention "innovative strategies to combat the opioid epidemic," those strategies tended to center around improved formulary management of opioids, substance abuse treatment, and identification of opioid over-users and over-prescribers—"less so on innovations aimed at optimizing coverage and access to nonpharmacologic therapies for chronic pain," they write.

    "The findings of this study support what we find on the ground with our members—namely, that while we have made progress in areas such as basic coverage and direct access, there's still much more work to be done to increase patient access to physical therapy and other nonopioid treatments," said Carmen Elliott, MS, APTA vice president of payment and practice management. "That's why we continue to engage with commercial payers, utilization management providers, and insurer interest groups to help them find a way to apply the evidence of physical therapy's effectiveness to their own policies."

    Authors of the study echo that sentiment, writing that "despite a growing evidence base supporting the effectiveness and cost-effectiveness of many of the nonpharmacological treatments examined in our study, our findings depict inconsistent and often absent coverage for many of these treatments."

    These inconsistencies present a challenge for patients, particularly those who are pursuing a multidisciplinary approach to treatment, they add.

    "Treatment-based approaches can require a co-payment for each visit, in addition to costs associated with travel and missed work," authors write. "These issues are multiplied if a patient is taking a multipronged approach that incorporates multiple therapies for chronic pain. In addition, the wide variation in utilization management criteria…underscores the uncertainty that may exist around what constitutes an appropriate duration and intensity of treatment (eg, physical therapy) for chronic noncancer pain."

    Authors of the study believe the way out of this dilemma may depend on establishing and promoting the evidence base for nonpharmacological pain treatment and—most important—for these treatments to be widely used by providers.

    "Utilization management requirements were highly variable, which speaks to a need for evidence-based guidance regarding optimal use of these therapies, and standardized, comprehensive training for practitioners to effectively implement the evidence base into their practice," 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: Unwarranted Variation in Pelvic Floor Muscle Function Terminology an Obstacle to Advances in Treatment

    Researchers use a wide variety of terms and definitions in published studies on pelvic floor muscle function (PFMF), according to authors of a new study in the October issue of PTJ (Physical Therapy). They say that it's this lack of standardized terminology, combined with too much focus on how to measure versus what to measure, that may be hindering “effective communication, data gathering, and advances in the evidence-based approach to women” with urinary incontinence (UI). [Editor's note: APTA members may access the full article for free through the "sign in via society site" link on the PTJ website.]

    The study examined terms related to PFMF, as well as their "conceptual" and "operational" definitions, used in 64 cross-sectional studies in women with and without UI. Authors of the study were particularly interested in how definitions of terms (or the lack of definitions) impacted both the individual studies as well as the degree to which the studies could be compared with each other.

    Authors began by clarifying what they meant by "conceptual" and "operational" definitions used in the studies they reviewed. For the PTJ study's authors, a conceptual definition involves a description of what needs to be measured—for example, a conceptual definition of the term strength is capacity of a muscle to generate force. An operational definition could be a procedure, such as vaginal manometry, as well as an explanation of how it was performed.

    Authors identified 196 terms used in the various studies and grouped them into 61 categories—for example, "strength" was used as an umbrella term for 11 other terms such as "pelvic floor strength." The authors then looked at how well the studies managed terms and definitions. Here's what they found:

    • Only 29.7% of the studies included operational definitions of terms.
    • A single study might use different terms to refer to the same muscle function.
    • While "strength" was the most commonly researched muscle function, the term was conceptually defined in only 5 studies—in 3 different ways.
    • The operational definitions of "strength" included both dynamometry and manometry; however, several different scales were used, making it impossible to compare results.

    “Concepts are the building blocks for all thinking,” write authors, who warn against “operationism”—focusing on how to measure variables as opposed to “what is relevant to be measured.”

    “Once the concept being measured becomes synonymous to the measurement outcomes, even small changes in method produce a new concept,” researchers say. This leads to an increasing number of terms and definitions that make it difficult to gather and analyze data or generalize results. It also restricts a study’s results to its “particular methodology,” authors write.

    The study results, say authors, “pose an urgent need to build and adopt a standardized terminology based on a sound theoretical framework encompassing the different disciplines, related areas, researchers and policy makers in order to increase understand¬ing of PFMF in women with UI and hopefully to provide higher quality of health care.”

    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.

    New White Paper Presses for Consistent Mobility Assessments, More Outcome Measures for Hospitalized Older Adults

    The impact that loss of mobility can have on hospitalized older adults can reach far beyond the hospital stay, yet there is little consistency in the ways hospitals assess and promote movement, and almost no acknowledgement of mobility as an outcome measure. That needs to change, and soon, say authors of a new white paper advocating for a shift in "a hospital culture that does not value or prioritize mobility." APTA was among the organizations that participated in a peer review of the document, with member James Tompkins, PT, DPT, conducting the review.

    The white paper, produced by the American Geriatric Society's (AGS) Quality and Performance Measurement Committee, describes the current state of mobility assessment in acute care settings as spotty at best, with a few hospitals conducting regular, validated mobility reviews with patients, and many others using inconsistent assessments or relying too much on hospital physical therapy departments to keep up with tests and measures that could be conducted by nurses. The assessment gaps, coupled with what researchers describe as a "focus on fall prevention at all costs," result in dramatic and potentially long-lasting losses in mobility in a population already at risk.

    The lack of thorough and consistent assessments isn't necessarily surprising, given the general lack of attention paid to mobility as an outcome measure for acute care, according to authors of the white paper. "Nursing staff may be assessing mobility routinely and repeatedly, but they are not doing so in the standard or validated manner necessary for mobility quality measurement or intervention," authors write, adding that entities including the Joint Commission and the US Centers for Medicare and Medicaid Services (CMS) largely ignore mobility as an outcome measure.

    To help fuel the needed changes, the white paper offers 7 recommendations:

    • Promote mobility assessment in acute care through "incentives for the use of standard, validated, mobility assessments" by CMS and other regulators
    • Advocate for more research funding for translational research in mobility assessment and intervention programs
    • Develop a consensus on standard methods to assess mobility "appropriate for acute care settings and clinically meaningful for providers and patients"
    • Minimize the burden of mobility measurement through, among other efforts, "optimizing workflow and documentation and minimizing redundancy by specifying the roles of various health care professionals such as nurses and physical therapists"
    • Evaluate the feasibility of a mobility quality measure for use by CMS
    • Reframe the current regulatory focus on falls in acute care to focus on safe mobility "in the face of little evidence of the effectiveness of strategies to prevent falls in acute care"
    • Develop resources for acute care providers available from AGS and other entities

    One bright spot, according to the white paper authors, is that several standardized mobility assessments could fit the bill. Authors identified 6 assessments as especially promising, with most able to be administered by a nurse: the Activity Measure for Post-Acute Care 6-Clicks; the Banner Mobility Assessment Tool; the de Morton Mobility Index; the Hierarchical Assessment of Balance and Mobility; the Johns Hopkins Highest Level of Mobility assessment; the Minimum Data Set 3.0 version 1.14, Section G; and the Minimum Data Set 3.0 version 1.14, Section GG. [Editor's note: many of these assessments are available in APTA's PTNow online resource center.]

    The end result, according to white paper authors: "We anticipate that routine mobility assessment will lead to a new paradigm in which stabilization of or improvement in mobility will be a universal indicator of high-quality hospital care."

    Researchers Say Mobility Is Key Quality-of-Life Issue for Individuals With SCI

    While individuals who have experienced a traumatic spinal cord injury (TSCI) can face a wide range of challenges affecting their health-related quality of life (HRQoL), a new study is helping to clarify that 1 particular functional ability stands out as the most important factor: independent mobility.

    Researchers analyzed data from 195 patients who had sustained a TSCI between 2010 and 2016 and participated in a series of assessments conducted between 6 and 12 months after the injury. Those assessments included the Spinal Cord Independence Measure Version 3 (SCIM-III), a detailed assessment of functional abilities, as well as the SF-36v2 assessment of HRQ0L, a 36-question survey covering 8 domains that produces both a physical component score (PCS) and a mental component score (MCS). Authors say their study is the first to establish correlations between these assessments, allowing the researchers to more specifically pinpoint which factors most affect HRQoL.

    The study population included individuals 17 years and older who sustained a TSCI between C1 and L1 that required surgery. More than half of the study population—65%—experienced tetraplegia (also referred to as quadriplegia) as a result of the injury; the remaining 35% experienced paraplegia. Participants were excluded if a penetrating trauma was the cause of the TSCI or if they did not complete the assessments between 6 and 12 months after the injury. Results were e-published ahead of print in the American Journal of Physical Medicine & Rehabilitation.

    Here's what the researchers found:

    • Overall, the strongest correlation was between mobility in the abilities assessment and PCS in the HRQoL assessment. Researchers also noted a small-but-significant correlation between respiration/sphincter management and PCS.
    • The tetraplegic group showed the strongest correlations between mobility and PCS, particularly for mobility outdoors, mobility indoors, mobility for moderate distances, and stair management.
    • In the paraplegic group, "moderate significant" correlations were also found for lower body bathing.
    • Researchers were unable to establish a strong correlation between the functional abilities assessment and the mental component score on the HRQoL assessment.

    Authors of the study believe their findings line up with previous research into HRQoL among individuals who sustained TSCI, but they note that theirs is the first to examine which specific functional abilities were most important to this population.

    "In our study for both tetraplegic and paraplegic patients, mobility on even surfaces was more strongly correlated with PCS than items related to transfers," authors write, adding that "our study suggests that higher mobility is better correlated to quality of life than higher arm/hand function for both tetraplegic and paraplegic subjects."

    Authors also note that the lack of correlation between function and the MCS on the HRQoL assessment may seem "counter-intuitive," but they suggest that the findings point to the possibility that "mental health after a TSCI strongly depends on other factors that were not considered in the current study," including depression, hope, purpose, and feelings of self-worth.

    "The current study showed that it is of paramount importance to analyze tetraplegic and paraplegic patients distinctly when evaluating impact of function on [quality of life], considering the magnitude of difference between the strength and correlation of SCIM sub-scores," authors write. "Different priorities for patients lead to distinct goals in the rehabilitation effort."

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