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  • Paul Rockar Named Foundation President

    The Foundation for Physical Therapy Research (FPTR) has named former APTA President Paul Rockar Jr., PT, DPT, MS, as its president. Rockar, who served as a foundation trustee for three years prior, assumed his new role on January 1, 2020.

    Rockar is a well-known figure in the physical therapy profession, having served as a member of the APTA Board of Directors, as its vice president, and finally, as president of the organization from 2012 to 2015. Rockar is the former CEO of the Centers for Rehab Services.

    APTA and the foundation have a more than 40-year relationship focused on promoting physical therapy research. As a designated Pinnacle Partner of the foundation, APTA invested over $500,000 to support foundation initiatives including scholarships and fellowships in 2019.

    In his role as president, Rockar will work alongside his fellow Board of Trustees members to continue the foundation’s 2019-2022 strategic plan.

    “I am honored to have been chosen by my fellow trustees to lead FPTR at a time when research is so important to the profession,” said Rockar. “I look forward to collaborating with our partners and like-minded supporters — including APTA — to support research that leads to the best clinical guidelines and excellent patient care.”

    Rockar succeeds Edelle Field-Fote, PT, PhD, FAPTA, who concluded her term at the end of 2019.

    Separate Studies, Similar Conclusions: Bundling for Knee, Hip Replacement Seems to be Working

    Has all the bundling been worth it? Two new studies of bundled care models used by the Centers for Medicare and Medicaid Services (CMS) conclude that, at least for lower extremity joint replacement (LEJR), the answer is yes. Taken as a whole, the studies make the case that while the savings achieved through some bundled care models may not be dramatic, they do exist — and aren't associated with a drop in quality.

    The studies, published in Health Affairs, take different approaches to answering questions about the effectiveness of bundling programs mostly associated with CMS' voluntary Bundled Payments for Care Improvement (BPCI) initiative: one was a systematic review that analyzed existing research (abstract only available for free) on the programs, while the other focused on data from hospitals that did and did not participate in BCPI (abstract only available for free) over a three-year period. Their conclusions, however, had much in common.

    The bottom line, according to both studies, is that bundled care models for LEJR seem to be lowering overall costs without sacrificing quality.

    The systematic review revealed that most studies that evaluated spending recorded decreases in overall postacute care spending of between $591 and $1,960, while the hospital data researchers identified an average 1.6% decrease in episode spending for LEJR — about $377 per patient. At the same time, neither study uncovered evidence of reduced quality outcomes, with the hospital study finding variances between BPCI and non-BPCI care for LEJR of less than 2%. The systematic review found that, if anything, research indicates that bundled care tends to lead to lower rates of hospital readmission, a datapoint strongly associated with quality.

    The studies did have some differences. The hospital data researchers focused solely on LEJR data, which they describe as the most common procedure associated with BPCI, while the systematic review included a bundled care model for a range of procedures. In the end, authors of the systematic review found that bundled payment "has yet to demonstrate [benefits similar to those associated with LEJR bundling] for other clinical episodes," including spinal fusion, shoulder arthroplasty, and cardiac surgery. Another difference between the studies: The systematic review included data from CMS' Comprehensive Care Joint Replacement (CJR) model mandated for use in some 450 facilities across the country; the hospital data review excluded CJR facilities.

    [Editor's note: APTA offers multiple resources on bundling, including separate webpages devoted to BPCI Advanced participation and the CJR.]

    Each study offered its own takeaways. The systematic review emphasized the effectiveness of bundling for LEJR and suggested that CMS "scale up” its bundling programs in those areas, while cautioning that more work needs to be done on bundling programs for other procedures, especially those that tend to be associated with higher baseline patient complexity. The hospital data study, focused on LEJR only, found that most of the savings associated with bundling came from early adopters (which maintained their savings over time), and less so from facilities that joined later, which "may have been less able to influence episode spending." That study also acknowledged that while voluntary bundling models may be subject to cherry-picking of less complex patients, data revealed that "it does not fully account for associated savings."

    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 APTA-Supported CPG Looks at Best Ways to Improve Walking Speed, Distance for Individuals After Stroke, Brain Injury, and Incomplete SCI

    In this review: Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury
    (Journal of Neurologic Physical Therapy, January, 2020)

    The message
    A new clinical practice guideline (CPG) supported by APTA and developed by the APTA Academy of Neurologic Physical Therapy concludes that when it comes to working with individuals who experienced an acute-onset central nervous system (CNS) injury 6 months ago or more, aerobic walking training and virtual reality (VR) treadmill training are the interventions most strongly tied to improvements in walking distance and speed. Other interventions such as strength training, circuit training, and cycling training also may be considered, authors write, but providers should avoid robotic-assisted walking training, body-weight supported treadmill training, and sitting/standing balance that doesn't employ augmented visual inputs.

    The study
    The final recommendations in the CPG are the result of an extensive process that began with a scan of nearly 4,000 research abstracts and subsequent full-text review of 234 articles, further narrowed to 111 randomized controlled trials (RCTs), all focused on interventions related to CNS injuries, with outcome data that included measures of walking distance and speed. CPG panelists evaluated the data and developed recommendations, which were informed by data on patient preferences and submitted for expert and stakeholder review.

    Development of the CPG was supported through an APTA-sponsored program that assists APTA sections — in the case, the Academy of Neurologic Physical Therapy — in the development stages such as drafting, appraisal, planning, and external review (for more detail on the program, visit APTA's CPG Development webpage).

    Findings

    • Moderate- to high-intensity (60%-80% of heart rate reserve or up to 85% of heart rate maximum) walking training was associated with the strongest evidence for improvements in walking speed and distance.
    • Walking training using VR also fared well, due in part to the ability of a VR treadmill system to allow "safe practice of challenging walking activities," something that's hard to do in a more traditional hospital or clinic setting.
    • Strength training, while not included among the interventions that should be performed, was designated as an intervention that may be considered. Authors cite inconsistent evidence on the connection between strength training and improved walking speed and distance, but they acknowledge potential benefits.
    • Also among the list of interventions that "may be considered": circuit training, as well as cycling training. In both cases, authors cite a paucity of evidence related to how the interventions affect walking speed and distance. They note that these interventions may be revisited during a future reevaluation of the CPG.
    • Body-weight supported treadmill training was labeled as an intervention that should not be performed in order to increase walking speed and distance, with authors finding little evidence supporting the approach, which is often associated with a greater cost. However, they write, the individuals included in the studies reviewed for the CPT were able to ambulate over ground without the use of a body-weight support device, and "different results may occur in those who are nonambulatory or unable to ambulate without the use of [body-weight support]."
    • Both static and dynamic (nonwalking) balance training and robotic-assisted walking training were also characterized as interventions that should not be performed. Authors acknowledge the ways that postural stability and balance are associated with fall risk and reduced participation, but they were unable to find sufficient evidence to support these particular interventions as effective in increasing walking speed and distance (although static and dynamic balance training with VR fared a bit better). As for robotic-assisted walking training, CPG authors note that while ineffective for individuals with CNS who were already ambulatory, "this recommendation … may not apply to nonambulatory individuals or those who require robotic assistance to ambulate."

    Why it matters
    Authors note that "the implementation of evidence-based interventions in the field of rehabilitation has been a challenge," and they believe that the new CPG offers a real opportunity for clinicians to "integrate available research into their practice patterns." Further, they believe that the CPG has arrived at an important moment in the evolution of health care, with its greater emphasis on evidence for the cost-effectiveness and outcomes of various interventions.

    More from the study
    The CPG also offers tips for clinicians to implement its recommendations, including acquiring equipment to help providers monitor vital signs, implementing "automatic prompts in electronic medical records that will facilitate obtaining orders to attempt higher-intensity training strategies," providing training sessions for clinicians, establishing organizational policies to promote use and documentation of the recommended interventions, and simply keeping a few copies of the study on hand for easy reference.

    Keep in mind …
    Authors acknowledged that the CPG has a few limitations. While the review of RCTs only is a strength, they write, some of those studies involved small sample sizes, and many lacked details on intervention dosage. Additionally, the CPG does not fully address the potential costs associated with its recommendations — specifically VR — which could impact a clinic's ability to implement a particular intervention. Authors also acknowledge that walking speed and distance are not the only important outcomes related to mobility among individuals with CNS injury, and that other factors such as dynamic stability while walking, peak walking capacity, and community mobility may be incorporated in an assessment of walking function.

    APTA's TKA Guidelines: Your Comments Needed by January 3

    APTA is developing a new clinical practice guideline (CPG) on total knee arthroplasty (TKA) and your help is needed.

    The CPG is now in the public review phase of its development, and APTA is asking for public comment. But hurry—deadline for comments is January 3, 2020.

    Funded entirely by APTA, the draft CPG covers topics ranging from preoperative exercise to physical therapy discharge planning and assessment of outcomes. The resource was developed by a volunteer development group that included member expert PTs from many of the Academies, an orthopedic surgeon, a nurse, and a consumer, and was based on systematic reviews of current scientific and clinical information related to the PT management of TKA.

    APTA has created a webpage that links to the CPG and allows visitors to provide comments.

    Foundation Grants Focus on ICU Survivors, Exercise Effects on Diabetes, Blood Flow Restriction, and More

    An APTA-sponsored $40,000 Health Services Research Pipeline grant will support a project aimed at conducting the first-ever comprehensive evaluation of variability in rehabilitation delivery to older intensive care unit (ICU) survivors. The award was among several Foundation for Physical Therapy Research (Foundation) grants and scholarship awards totaling more than $600,000 in 2019.

    Grant recipient Jason Falvey, DPT, PhD, will investigate both in-home and community- based rehabilitation of the older ICU survivor population, including an exploration of the impact rehabilitation may have on functional outcomes and hospital readmissions. Falvey is a postdoctoral fellow at the Yale School of Medicine.

    APTA is the Foundation's Pinnacle Partner in Research and has been a leading donor in funding major research initiatives such as the Center on Health Services Training and Research (CoHSTAR), investing in research priorities to strengthen the physical therapy profession, and supporting the Foundation's scholarship program each year.

    In addition, the Foundation expanded its portfolio of grant and scholarship opportunities in 2019 with the launch of the Goergeny High-Impact Research Grant, an offering focused on the role of physical therapy in the prevention of secondary health conditions, body structures and functions, activity limitations, or participation restrictions. The first investigator to receive the Goergeny award is Smita Rao, PT, PhD, of New York University, who will receive $240,000 over the next 2 years for a study that will investigate the effects of exercise on hyaluronan accumulation in people with type 2 diabetes.

    Other grant and scholarship announcements from the Foundation:

    Saurabh Mehta, PT, MSc, PhD, the recipient of the $40,000 VCU-Marquette Challenge Research Grant, will examine the feasibility, acceptability, and preliminary outcomes of an evidence-based program (developed by physical therapists in Denmark) for people with knee osteoarthritis. This grant is funded in part by APTA's Supporting the Professions Fund.

    Aliza Rudavsky, PT, DPT, PhD, was awarded the $40,000 Pelvic Health Research Grant. The goal for her project, titled “Concurrent Validity of Novel Transabdominal Pelvic Floor Ultrasound During Glottis Tasks,” is to test a new method of measuring transabdominal ultrasound imaging and comparing it with the gold standard transperineal method. This award is supported by the APTA Academy of Pelvic Health Physical Therapy.

    Cristine Agresta, PT, MPT, PhD, was named recipient the $100,000 Magistro Family Foundation Research Grant in support of a project that will assess the effectiveness of personalized blood flow restriction against current standard rehabilitation procedures after anterior cruciate ligament reconstruction surgery. This project is funded by the Foundation's Magistro Family Endowment Fund and Legacy Research Fund.

    Alyssa LeForme Fiss, PT, MPT, PhD, who was awarded the $40,000 Pediatric Research Grant, will conduct research to determine the effects of adaptive behavior physical therapist intervention delivered in addition to traditional physical or occupational therapist services for families with infants diagnosed with or at high risk for cerebral palsy. This grant is supported by the Pediatric Research Fund and the APTA Academy of Pediatric Physical Therapy.

    “FPTR grants help strengthen the profession and elevate research in physical therapy,” said Foundation Board of Trustees President Edelle Field-Fote, PT, PhD, FAPTA, in a Foundation news release. “With the help of our community of donors, we continue to fund top researchers and the most promising science in the field of physical therapy. Each project has the potential to improve outcomes for the patients we serve as physical therapists.”

    Study: Among Individuals Who Qualify for Medicare Due to Disability, Opioid Overdose Deaths Nearly 5 Times Higher Than Total US Rate

    In this review: Association of Disability With Mortality From Opioid Overdose Among US Medicare
    (JAMA Network Open, November 15, 2019)

    The message
    While Medicare beneficiaries who qualify for Medicare because of disability account for one quarter of all deaths from prescription opioid overdose annually, not much research has focused on the relationship between various combinations of conditions in this population and their correlations to overdose mortality. It's a connection that authors of a recent study believe is essential to developing successful evidence-based interventions addressing Medicare enrollees with disabilities.

    The study
    Authors examined Medicare data linked to the National Death Index for a random sample of 20% of Medicare enrollees between the ages of 21 and 100 during the time period from 2012 to 2016. They calculated the rate of opioid overdose deaths for the entire Medicare population as well as for individuals with any of 55 chronic or potentially disabling conditions contained within the Centers for Medicare & Medicaid Services Chronic Disease Data Warehouse.

    Opioid overdose deaths were identified by codes for opium, heroin, natural or semisynthetic opioids, methadone, synthetic opioids other than methadone, or other and unspecified narcotics prescribed for their underlying conditions.

    Findings

    • Enrollees younger than age 65 who qualify for Medicare due to disability comprise approximately 15% of the overall Medicare population. However, they account for 81% of opioid overdose deaths among Medicare beneficiaries overall.
    • While 32% of enrollees who are qualified for disability had at least 2 major condition categories, these individuals accounted for 78% of all opioid overdose deaths among Medicare beneficiaries.
    • Opioid overdose mortality in the disability group increased from 57.4 per 100,000 in 2012 to 77.6 per 100,000 in 2016.
    • Among beneficiaries who qualified for Medicare because of disability, opioid overdose deaths were highest for those aged 51–64. In addition, those who were male and white, had higher income, had Medicare Part D coverage, had been enrolled under disability for less than 15 years, and who lived in metropolitan areas had higher rates of opioid overdose death.
    • Of the disabling conditions examined, substance abuse, psychiatric diseases, and chronic pain were significantly associated with higher rate of opioid overdose deaths. The opioid overdose mortality rate among those with all 3 conditions was 363.7 per 100,000—23.4 times higher than for those with no disabling conditions. Chronic kidney disease, pressure and chronic ulcers, and hepatitis also were associated with a higher likelihood over opioid overdose death.
    • The opioid overdose mortality rate among those who qualify for Medicare due to disability is nearly 5 times higher than that of the general United States population.

    Why it matters
    Subgroups of Medicare beneficiaries "present different risk profiles for opioid overdose death, authors say. "Patients qualifying for Medicare disability have the highest rates of opioid use compared with older Medicare beneficiaries and commercial insurance beneficiaries." Future studies can help develop targeted interventions to decrease opioid overdose deaths in high-risk populations.

    More from the study
    Researchers were surprised to see a positive association between high income and opioid overdose death, as one previous study found that lower-income individuals "were more likely to misuse opioids and had higher rates of opioid use disorder than the general US population" and another showed that higher-income Medicare enrollees had lower rates of long-term opioid prescriptions.

    Authors suggest that future research should examine these associations by opioid type.

    Keep in mind…
    Authors note that "the quality and accuracy of death certificate data associated with overdose varies across states." Likewise, the validity of medical conditions in claims data varies. From the available data, researchers could not distinguish between accidental, suicide, or homicide deaths or whether they occurred in the inpatient or outpatient setting.

    In addition, because they analyzed data only from enrollees with 2 years of continuous enrollment with fee-for-service coverage, the results "may not be generalizable to health maintenance organization populations."

    Authors also did not examine "competing causes of death" or the association of drug interactions or contaminated street drugs with opioid overdose death. They suggest future research on overdose deaths due to different types of opioids.

    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: For Children With Autism, Yoga Improves Motor Skills, May Buffer 'Cascading' Effects

    In this review: Creative Yoga Intervention Improves Motor and Imitation Skills of Children With Autism Spectrum Disorder
    (PTJ, November 2019 )

    The message
    There's mounting evidence that motor impairments are particularly prevalent among children with autism spectrum disorder (ASD), but research on how to address these impairments is scant. Authors of a new study believe they may have hit upon an approach: physical therapist-led "creative yoga," which they say improved both gross motor skills and the ability to imitate movement patterns among children with ASD. Those gains, they believe, could play a role in improving social communication and behavioral abilities.

    The study
    Researchers divided 24 children with ASD, ages 5 to 13, into 2 groups: the first group received an 8-week "academic intervention" that focused on reading, arts, crafts, and other "sedentary activities usually practiced within school settings"; the second group participated in an 8-week yoga intervention, led by a physical therapist (PT), that "was made fun and creative through the use of songs, stories, games, and props." The children were assessed for motor skills using the Bruininks-Oseretsky Test of Motor Performance-2nd Edition (BOT-2) at baseline and after completion of the programs, and tested for imitation skills at 3 points (baseline, midpoint, completion) using a researcher-created instrument. Sessions were conducted 4 times a week for 8 weeks, divided into 2 expert-led sessions lasting 40 to 45 minutes per week and 2 parent-led sessions lasting 20 to 25 minutes per week.

    Participants included in the study had a confirmed ASD diagnosis and showed social communication delays. All scored at average or below on the BOT-2 at baseline, and the groups were matched for baseline mobility scores as well as demographic, IQ, and other characteristics.

    APTA members Maninderjit Kaur, PT, and Anjana Bhat, PT, coauthored the study.

    Findings

    • After 8 weeks, the yoga group improved subtest scores for gross motor performance and bilateral coordination, whereas the academic group showed no statistically significant improvements in these areas.
    • The academic group improved scores related to fine motor precision and integration, but not so the yoga group, which recorded no statistically relevant changes.
    • Imitation skills improved for both groups, but at different points: the yoga group began showing improvements in imitation skills by the midpoint assessment, while the academic group's improvements didn't register significant change until the last assessment.
    • Among child-specific factors such as age, autism severity, and IQ, the only element that seemed to correlate to improvement in scores was IQ: in the academic group, children with higher IQs tended to achieve larger individual gains in imitation skills, while in the yoga program, children with lower IQs were the cohort that achieved larger individual gains in imitation (specifically, pose imitation).

    Why it matters
    A growing body of evidence suggests that children with ASD also tend to experience motor impairments of balance, postural control, gait, and coordination, as well as worse dexterity skills than do children with typical development (TD). In fact, authors write, researchers have estimated that children with ASD typically display motor development that is consistent with children half their age. Deficits in the ability to imitate demonstrated behaviors or movements are also associated with ASD.

    The concern, according to authors, is the possibility that these impairments could have "cascading effects on the social, communication, and cognitive development of children with ASD."

    "Given the evidence for motor impairments and their broader impact on social communication development," authors write, "there is a clear need to devise interventions that could offer opportunities to improve both motor skills and their use in developing social communication skills in children with ASD."

    More from the study
    Authors were surprised that the yoga group didn't report any improvements in balance, but they speculate that the unchanged BOT-2 scores may be related to the test's reliance on a mix of static and movement-based activities, as opposed to the yoga classes' focus solely on static balance. Additionally, they write, the BOT-2's balance subtest includes assessments with and without visual input, whereas the yoga classes consistently used visual input to help children hold poses.

    As for the academic group's improvements in fine motor skills, the effect sizes were relatively small, but researchers believe that may be due to the fact that most of the children were already engaged in similar activities in their school settings, creating a "smaller scope for improvement."

    Keep in mind…
    The study population was small and heterogenous, and the training duration was relatively short. Additionally, researchers weren't able to assess the long-term effects of the classes.

    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.  

    Does Everyone Have a Unique Muscle Activation 'Fingerprint?' Researchers Say Yes

    In this review: Individuals have unique muscle activation signatures as revealed during gait and pedaling
    (Journal of Applied Physiology, October 2019 )

    The message
    It's no secret that people move differently, but researchers who carefully tracked muscle movements of study participants during exercise think the differences may go even deeper than variation in movement styles. Their conclusion: humans possess muscle activation "signatures" that are as unique to each individual as fingerprints or iris structure. Not only could these patterns be used to identify an individual, they write, but finding a person's activation strategies could help to identify the potential for future musculoskeletal problems, and better tailor treatments to individual patient needs.

    The study
    Researchers analyzed movement patterns of 53 individuals using surface electromyography (EMG) on their legs as they pedaled on a stationary bicycle and walked on a treadmill. Using a machine learning protocol, authors of the study tracked activation patterns from 8 muscles of the right leg: the vastus lateralis (VL), rectus femoris (RF), vastus medialis (VM), gastrocnemius lateralis (GL), gastrocnemius medialis (GM), soleus (SOL), tibialis anterior (TA), and biceps femoris-long head (BF). They used the data to establish unique muscle activation signatures recorded during an initial session. Participants then returned for a second round of the same activities between 1 and 41 days after the first (average, 13 days), allowing researchers to evaluate the similarities between activation patterns observed at each session.

    Participants were in good health. Most were male (77%), with an average age of 23.1 years and average BMI of 23.2 for males and 21 for females.

    Findings

    • Researchers found "substantial" variability in activation patterns among individuals, especially in the RF, GL, BF, and SOL muscles, with the same types of variability recorded on both days of activity.
    • The machine learning system was able to identify individual muscle activation patterns during the first session with a high degree of accuracy, particularly when more of the tracked muscles were factored into the mix. The classification rate was just over 99% for pedaling and 98.86% for treadmill gait.
    • Recognition rates were nearly as accurate when focused on the second session, where accuracy was 89.80% for 7 muscles in pedaling, and 86.20% for 7 muscles during walking. Authors of the study think the differences between the first and second sessions are due to variations in placement of the EMG sensors, but they believe that given the highly similar results, the differences in placement only strengthen their conclusions.
    • The RF, GM, GL and SOL muscles provided the best recognition data for pedaling, while the TA and BF muscles were tied strongly to better recognition data related to gait.

    Why it matters
    Earlier studies have established that movement patterns such as gait can be consistently linked with individuals—a kind of signature—but those studies stopped short of an examination of identifying the muscle activation strategies that may (or may not) influence the movement pattern. Authors of the EMG study believe theirs is the first to look into activation itself as a biomarker.

    Although they call for further study, authors believe that individual muscle activation signatures may have "specific mechanical effects on the musculoskeletal system" and could help identify individuals who are at greater risk of musculoskeletal disorders. For example, they write, the activation patterns of the GM, GL, and SOL muscles tended to vary significantly between individuals; because these muscles are attached to the Achilles tendon in different fascicle bundles, "different activation strategies might induce unique load patterns of load distribution within the Achilles tendon, with some strategies being more likely to lead to tendon problems."

    More from the study
    Authors didn't land on a single explanation for why muscle activation patterns might be individualized, but they write that both "optimal feedback control" and "good enough" theories of motor control could be at play in activation signatures.

    Activation patterns may be consistent with the optimal feedback control theory in that "it is possible that each individual optimizes their movement with the muscle activation strategies that are best, given that individual's mechanical and/or neural restraints," they write. On the other hand, they add, it's also possible that the signatures develop according to the "good-enough" concept, "through motor exploration, experience, and training, leading to habitual rather than optimal strategies." It's a debate that likely won't be settled without "retrospective studies on large cohorts or longitudinal studies performed at different lifespans," authors note.

    Keep in mind…
    The study population was small, and homogenous. While the homogeneity was intentional to tease out the accuracy of the machine learning process, the approach limited researchers' ability to identify potential motor control theories at play, and whether at least some of the activation strategies are innate.

    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.

    APTA Cosponsored Study: Direct Access to Physical Therapy for LBP Saves Money, Lowers Utilization Better When It’s Unrestricted

    In this review: Unrestricted Direct Access to Physical Therapist Services Is Associated With Lower Health Care Utilization and Costs in Patients With New-Onset Low Back Pain
    (e-published ahead of print in PTJ, November 2019 )

    The message
    Does unrestricted direct access to a physical therapist (PT) make a difference compared with "provisional" direct access systems that include restrictions such as visit limits and referral requirements for specific interventions? A new analysis of insurance claims records from nearly 60,000 adults across the US says yes.

    The study, cosponsored by APTA, reveals that for patients with new-onset low back pain (LBP), seeing a PT first in states with unrestricted direct access resulted in lower health care costs and use compared with patients seeking care in provisional access states. And the differences don't end there: researchers found that patients in provisional access states who saw a PT first tended to incur higher costs than those who saw a primary care provider (PCP) first, while data from unrestricted direct access states showed relatively equal, if not slightly lower, costs for seeing a PT first compared with PCPs.

    The study
    Researchers reviewed private and Medicare Advantage insurance claims from 59,670 adults with new-onset LBP between 2008 and 2013 to explore health care cost and utilization from 2 perspectives: first, in terms of differences between patients who saw a PT first for LBP in states with unrestricted direct access versus those who sought PT care in states with provisional direct access provisions; and, second, in terms of differences between patients who saw a PT first versus those whose first meeting was with a PCP.

    The deidentified data was provided by OptumLabs®, which worked collaboratively with APTA and UnitedHealthcare to produce this and 2 other research articles related to access to PTs first for LBP. Authors of this study included APTA member Christine McDonough, PT, PhD.

    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, no patients diagnosed with neoplasm 12 months prior and 3 months after the first visit, and insurance enrollment for at least 12 months before and after the index date), nearly 98% initially met with a PCP. Overall, more women than men sought care for LBP, with around 21% of all patients reporting prior physical therapy use. Among patients who sought treatment from a PCP, experience with physical therapy was much lower—about 2.1%.
    • Among patients who saw a PT first, those in provisional-access states recorded 31% more physician visits and had 58% higher odds of having imaging in the first 30 days of the index visit, compared with patients from unrestricted states.
    • Average 30-day costs were lowest for patients in unrestricted states who saw a PT first for LBP, at $511. The next-to-lowest costs were associated with patients who saw a PCP first in unrestricted-access states ($556), followed by patients in provisional-access states whose first visit was with a PCP ($632). The highest costs were for patients in provisional-access states whose index visit was with a PT, at $726. After 90 days, the rankings shifted, but only slightly: seeing a PT first in a provisional-access state was associated with the highest costs ($1,269), followed by index visits with a PCP in provisional-access states ($1,046), PT-first visits in unrestricted states ($1,032), and PCP-first visits in unrestricted states ($948).
    • Patients in provisional-access states who saw a PT first averaged LBP-related costs that were 19% higher than PCP-first patients at 30 days. It was a different story in unrestricted-access states, where patients who visited a PT first averaged costs that were 4% lower than PCP-first patient costs, a difference that authors call "insignificant."

    Why it matters
    This large-scale retrospective study—authors believe it's the first to analyze how state limits on PT access affect utilization and costs—adds to the evidence that direct access to a PT for LBP (and seeing a PT first) achieves effective results. The cost differences alone are potentially significant, given the estimate that as many as 70% of people will experience LBP in their lifetimes, making it "the third most costly medical condition in the United States," according to authors.

    More from the study
    Authors were particularly interested in the findings that patients in provisional-access states who saw a PT first tended to incur higher cost and utilization than those whose index visit was with a PCP. Authors believe the explanation for the difference may have something to do with the way the restrictions tend to increase the need to visit physicians following the initial PT visit to comply with requirements around, for example, imaging or specific procedures.

    Similarly, authors theorize that the cost ratio—in other words, the magnitude of the differences—may also be due to the pressures provisional-access systems bring to bear on LBP treatment.

    "Given that patients in provisional-access states often are required to see a PCP after a certain number of physical therapist visits or required a PCP shortly after the initial physical therapist visit, these additional visits likely increase the cost of care in provisional-access states," authors write. "Since physician gatekeeping does not occur in unrestricted-access states, which would increase the cost of care, we would postulate that this restriction accounts for the differences in 30-day costs between provisional-access states and unrestricted-access states."

    APTA's role
    APTA has been working with UHC and OptumLabs to investigate both the efficacy of physical therapy as a first treatment option for LBP as well as the effects insurer payment policies have on patient access to more conservative approaches to the condition. Those efforts yielded 3 research articles: a study affirming that higher copays and payer restrictions steer patients away from conservative LBP treatments; an analysis that found lower odds of early and long-term opioid use among patients who see a PT first for LBP; and the investigation included in this review. APTA cosponsored all 3 studies

    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 and were limited to evaluation of only "certain variables." Additionally, data from patients in states that changed their access regulations between 2008 and 2016 were excluded, reducing sample size.

    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 is the recipient of a 2015 Foundation for Physical Therapy Research Magistro Family Foundation Research Grant and of the 2009 New Investigator Fellowship Training Initiative in Health Services Research.]

    Study: Despite Guidelines for OA, Rates of Physician Referral to Physical Therapy Remained Low, Orthopedic Surgeon Narcotic Prescriptions Increased between 2007 and 2015

    In this review: Recommendation Rates for Physical Therapy, Lifestyle Counseling, and Pain Medications for Managing Knee Osteoarthritis in Ambulatory Care Settings
    (e-published ahead of print in Arthritis Care & Research, October 2019)

    The message
    Despite longstanding guidelines that recommend physical therapy and lifestyle changes over pharmacological approaches as a first line of treatment for knee osteoarthritis (OA), orthopedic surgeons and primary care physicians (PCPs) don't seem to be getting the message, according to researchers. If anything, they say, the situation deteriorated between 2007 and 2015, with orthopedic surgeons moving in the opposite direction from the guidelines, and PCPs making no significant changes apart from increasing a tendency to prescribe nonsteroidal antiinflammatory drugs (NSAIDs).

    The study
    Researchers reviewed data from National Ambulatory Medicare Care Surveys (NAMCS) administered between 2007 and 2015. The surveys, conducted by a branch of the US Centers for Disease Control and Prevention, focus on non-federally employed office-based physicians in direct patient care, and involve collection of data over a 1-week period, as well as practice visits and physician interviews.

    For the study, researchers focused on visits associated with a knee OA diagnosis, tracking whether the physician prescribed physical therapy, provided advice on exercise and/or weight reduction, or provided pain medications during the visit. The prescribed pain medications were categorized as NSAIDs, "narcotic analgesics," or "other." Researchers also tracked patient demographic data, as well as physician specialty, practice location, type, and ownership, among other characteristics.

    Researchers crunched the numbers to establish triennial rates of various recommendations during the 9-year study period. The results were based on 2,297 knee OA-related visits, which they approximated to about 8 million visits per year between 2007 and 2015. APTA members Samannaaz Khoja, PT, PhD; Gustavo Almeida, PT, PhD; and Janet Freburger, PT, PhD, coauthored the study.

    Findings

    • Authors found a "significant decline" in rates of physical therapy referral by orthopedic specialists, from 158 per 1,000 visits in 2007-2009 to 86 per 1,000 in 2013-2015. Lifestyle counseling also dropped, from 184 per 1,000 to 88. During the same 9-year period NSAID prescriptions increased from 132 per 1,000 visits 2007-2009 to 278 per 1,000 in 2013-2015. Even more concerning, prescription rates for narcotics tripled during the study period, from 77 per 1,000 visits in 2007-2009 to 236 per 1,000 by 2015.
    • Among PCPs, low initial rates of referral to physical therapy increased but remained low throughout the study period, moving from 26 per 1,000 visits to 46 per 1,000 visits. Recommendations for lifestyle changes remained about the same during the study period, ranging from 243/1,000 to 221. Researchers noted a slight uptick in prescriptions for narcotics (233 per 1,000 to 316 per 1,000), and a notable increase in NSAID prescriptions, from 221 per 1,000 visits in the 2007-2009 study period to 498 per 1,000 visits during 2013-2015.
    • Patients who visited an orthopedic specialist were more likely to be prescribed narcotics and NSAIDs if they were Hispanic, and more likely to receive a physical therapy referral if they were non-white and non-black. A decreased likelihood of receiving a physical therapy referral or lifestyle counseling was associated with orthopedic surgeons in rural areas.
    • In terms of referrals and prescriptions, patient demographics were not as much of a factor among patients who visited a PCP for knee OA, although there was a slightly higher likelihood of receiving narcotics among females and individuals who were black. Visits that included imaging were more likely to include narcotics prescriptions; visits covered by workers compensation were less likely to result in a prescription for NSAIDs.
    • Narcotic prescriptions were more likely among advanced practice orthopedic surgeons. That wasn't the case for PCPs.
    • The study sample was mostly white, female, and non-Hispanic, with an average age of 64. A chronic problem was the most common reason for the visit.

    Why it matters
    Knee OA is widely experienced, and its prevalence is on the rise, growing from an estimated 9 million individuals with the condition in 2005 to 15 million in 2012. Guidelines stressing the effectiveness of physical therapy and lifestyle modifications have been around since as far back as 1995, authors write, and the evidence supporting those recommendations has only increased. At the same time, the nation faces an opioid crisis at least partly linked to the use of prescription medications.

    Authors believe their study suggests a "counterintuitive" picture—"adherence to guideline-based care for non-pharmacological, non-surgical treatments such as [physical therapy], exercise, or weight loss is low for knee OA and does not seem to be improving over time." They write that "this contrasting trend suggests that knee OA is primarily managed from a perspective of symptom control and not from the perspective of improving physical function, fitness, and overall well-being."

    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.

    APTA offers multiple resources to help physical therapists and physical therapist assistants develop community-based arthritis programs, including a reference guide to various programs, a consumer-focused webpage that helps patients and clients understand the importance of movement to address OA, and links to offerings from the US Bone and Joint Initiative, such as its "Experts in Arthritis" program. Further information is available at PTNow, including tests and clinical guidelines.

    Keep in mind…
    Authors write that because the study was based on visits and not the patient, the analysis may have missed referrals to physical therapy or counseling on lifestyle that was not a part of the NACMS data collection effort. The study was also limited by drug groupings that did not distinguish between types of opioids, and a lack of indicators for disease severity and degree of disability.

    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.