PTinMotion_Feb2015

For MeMbers oF the AMericAn PhysicAl therAPy AssociAtion February 2015

Healing Lacrosse Players

The Future of Physical Therapist education

HealtH Care teCHnology

today

http://link.argifocus.com/4M7-33

2 PtinMotionmag.org / February 2015

Vol 7 no 1 February 2015

6 ComplianCe matters

What you need to know about utilization management.

10 ethiCs in praCtiCe

Weighing the pros and cons of a Facebook friend request.

82 ptas today

APtA membership is important in advancing the profession’s future, the author says.

84 defining moment

cleaning house—literally—confirmed her career choice.

the fUtUre of physiCal therapist edUCationAs health care evolves, so must the education of physical therapist students. What will physical therapist education look like in 20 years?

Columns

DeParTmenTs

48 ProFessionaL PuLse

+ Data Points

+ health care headlines

+ business sense

+ Association resources

+ research roundup

72 MarketPLace+ career opportunities &

continuing education

+ Products

78 advertiser index

88 By tHe nuMBers

28 stiCKs and stones: treating laCrosse playerslacrosse is classified as a collision sport, the same as football. And its name comes from the stick wielded by the players. these Pts help prevent lacrosse injuries and are involved in rehabilitation when the inevitable injuries occur.

38 health Care teChnology todaytechnological advances highlighted in this issue include nasal cells used in a spinal cord transplant, telehealth kiosks, tips to control technology vendor demos, the risk of medical device hacking, a robotic exoskeleton whose developer is seeking approval for home use, and more.

15

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APTA Board of DirectorsOfficersPresident

Paul A. Rockar Jr, PT, DPT, MSVice President

Sharon L. Dunn, PT, PhD, OCSSecretary

Laurita M. Hack, PT, DPT, MBA, PhD, FAPTATreasurer

Elmer R. Platz, PTSpeaker of the House

Susan R. Griffin, PT, DPT, MS, GCS, RPVice Speaker of the House

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Sumesh Thomas, PT, DPTMary Ann Wharton, PT, MS

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Valentine’s edition 2.7 years additional lifespan of a married versus

a never-married woman at age 55. among men, marriage adds 3.4 years.Brown d. Life expectancy differentials by marital status, individuals’ own education, and spousal education in the united states. 2014. http://paa2014.princeton.edu/papers/142823.

4,740 patients with heart failure in a

Cochrane review of 33 studies that found that exercise-based rehabilitation reduces the risk of hospital admissions and confers “important improvements” in health-related quality of life.taylor rs, sager va, davies eJ, et al. exercise-based rehabilitation for heart failure. cochrane database syst rev. 2014 apr 27;4;cd003331. doi: 10.1002/14651858. cd003331.pub4.

13.9% the difference in monthly exercise

program attendance rates for married couples attending together versus married individuals attending alone. 54.2% of the married pairs attended monthly; only 40.3% of the married singles did.Wallace JP, raglin Js, Jastremski ca. twelve month adherence of adults who joined a fitness program with a spouse vs without a spouse. 1995. J Sports Med Phys Fitness. 35(3):206-213.


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Compliance matters


by Lindsey Still, JD

Compliance matters

Utilization Management Review EssentialsEngagement with payers is key.

As payers explore ways to cut health care costs and reduce utilization, APtA has seen a surge in the use of programs known as third-party physical medicine and rehabilitation (PM&r) benefit management, or utilization management (UM).their increased popularity is due in part to a provision of the Patient Protection and Affordable care Act (AcA) called the medical loss ratio (Mlr), which is intended to limit insurer profit by requiring that a minimum percentage of premium dollars be spent on medical care (as opposed to admin-istrative costs). Under this provision, midsized insurers are required to maintain an 80/20 ratio—meaning that at least 80% of premium dollars must be spent on medical care, and no more than 20% may be spent on administrative costs. large-group plans must maintain

an 85/15 ratio. if an insurer does not achieve the medi-cal-care ratio target, it must pay a penalty in the form of customer rebates.

(note: the term “midsized” includes individual insurers and businesses with 1 to 100 employees. “large-group” applies to employers with more than 100 employees.)

While rebates to consumers may be viewed as beneficial, the Mlr also has produced unforeseen consequences, such as the outsourcing of UM. traditional UM per-formed by payers—including concurrent and retrospec-tive review—is considered

an administrative expense under the Mlr. if, however, the payer outsources the UM function to an external vendor that offers quality- improvement services, UM is considered to be a med-ical expense, and thus is included in the medical care portion of the Mlr.

creating and implementing an in-house rehabilitation quality-improvement pro-gram can be costly for the payer. to control costs, there-fore, some payers are con-tracting with UM companies that purport to have exper-tise in rehabilitation and offer quality improvement services. Given the financial benefit to insurers, the trend toward outsourcing manage-ment of the rehabilitation benefit can be expected to continue, and accelerate.

Issues With UM ProgramsAPtA has been working with state chapters affected

Lindsay Still, JD, is a payment specialist in APTA’s Payment

and Practice Management Department. Senior Practice

Management Specialist Elise Latawiec, PT, MPH, contributed

to this column.


7PtinMotionmag.org / February 2015

by this trend. several common problem areas have been identified. they include the definition of medical necessity, admin-istrative burdens, delays in the review or appeals pro-cess, and provider tiering.

Defining medical necessity. one of the most critical issues is the definition of medical necessity. each payer has its own defini-tion of medical necessity and established criteria for meeting this standard. often, however, UM compa-nies do not follow the defi-nition of medical necessity established by the payer—employing, rather, a more restrictive definition. When definitions are not aligned, requests for treatment of conditions and injuries that normally would have been covered under the payer’s definition of medical neces-sity may be denied.

this also is confusing for patients with regard to their

policy benefits. Patients enroll in a health care plan expecting to receive its specified physical therapy benefit. if, however, the benefit management com-pany does not adhere to the payer’s rehabilitation policy and definitions, delays or denials may occur of med-ically necessary physical therapist services that are covered under the enroll-ee’s plan. this exacerbates patient uncertainty and confusion.

Administrative burdens. Administrative burdens imposed by UM companies can be daunting. Most of these companies require physical therapy clinics, for example, to complete an online medical neces-sity review (Mnr) form to request approval of ongoing visits. completing this form necessitates input from both clerical and physical ther-apy staff, and takes physical therapist (Pt) time away from direct patient care.

Additional patient visits often are approved only in small increments that have little or no correlation to clinical presentation. thus, Pts may have to submit multiple Mnr requests for a single patient. not only does this require additional paperwork and substantial data entry, but it may delay patient care when Mnr requests are not authorized in a timely manner. these

delays cause interruptions in necessary services, interfering with patients’ progress and adherence to the plan of care. such delays may increase patient apprehension, and concerns about payment may lead them to cancel scheduled appointments or discon-tinue therapy altogether. interruptions in treatment frequency, in turn, increase the likelihood of poor

more informationFor additional guidance, visit the office of the national coordinator for health information technol-ogy’s mobile device privacy and security webpage at http://healthit.gov. (Go to “For Providers & Pro-fessionals,” then “Privacy & security,” then “Mobile Devices Privacy and security.”) the site offers tips, videos, answers to frequently asked questions (FAQs), downloadable materials, and more.

For additional guidance on hiPAA privacy and security rules, go to APtA’s hiPAA resource page at www.apta.org/HIPaa/. the site offers FAQs, APtA summaries of legislation, links to pertinent videos from a variety of sources, and more.


Compliance matters


patient outcomes and higher down-stream costs.

Review or appeals. in addition to the administrative burden imposed by UM programs, the review or appeals pro-cess offered by most companies can be quite one-sided. one UM vendor, for example, requires 3 levels of internal review if a claim is denied, and a level of external appeal, as well, with strict limits on provider filing. conversely, many UM contracts do not specify any timeframe for responding to the provider’s appeal request.

Furthermore, authorization requests and appeals may well be reviewed by individuals who are not licensed Pts. APtA’s policy is that peer review of physical therapist services should be provided only by an actively licensed Pt free of sanctions to practice physical therapy. Given the potential impact on a Pt’s plan of care and interventions, APtA considers the involvement of a Pt peer reviewer to be critical.

Tiering. Most UM programs place providers or facilities into tiers based on utilization patterns and other poorly defined criteria. the tiering system can be extremely complex and may penalize even the most prudent provider. in addition, once tiering has been established, the provider’s opportunity to improve or appeal its tier placement can be limited. Most UM programs, for example, review provider tier assignments annually and afford providers the opportunity to advance only a single tier per year. Moreover, depending on the tier to which a provider is assigned, pre- authorization requirements may be more onerous than they would have been in a different tier.

not only does the tiering system place additional burden on providers, but it also may adversely affect patients’ access to timely and appropriate physi-cal therapist services.

these are just a few of the common problems APtA has identified as large insurers across the country begin to contract with UM compa-nies. APtA also has observed issues related to functional measurements, patient access, documentation require-ments, billing policies, and payment methodologies.

What Providers and Chapters Can Doshould you learn that a payer in your state is planning to implement a UM program, there are several steps you can take to address the issues outlined in this column.

First, notify your chapter of the payer’s intent to implement a benefits-manage-ment program. the chapter then should reach out to the insurance company and request a meeting to discuss the UM program. Do not reach out to the UM vendor. it is best to start with the payer and see where that discussion leads.

When discussing the benefits-man-agement program with the insurance company, the chapter should ask such questions as:

\ What prompted the change? Might the insurer consider other options, such as starting with a pilot pro-gram rather than going directly to full implementation?

\ on what basis was this UM vendor selected? has the program been beta tested?

\ What type of documentation does the UM program require? how long will it take to complete an authoriza-tion request?

\ Will training be offered prior to implementation of the UM program?

your chapter also should determine if other states are affected by implementa-tion of the UM program. if so, state chap-ters can combine resources and work together to discuss the benefits-manage-ment program with the payer.

next, review the UM vendor’s physical therapy policy. compare the payer and UM definition of medical necessity. Also, see how the UM vendor defines function and functional change, and which assessment tools it designates to measure change.

chapters and providers also should closely review the UM vendor’s process to request patient visits, and determine the administrative burden accompanying such requests.

Finally, keep an eye out for tiering criteria, and review the UM company’s appeals process.

After the chapter has analyzed the physical therapy policy, it should iden-tify the person or people at the insur-ance company who handle inquiries about the UM program. it is prudent to develop a coordinated schedule to reg-ularly update the insurance company on how well the benefits-management program is working. chapters should provide their members with program updates, and may consider creating a webpage for reporting issues and collecting data.



be proactive. initiate dialogue with payers now. never assume that your relationship with a payer is good enough. building and maintaining a strong relationship takes continuous effort. there is no guarantee, however, that any payer will notify you before signing a UM contract. if you do not have a relationship with a payer in your state, start by inviting payer representatives to your facility to view typical therapy visits and discuss mutual concerns, such as operational obstacles or restricted access to care.

chapters also can hold payer/employer forums to educate attending parties on pertinent rehabilitation issues and facilitate the develop-ment of payer relationships. the key challenge for APtA, state chapters, and providers is to identify and offer payers viable alternatives to UM programs that are attractive to all stakeholders.

Don’t WaitAgain, as a result of this provision of the AcA, it is expected that more and more insurance companies will seek out the services of benefits-manage-ment providers in an effort to reduce rehabilitation costs, control utilization, and ensure compliance with Mlr requirements. but remember, it is never too late to develop a relationship with a payer. Do not wait to take action until after a UM program has been implemented.

Please contact APtA if you have ques-tions about PM&r benefits-manage-ment programs. call 800/999-2782, ext 8511, or direct e-mails to [email protected].




A Friendly ReminderSocial media can be great for public relations, but they also present conundrums.

ethics in practice

Nancy R. Kirsch, PT, DPT, PhD, FAPTA, a former member

of APTA’s Ethics and Judicial Committee, is the program director and a professor of

physical therapy at Rutgers University in Newark. She also

practices in northern New Jersey.

F-r-i-e-n-d. six letters that can mean a lot—or not so much. consider the following scenario, in which a simple request is weighted with potential ramifications.

Facing a ChoiceAs the youngest and newest physical therapist (Pt) at his clinic, Jeff is used to being the “go-to guy” for some of the older and less tech-savvy Pts on staff when it comes to issues related to internet technol-ogy (it) and social media. he has helped several Pts shape their personal Facebook pages, led a staff in-service on twitter, and contributes to the private practice’s website, in-house blog, Facebook page, and twitter feed.

Jeff tries to keep his per-sonal presence on social media separate from his professional one. While he

is personal-page “Facebook friends” with some of his coworkers and even with a few former patients (with a caveat that will be dis-cussed shortly), he makes it a rule never to discuss anything work-related in those interactions. he keeps up with the lives of selected work friends just as he would any other friend on Facebook. Jeff’s personal policy is to turn down friend requests from former or current patients—thanking them for their interest but politely explaining that that he would prefer to keep the relationship strictly profes-sional. (he knows, too, that former patients may well become future ones.)

there are a few exceptions that come with asterisks—former patients with whom Jeff has become both Facebook and full-fledged friends through shared interests in skiing and/or golf, Jeff’s biggest recre-ational passions. A couple of his former patients are, like Jeff, members of the local ski club. two other former patients are members of the golf club to which Jeff belongs. A fifth former patient belongs to both groups; Jeff now considers him to be a close friend.

one day, Jeff receives via Facebook a friend request from a recent patient named Michael, who had presented with several comorbidities and made great progress while he was under Jeff’s care. Michael sometimes made Jeff uncomfortable, however, by, in Jeff’s view, oversharing about his per-sonal life. During one visit he told Jeff that he often

by Nancy R. Kirsch, PT, DPT, PhD



feels insecure and defen-sive, that he has few friends, and that he gets depressed when he feels that his overtures of friendship have been rebuffed. on another occasion he told Jeff that he’s “been told” he can be pushy and needy, but that he finds it difficult to back off.

Jeff doesn’t know whether Michael ever has seen a mental health professional, but he suspects the possi-bility from some allusions Michael has made. Jeff never encouraged or sought to prolong these personal lines of conversation when Michael introduced them. he typically tried, rather, to refocus Jeff on his physical therapy and the movement issues on which Michael and he were working.

on this final visit for physi-cal therapy, Michael pointed to a photo on Jeff’s desk of the Pt standing on a golf

course with his clubs and remarked out of the blue, “i really like you. you should teach me to play sometime.”

Jeff had responded lightly, “Golf will break your heart! Get out before you even start, my friend. that’s my advice to you.”

Jeff replays that conver-sation as he views the

Facebook friend request on his computer screen. could Michael have imbued Jeff’s innocuous word choice with unintended meaning?

in this particular case, Jeff is reluctant to proceed as he typically does—explaining his reasoning and declin-ing Michael’s Facebook request. he doesn’t really know what to do. so, at first

he does nothing. he hopes the request has no out-sized meaning for Michael. Maybe it’s just 1 of many “friend” requests Michael has made, and Michael won’t pursue it further.

the next day, however, Jeff returns to his office after lunch to find a voicemail message from Michael asking if he’d received the

resourcesat www.apta.org/Policies/ethics/:\ standards of conduct in the Use of social Media

at www.apta.org/ethicsProfessionalism/:\ core ethics documents (including the code of ethics for the Physical therapist and

standards of ethical conduct for the Physical therapist Assistant)

\ ethical Decision-Making tools (past ethics in Practice columns, categorized by ethical principle or standard; the realm-individual Process-situation (riPs) Model of ethical Decision-Making; and opinions of APtA’s ethics and Judicial committee)

at www.apta.org/PTinmotion/2006/2/ethicsinaction/:\ “ethical Decision Making: terminology and context


ethics in practice


Considerations and Ethical Decision-MakingJeff must determine whether to respond to Michael’s Facebook friend request in the same manner as he has addressed past requests from other former patients, or whether to accept the request as, essentially, a goodwill gesture to a patient who Jeff believes has emotional issues.

realm. Individual, as the scenario focuses on rights, duties, relationships, and behaviors between 2 people.

Individual process. Moral courage and moral potency. there are risks to whichever course of action Jeff takes. “Friending” Michael on Facebook holds untold potential ramifications. but declining to do so could have an adverse effect on a former patient. Assessing his ethical obligations and choosing a path requires of Jeff both moral qualities cited above.

situation. this is a problem or issue, in that important moral values are being challenged.

Ethical Principles and Complementary Materials the following principles of the code of ethics for the Physical therapist offer Jeff guidance:

\ Principle 2a. Physical therapists shall adhere to the core values of the profession and shall act in the best interests of patients/clients over the interests of the physical therapist.

\ Principle 3a. Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings.

\ Principle 3d. Physical therapists shall not engage in conflicts of interest that interfere with professional judgment.

\ Principle 4B. Physical therapists shall not exploit persons over whom they have supervisory, evaluative, or other authority (eg, patients/clients, students, supervisees, research participants, or employees).

the APtA position standards of conduct in the Use of social Media (hoD P06-12-17-16) is instructive, as well. While many of the issues with which it deals are not germane to this scenario, it does instruct Pts, physical therapist assistants (PtAs), and students to “consider when and how to separate their personal and professional lives on social media.” the document further urges Pts, PtAs, and students to “consider whether to interact with patients” on their personal—as opposed to work-related—social media outlets.

e-mail from Facebook. the Pt real-izes at that moment that he’s probably going to have to engage Michael soon on the subject. but he isn’t sure what exactly to say or write to Michael—recalling how deeply affected his for-mer patient had seemed to be by the perceived rejections he’d recounted during his physical therapy visits. Jeff doesn’t immediately respond to the phone message, either, unrealistically hoping—but hoping nonetheless—that Michael’s inquiries will end there.

Unsurprisingly, however, when Jeff checks his e-mail between patient visits the following morning, he finds that he’s received a message from Jeff that reads, simply, “left you a phone message. Please check.” there’s also an automated message from Facebook reminding Jeff that Michael had sent him a friend request the day before.

Jeff slumps down in his office chair. he doesn’t want to further dent Michael’s self-esteem, but neither does he wish to engage in this way with a former patient. he also worries about leading Jeff on, in a sense, as he has reason to believe that his former patient may equate Facebook friend-ship with a real, multidimensional relationship. how to let him down gently?

or, should he let him down at all? could a Facebook friendship with Michael “work”? Might his profes-sional/personal rule of thumb toward social media, Jeff wonders, be a little too rigid?

his phone buzzes, alerting him that his next patient has arrived. As he exits his office, he eyes the copies of Physical therapy on his bookshelf,



which remind him that he can draw on APtA resources in considering his course of action. he resolves to explore the association’s website at lunchtime to see what guidance the code of ethics for the Physical thera-pist might offer him, and whether any other APtA documents shed addi-tional light.

For ReflectionJeff will find useful not only APtA’s code of ethics for the Physical thera-pist, but also the document standards of conduct in the Use of social Media. (see the “considerations and ethical Decision-Making” box) Might Jeff also consider using those documents as blueprints for crafting a practice-wide policy on the use of social media in all its facets?

For Follow-upi encourage you to share your thoughts about the issues raised in this scenario by e-mailing me at [email protected].

if you are reading the print version of this column, go online to www.apta.org/PtinMotion/2015/1/ethicsinPractice/ for a selection of reader responses to the scenario presented in this column, as well as my views on how the situation might best be handled. if you are read-ing this column online, simply scroll down for that material.

be aware, however, that it generally takes about 2 weeks after initial publi-cation for feedback to achieve sufficient volume to generate this online-only feature.






the Future of Physical therapist education

By Michele Wojciechowski

As health care continues to evolve rapidly, so will the physical therapy profession and the ways students are educated. What will physical therapist education look like in 10 or 20 years? Experts weigh in.



if any of that anecdote seems implausible—a physical therapist working as the leader of a shared leadership interdisciplinary health care team, students being taught how to be leaders in this environ-ment, or both—consider: the future is coming, and that scenario could well come true. Just 20 years ago, physical therapists couldn’t have imagined being able to use the internet to teach classes. ten years ago, most didn’t envision using their phones to watch a youtube video of a Pt working with a patient. And today it’s difficult to know what the physical therapy field and its education will be like over the next several decades.

however, it is possible to make some educated predictions.

interprofessional teams“the way we practice is going to affect physical therapist educa-tion,” says Jody Frost, Pt, DPt, PhD, FnAP, lead academic affairs specialist at APtA. “in the future,

you’re going to see health care moving from provider-centric to patient-centric, in which patients identify what their issues are. More and more, our curricula must begin to prepare learners for a whole different health care system.”

because health care is becoming more patient-centered, it also is moving to team-based, collabo-rative care, explains Frost. “As a result, over time you’re going to see that independent practitioners, no matter what profession—Pt, ot, etc—are going to practice in team-based situations. they will not be independent, freestanding, or private without any partners. they will be on a team because the health care system is being designed to make it easier for the patient, not more difficult.

“here’s the mantra—the right peo-ple at the right place and the right time for the patient.”

to understand what this will mean for physical therapist education, the Pts interviewed for this article

explain, you first have to under-stand what the mantra will mean for the physical therapists themselves.

With the focus on the patient, Frost says, more interventions may occur in community practices rather than hospitals. if a patient comes into a community practice, he or she will be evaluated by the entire team at once—the patient won’t need to repeat the same information mul-tiple times. the team may ask the patient what he or she is having the most problems accomplishing and then identify the primary issues to address. they will figure out which team members can best address those issues.

Furthermore, Frost says that there may be a stronger emphasis on prevention and wellness care. some people already schedule reg-ular wellness visits with their Pts today; more will do so in the future. clients will have annual movement screenings just as they have annu-al dental appointments.

overall, Frost predicts that one of the biggest changes in education is that certain curriculum com-ponents will become interprofes-sional. And this won’t happen only in physical therapy but across all health care professions. Particular parts of the curriculum will be about integrating the 4 interpro-fessional education (iPe) core competencies: values/ethics for interprofessional practice, roles/responsibilities of different health professions, interprofessional communication, and teams and teamwork.

the physical therapist fits into the health care team as the movement system expert. Depending on the patient’s diagnosis, the Pt may immediately lead the team, may share the leadership as described in the opening anecdote, or may serve as a member of the team. Pts will need to be able to work within

the year is 2025. A surgeon has performed a total hip replacement on a patient. As the patient is taken to recovery, the next steps in his recovery are discussed by his health care team: a physician,

a nurse, a physical therapist (Pt), an occupational therapist (ot), a pharmacist, and a psychologist. the focus now will be on recovery and movement. “My work with Mr smith is done,” says the surgeon while looking at the physical therapist. “you take it from here.” the physical therapist looks at her team, steps into the leadership position, and says, “let’s gauge his recovery. then i want to set up a schedule for physical therapy and other interventions to get him up and discharged as soon as appropriate.”

the professor turns to his webcam and speaks to his class about the interaction they just observed through real-time cameras. “What steps will the physical therapist take now that she’s the team leader? how can she work with the team to best help the patient?” asks the instruc-tor. “in other words, where do we go from here?”

Good question.



a team environment, but also be able to step in as leader when needed. therefore, they need to be educated in how to be leaders and how to work with other health care professionals.

educational needsWhile health care systems are beginning to deliver team-based health care, physical therapist education generally is not yet structured to provide that range of skills. but the movement is in the right direction. “there are insti-tutions doing interprofessional education, and they’re doing it very well,” says Janet bezner, Pt, DPt, PhD, associate professor in the Department of Physical therapy at texas state University. she says that while interprofessional edu-cation is not now an accreditation

requirement in physical therapy, it probably will be in the not-so-dis-tant future.

because they will work with other health care providers, Pts will need to know how to communicate in ways that all team members understand. Just like other health care workers, Pts have a specific terminology. to work together, providers will need to standardize or at least understand each other’s terminology to effectively share information. “We need to think differently about content,” says bezner.

in the 44th Mary McMillan lec-ture in 2013, roger nelson, Pt, PhD, FAPtA, professor emeritus at lebanon Valley college in Penn-sylvania, made a similar point when he stated, “physical thera-pist professional education must

increase its emphasis on … the development of communication skills, including communication with the patient, communication with the caregiver, communication with other health care profession-als, and communication with the third-party payer.”1

Physical therapists will need to learn how to communicate with all these players in health care. Further, nelson adds, they’ll have to be able to do it in a relaxed, easy manner rather than the formal way they do now.

“leadership needs to be more front and center in our curriculum,” says bezner. she’s uncertain, though, about whether leadership will be taught as a separate class or threaded throughout the Pts’ en-tire curriculum. the answer should become more apparent in the fu-




ture, as more of the Pt curriculum begins to evolve, she says.

hybrid learning today, the cost of Pt education is high and continues to grow. Frost says, “Pt schools are outpricing themselves with their current model. to survive, they may move more to ‘hybrid learning’ or ‘universities without walls.’” there will be changes to what is offered face-to-face and to what is offered via online classes, webinars, and other communication forms, she suggests. in fact, this transition has already begun in some Pt education programs.

bezner adds that another innova-tion—flipped classroom models—will become more common. “his-torically, we have used classroom time to teach the information. then

students use their homework time to think about how it applies. With the flipped classroom, it’s the op-posite,” she explains. “students are exposed to the information for the first time on their own—today it’s usually through a recorded lecture or some other resource. then, they come into the classroom, and we talk about how it applies. in the future, we will use classroom time to really solve problems and apply the conclusions to patient care.”

Gina Maria Musolino, Pt, Msed, edD, agrees. “We need to be more efficient so that we can use our future face-to-face time to do the higher-level learning,” she says. Musolino is associate professor and director of clinical education in the Morsani college of Medi-cine’s school of Physical therapy & rehabilitation sciences. she also

is the president of APtA’s educa-tion section. “i don’t get together with my students any more without them having completed something outside the classroom,” she says.

Making these changes—moving more of the educational process outside the classroom—may result in another change. in the future, Frost says, the curriculum struc-ture could allow students to move at their own pace. not all students necessarily will begin their edu-cation at the same time or finish at the same time, as is the practice today. the educational process will begin to account for the differences in learners’ styles and capacities. students who move through the curriculum more slowly might not be penalized. if students can move faster, though, it may reduce their tuition and other costs.




Adam, PT, DPT, has been a practicing physical therapist for nearly 10 years in an orthopedic private practice. His schedule is fully booked for the day when a patient walks in requesting to be seen for neck strain following an auto accident.

Adam wants to help the patient, who is clearly in pain, and he doesn’t want to disappoint the patient or the referring physician, one of his top referral sources. Since he doesn’t have time to fit a full evaluation and treatment session into his schedule, Adam directs Katie, his physical therapist assistant (PTA), to perform the evaluation and document her findings within the patient’s chart. Adam knows he can find a few minutes to review the evaluation between his other patients and provide treatment to his new patient.

What Adam doesn’t realize is that, even though his goal to ensure the patient is seen as soon as possible is a noble one, he is asking Katie to perform the physical therapist evaluation, which is outside of the scope of a PTA’s licensure. This is considered inappropriate use of supervised personnel and is a violation of state law.

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Allowing students more flexibility in setting their own pace will be beneficial, bezner says, because the Pt student is changing. she already has a handful of students with different needs—in-cluding second-career students, single parents, and those with families—and those numbers are increasing. “it’s difficult for these students to dedicate 8 am to 5 pm Monday through Friday to school,” she says. While some programs already offer weekend or online classes, many more will.

research and evidence-Based practicein addition, future Pt education pro-grams will include a strong emphasis on research, says Jim Gordon, Pt, edD, FAPtA. Gordon, who presented the 2014 McMillan lecture, is profes-sor and associate dean in the Division of biokinesiology and Physical ther-apy at the herman ostrow school of Dentistry at the University of south-ern california.

“We understand when the training of physicians requires them to go to larger academic institutions, and i think we need to take our profession seriously in the same way. We need to have programs at strong institutions that are capable of excellent teaching, cutting-edge research, and true inter-professional education,” Gordon says.

Gordon says he wants to see the pro-fession develop the physical therapy equivalent of the medical profession’s 1910 Flexner report which, one observ-er said, “transformed the nature and process of medical education in Amer-

Allowing students more flexibility in setting their own pace will be beneficial because the PT student is changing.






ica with a resulting elimination of proprietary schools and the estab-lishment of the biomedical model as the gold standard of medical training.”2

Gordon envisions the study lead-ing to recommendations regarding the structure of future physical therapist education. health care professionals who aren’t Pts would compare physical therapist academic programs with those of other health professions and pro-vide advice on the structure of Pt academic institutions.

having such a report would provide a mechanism to eliminate what Gordon sees as an evolving 2-tiered education system, because the small, inadequately resourced programs with too few faculty members and not enough empha-

sis on research would be forced to either change or close.

the movement systemAPtA’s vision statement sees the physical therapy profession as “transforming society by opti-mizing movement to improve the human experience.” Frost says that physical therapist education may be affected by the vision’s focus on movement. “the experts in the movement system are physical ther-apists, and the curriculum might be organized differently around the movement system,” says Frost.

For example, Frost says that if Pts want to look at how and why patients move, they won’t focus on a specific joint. instead, they also will consider the patient’s motivation, the patient’s function,

and how he or she is moving. All those factors will be analyzed to help determine which areas of movement are problematic and prevent patients from performing their desired activities. “education is going to be oriented a little dif-ferently,” says Frost. “instead of an orthopedics 1 class, you might find an integrated curriculum around the movement system.”

nelson, during his McMillan lecture, told about an experience he had nearly half a century earlier. he had been assigned to the care of a seaman who worked in a ship’s galley. the seaman’s thumb had to be amputated. nelson knew that most of the seaman’s hand function depended on a prehensile thumb, so he had a dentist cast a prosthetic thumb in the prehensile position.




nine months later, the seaman visited nelson—with no thumb. nelson asked what had happened. the seaman responded that he had thrown it overboard after receiving complaints from his fellow sailors who had repeatedly found his pros-thetic thumb in the meals he served them. the seaman had found a way to do his job without an opposing thumb on his dominant hand.

that experience, nelson says, “helped me to see the importance of looking beyond the pathology and obvious impairment—to inter-act with all aspects of the patient,

and understand the patient’s envi-ronment and his individual expec-tations for the services received.”

nelson hadn’t been taught that in school. tomorrow’s students may be.

Clinical education and residenciesclinical education may be different as well. “you’re going to see some shifting occurring regarding what is still in the curriculum and what is actually in clinical practice,” says Frost. Pt students who will have learned via some iPe classes

may be prepared for collaborative patient-centered teams for their clinical education. they will work with students from other health care professions such as medicine, nursing, pharmacy, psychology, and occupational therapy.

in addition, physical therapist educa-tion may offer more residencies. “in the future, we may find the profes-sion of physical therapy requiring residencies for those who want to be-come specialists,” says Frost. “i think we’re going to see more residencies and fellowships develop. We have quite a few now, but those are going to grow significantly to accommo-date a need and a demand within the profession from graduates.”

however, that may require a major change in the profession’s ap-proach to residencies. in the 18th John h.P. Maley lecture in 2013, Kornelia Kulig, Pt, PhD, FAPtA, FAAoMPt (hon) noted that “the ratio of applicants to residency acceptance is rapidly increasing.”3 she cautioned, “Although this is a good problem to have, we need to avoid the potential pitfall of creat-ing new residencies solely for the purpose of meeting the demand.”

Kulig proposed shifting the bulk of residencies from “small clinical communities” to universities. she explained, “it is time to look for an optimal, not just suitable, environ-ment in which to house residen-cies. this environment includes clinicians, clinical scholars, and laboratory researchers … i believe that university-based education programs provide for an optimal residency environment.”

technology and the facultyAs the health care field and edu-cation change, so will the require-ments of faculty. in the future, fac-ulty members and faculty experts are going to be blended differently,

“it is time to look for an optimal, not just suitable, environment in which to house residencies.”






says Frost. Faculty will engage in team teaching with professionals in other fields and teach across spe-cific areas, both theoretically and practically. besides interprofession-al team teaching, they will engage in case-based teaching. they also will conduct online education and whatever other new technological teaching modes that exist.

Musolino says that as more gets shared via telehealth, students will need to learn how to perform new procedures. As a result, so will their professors before them.

For example, Musolino describes research addressing people with chronic diseases. sensors can be placed on the patients’ feet, mea-suring the pressure. if patients are staying in their homes longer—as opposed to the hospital or skilled care—these sensors may provide data that can be transferred remotely to let the physical therapists know if these patients are moving around enough throughout the day. Pts may then become “real-time responsive” to prevent movement from declining.

suppose, Musolino continues, that garments with sensors are worn not only by patients, but also by phys-ical therapists. Physical therapists then might be capable of remotely facilitating their patients’ move-ments through the interconnected 3-D and 4-D sensing technologies. if the technology enables Pts to feel what their patients are feeling and to guide movement, instructors will have to learn these technologies to teach them to students.

on the other hand, if a single Pt is able to teach this to hundreds or even thousands of Pt students across the country online or using another technology, then not all in-structors will need to be proficient in that specific new application.

tomorrow’s instructors, howev-er, will need to be able to teach students who are comfortable

with technology. they will teach students who are unlike earlier Pt students. bezner points out that to-morrow’s students will have known and used technology all their lives. that familiarity will have direct implications in terms of the con-tent that will be taught.

Musolino agrees. she says that students today grew up with gam-ing—using video game systems—in their lives and often want to use the same elements to motivate patients and clients, often through the use of gamification. this will continue, and future students undoubtedly will develop different kinds of games to use with patients.

addition and subtractionWith all these different educational components being added to the fu-ture DPt curriculum, will some of today’s content have to be reduced or eliminated?

“interventions that are demonstrat-ed not to be evidence-based or that are shown not to really make a dif-ference, that’s what will come out of the curriculum,” explains Frost.

nelson, in his McMillan lecture, identified 2 areas “for less empha-sis to balance those areas in which the emphasis is increased”: (1) teaching impairment ratings and (2) the use of passive modalities.

regarding the former, nelson said, “range of motion and manual mus-cle testing measures are not partic-ularly reliable and are irrelevant to the more important measure of the patient’s ability to function in his or her environment.” regarding pas-sive modalities, nelson observed, “successful outcomes are related to the therapist’s skilled intervention to maximize the patient’s func-tional outcome, not to the type and amount of modalities used.”

no matter the specific developments over the coming decades, the Pts

interviewed for this article said that 1 theme was particularly important to include in physical therapist education. “We have to continue to teach our students how to clinically reason and to critically think,” says Musolino. “We will never be able to totally predict the future. because of this, we have to teach students how to think and absorb evidence and to be critical in their analysis as well as to clinically reason through problem solving and cases.”

nelson made a similar point during his McMillan lecture: “our DPt programs do an excel-lent job of preparing students for a position in physical therapy as the position now exists, but not for the position of the future. We need to encourage broader and more creative thinking and problem solving, teaching our students to think about the most efficient ways to deliver patient care and how to build on their competencies.”

Frost picks up on that theme: “some of the diseases we have today won’t exist or will be modified in the future. some people who are para-lyzed today may eventually not be. With this in mind, we’ll need to fig-ure out the role of physical therapy and the professional education that will be needed to graduate a compe-tent and collaborative team-based practitioner to provide patient-cen-tered care. We’ll have some things in the future that we can’t even begin to imagine now.”

michele Wojciechowski is a free-lance writer based in maryland and a frequent contributor to PT in Motion.

reFerenCes

1. Nelson RM. The Next Evolution. Phys Ther. Oct 2013;93(10):1415-1424.

2. Duffy TP. The Flexner Report—100 Years Later. Yale J Biol Med. Sep 2011;84(3):269–276.

3. Kulig K. Residency Education in Every Town: Is It Just So Simple? Phys Ther. Jan 2014;94(1):151-161.






Lacrosse was named for the stick its players wield. As the saying goes, sticks and stones can break bones. Lacrosse players experience myriad other injuries as well. Physical therapists help prevent injuries and rehabilitate injured players.

By Keith loria



L acrosse is a comparatively old sport— certainly older than baseball, basketball, football, or rugby. historians believe it

was played as early as the year 1100 among indigenous peoples in north America.

More recently, lacrosse has become one of the fastest-growing team sports in the United states, with an annual growth rate of nearly 10% during the past decade. in 2013, nearly 750,000 lacrosse players participated on organized teams. More than a third of the players—37%—were female.1

in competitive lacrosse, men’s lacrosse is consid-ered a contact sport. body contact is allowed and is part of the game’s tactics. in fact, the national collegiate Athletic Association (ncAA) classi-fies men’s lacrosse as a “collision sport,” placing it in the same category as football and ice hock-ey. Meanwhile women’s lacrosse—with different rules—is considered a non-contact sport. Any contact is usually incidental. but contact and injuries still occur.

injury rates are expressed as injuries per “athletic exposure” (Ae)—which refers to either a practice session or game. those rates vary widely based on the player’s age, sex, and whether the injury occurred during practice or a game. For example, based on recent studies, the overall injury rate for men’s lacrosse during games is 11.5 per 1,000 Aes.1 Among high school boys in competition, the injury ratio is 3.61. Among high school girls during practice, the injury rate drops to 1.54.3

According to the ncAA, the most frequently injured body parts for male lacrosse players are the ankle, upper leg, and knee, which when com-bined account for 48% of all injuries. Meanwhile,

the most common injuries are ligament sprains (incomplete) and muscle strains, which, together, account for 50% of injuries in male lacrosse.2

the picture is somewhat different for high school players. there, the most common injury among both boys and girls is sprains/strains (boys: 35.6%; girls: 43.9%) and concussions (boys: 21.9%; girls: 22.7%). the most commonly injured body sites in high school competition are the head/face (32.0%), lower leg/ankle/foot (17.8%), and knee (12.2%).3

Part of the variation in injuries also is due to the different types of lacrosse. “outdoor and indoor lacrosse are actually 2 different brands of lacrosse that see 2 different styles of play and, subsequently, a variety of pathologies,” accord-ing to Adam thomas, Pt, DPt, Atc.

thomas is an assistant clinical professor at northeastern University and serves as head ath-letic trainer for the boston cannons professional lacrosse team and assistant trainer for team UsA lacrosse. he’s also worked as a trainer for the bos-ton blazers Professional indoor lacrosse team.

thomas says, “With regards to outdoor lacrosse, i tend to see more traditional orthopedic injuries, and usually lower body injuries. over the last



Common InJurIes

few years, we have seen lower back injuries and hamstring injuries at the beginning of the season.”

timothy tyler, Pt, Ms, Atc, a physical therapist at the nicholas institute of sports Medicine and Athletic trauma at lenox hill hospital, has worked with a number of lacrosse players through the years. in his experience, hamstring injuries are the most common.

other common injuries include frac-tured thumbs (typically with goalies and also from getting slashed) and inversion ankle sprains. still, thomas says that the most common injury he deals with is hamstring strains, typically as a result of an imbalance, or improper warm-up or poor off-season training.

yoni rosenblatt, Pt, DPt, ocs, of baltimore-based true sports Physical

therapy, was part of the israel men’s national lacrosse team’s training staff last summer. rosenblatt has worked with nationally ranked boys and girls high school lacrosse teams, current Di-vision i, ii, and iii athletes, and World championship competitors.

“i see a lot of strains and sprains. A lot of Acls and strains of the lower extremities. i have seen an inordinate amount of hip pathology in the la-crosse athlete,” he says. but rosenblatt suggests that a significant factor in injuries may have little to do with the game itself: “i think it has a lot to do with the training regimen and then the 12-month season in which they com-pete. it’s just overload. And when the hips, particularly, become overloaded and they’re put in those compromising lower positions.”

Further, rosenblatt says that a contrib-utor to some injuries isn’t connected in any way with athletics.

“When a patient comes to me with groin pain, first it’s important to figure out: is this a muscle strain? is this a muscle tear or is this coming from some type of inside-the-joint pathol-ogy? then there’s a matter of really teasing out which muscles are weak. Very commonly, especially in student athletes because they’re spending so much time sitting at a desk, the front of their hips are very tight and the back of their hips, their glutes, are very weak,” he says. “And so my first attempt is to try to figure out how we can flip that. how do we open up and loosen the front of the hip and how do we tighten up and strengthen [the back]? sometimes it’s a matter of

AnkLe

knee

FACe

48% oF All InjURIEs:AnklE, UPPER lEg, & knEE

32% HEAD, FACE

50% lIgAMEnt sPRAIns AnD MUsClE stRAIns

17.8% loWER lEg,

AnklE, Foot

12.2% knEE

In tHE nCAA In HIgH sCHool

upper Leg

LowerLeg

HeAd

Foot



waking the muscles up or activating the posterior of the joint or the glute to offload the hip.”

once he’s determined that, he con-siders which exercise and manual interventions will help the joint.

rosenblatt worked with player lee coppersmith while coaching the team israel squad this past summer. copper-smith is considered by followers of the sport to be 1 of the fastest lacrosse play-ers in the country. he currently plays professionally for the Florida launch of Major league lacrosse (Mll).

coppersmith says, “i’ve had numerous sports injuries, but the muscle group that has given me the most problems are my hamstrings. i’ve pulled both of my hamstrings many times and i’ve required extensive therapy. the treat-ment helped me recover faster and become stronger than even before my injuries occurred. For my hamstrings, i had to train the imbalances in my legs, increase flexibility through stretching, and making sure to strengthen my hamstrings and surrounding muscles. i feel my injuries occur when i’m not training properly or when my nutri-tion/hydration are sub-par.”

rosenblatt adds, “i also perform dry needling. And then once they’re out of pain, we’ve got to figure out how they are playing within lacrosse. Are they cutting appropriately? Are they able to plan appropriately? Are they able to stop on a dime? Are they able to get down for a ground ball? Are they able to explode through the hips?” he asks. “i look at that entire kinetic chain. you need to understand the lacrosse shot or—with a goalie—understand reach-ing the top corners and the bottom corners. only then can you really put together a full-fledged lacrosse-specif-ic rehab program.”

For female players, rosenblatt encoun-ters higher rates of acetabular labral injuries.

“i see more hip problems with my female athletes and, to be expected, i see more Acl tears,” he says. “When i look to rehab the lacrosse athlete,

ADAM ThOMAS, PT, DPT, ATC, says that the most common injury he deals with is hamstring strains, typically as a result of an imbalance, or improper warm-up or poor off-season training.




there’s certainly a difference between female and male, obviously, in an-atomical makeup, but also in their expectations and their seasons. each athlete is individual in terms of his or her long-term goals. All that has to be considered when putting together a rehab program.”

Jessica hettler, Pt, MsPt, Atc, cert MDt, scs, meanwhile, says the more common injuries she encounters among women players include lower extremity sprains and strains (ankle, knee), low back pain, quad contusion, and Acl injuries (more noncontact then contact injuries).

MANAgINg ThE CLOCKPts who work with lacrosse players, especially the professional players, face a number of challenges dealing with time.

“What we’re finding is that we have about 4 to 6 weeks if it’s in season to get a player better. Usually we have 1 chance of getting that player better. if he is reinjured during that same season, it’s very hard to get him back on the field,” tyler says.

Further, due to the nature of profes-sional lacrosse, many players have full-time jobs and do not live in the market in which they play. As a result, Pts often see their lacrosse patients to monitor their progress only the day be-fore a game, Pts interviewed for this article explained. that, in turn, affects the Pt’s involvement with the patient.

ThE gAME MATTERSlacrosse consists of a lot of running and cutting. For face-off specialists, it requires a lot of explosiveness when in a crouched position.

hettler has covered middle school, high school, college, and men’s la-crosse leagues, plus girl’s high school lacrosse over the past 10 years, and has seen many lacrosse athletes in her clinic. she also worked with the wom-en’s irish national team during the european championship in 2012.

Lacrosse is a team sport played using a small rubber ball and a long-handled stick called a crosse or lacrosse stick. the head of the lacrosse stick is strung with loose mesh designed to catch and hold the lacrosse ball. offensively, the objective of the game is to score by shooting the ball into an opponent’s goal, using the lacrosse stick to catch, carry, and pass the ball to do so. defensively, the objective is to keep the opposing team from scoring and to gain the ball through the use of stick checking and body contact or positioning.

The sport has 4 major types: men’s field lacrosse, women’s lacrosse, box lacrosse, and intercrosse. the sport consists of 4 positions: midfield, attack, defense, and goalie. In field lacrosse, a men’s team includes 9 players, plus a goaltender; a women’s team has 11 players, plus the goalie.

Lacrosse games consist of 4 quarters, with length of the quarters increasing from 8 to 15 minutes as the levels go up from youth to pro international. Teams trade ends of the field at the end of each quarter. The field itself is slightly larger than a football field, measuring 60 yards wide by 110 yards long.

Lacrosse is believed to date back at least a thousand years. In 1637, French Jesuit missionary Jean de Brébeuf saw Iroquois tribesmen play the game in present-day new York. He called it la crosse (“the stick”). In 1855, william george Beers, a Canadian dentist, founded the montreal Lacrosse Club. In 1867, Beers codified the game, shortened the length of each game, and reduced the number of players to 12 per team.

From Canada, lacrosse spread to the united states, great Britain, and Australia. The first international lacrosse match was played in 1867 between Canada and the united states. olympic medals in lacrosse were awarded in 1904 and 1908. though lacrosse was a demonstra-tion sport at the 1928, 1932, and 1948 olympics, it has not returned to medal-sport status.

At the highest amateur level, lacrosse is represented by the collegiate NCAA Division I in the United States. In 2001, a men’s professional field lacrosse league, major League Lacrosse (mLL), was inaugurated in the united states. Initially starting with 3 teams, mLL has grown to 8 clubs located in major us metropolitan areas.

RefeRenceshttp://en.wikipedia.org/wiki/Lacrosse

http://www.ehow.com/way_5454002_basic-lacrosse-rules.html

http://www.sportsknowhow.com/lacrosse/history/lacrosse-history.shtml

http://www.dummies.com/how-to/content/understanding-how-lacrosse-is-played.html

ABout LACrosse



“repetitive overuse injuries of the hip and lumbar spine can occur with repetitive shooting. A common complaint in rotational and overhead athletes can be lower back pain or hip pain,” she says. “think of the men’s lacrosse shot and the amount of torque and velocity of speed from draw of the ball to the release phase of the shot. During the follow-through phase (re-lease), weight is moved to the lead leg. the lead leg moves into ir, flexion, and adduction, which can put the play-er at greater risk for hip impingement and labral pathology.”

hettler’s rehabilitation program focuses on a solid strength and stable base (core) before addressing the ex-tremities. A stable base and control of motion will set the stage for progres-sion to skill acquisition and safe return to play, she says.

ThE PLAYERS SPEAKone of rosenblatt’s patients is Gen-evieve eby, who was considered the best high school female player in the country when she chose the Universi-ty of new hampshire for her college career in 2012.

While in high school, eby suffered a concussion playing volleyball. those symptoms were reignited during a college lacrosse contest.

rosenblatt describes what followed. “she was diagnosed with having occipital neuroglia and received pe-ripheral nerve release on her occipital nerves in June of 2013. she had her skull operated on 2 times and needed to work on not just strength, endur-ance, and posture, but also vestibular rehabilitation and running progres-sion in an effort to return.”

rosenblatt has helped eby strengthen her neck and body as a whole.

eby says, “i would not be where i am today without yoni. before my second surgery, he would needle my neck to release the tight muscles caused by my nerve pain. he also helped me with my posture so i was not putting as much strain on my neck,” she says. “he

ThINK OF ThE MEN’S LACROSSE ShOT AND ThE AMOuNT OF TORquE AND vELOCITY OF SPEED FROM DRAw OF ThE bALL TO ThE RELEASE PhASE OF ThE ShOT.




ThERE’S SO MuCh ROTATION INvOLvED

whEN YOu ThROw—IN LACROSSE YOu ROTATE

YOuR whOLE uPPER bODY

would take a video and break down my positioning to help correct me. Keep-ing my neck in a neutral position while exercising decreased my pain.

“After my second surgery, yoni helped me ease into becoming active again. We started with body weight squats and worked up to cutting and sprinting in a

couple weeks. Vestibular exercises also were a main part of my rehab. i used to get dizzy running, but these exercises improved my vestibular system.”

other players also speak of the bene-fits of physical therapy. For example, in 2014, Duncan hutchins made it back to play for the Unc tar heels men’s lacrosse team after a spinal fusion cost him the previous season. throughout his athletic career, hutchins has faced everything from basic muscle tweaks to reconstructive back surgery.

“My first Pt visit came after an ar-throscopic procedure to repair a badly torn labrum in my shoulder. My reha-bilitation program included mobiliza-tion exercises and then strengthening. next were my back issues. i had stress fractures on my l3-l4 vertebrae that caused constant dull and achy pain that refused to die down whether i was sitting, standing, sleeping, working, or playing. After attempting to avoid it, i opted to have surgery.”

he lost 30 pounds and looked to his Pt for help. soon, hutchins was on a regimen of box jumps, hip bridges, core strengthening, stretching, and dry needling.

“the exercises and rehab abso-lutely was pivotal to me getting back on the field. i basically

had to rebuild my body from the 30 pounds of muscle i had lost due to my back fusion,” he says. “After i had that base i was allowed to pick up a stick.”

wORKINg wITh YOuNgER PLAYERSKevin Mchorse, Pt, scs, cert MDt, at central texas Pediatric orthopedics and current chair of the APtA sports section’s youth Athlete special inter-est Group, has been treating young lacrosse players since the sport took off 10 years ago.

“i’m seeing a lot more kids playing club lacrosse and with travel teams. last year there were a lot more lacrosse injuries specific to a popula-tion that i treat, and they tend to start coming in around 10 years old,” he says. “i see a lot of overuse injuries and so they get osgood-schlatters [an overuse injury affecting the knee] just from the constant running around and playing year-round on travel teams. then, on the trauma side, you see the typical ankle sprains, knee sprains, and some back injuries.”

gENEvIEvE EbY While in high school, eby suffered a concussion playing volleyball. those symptoms were reignited during a col-lege lacrosse contest. eby says, “i would not be where i am today without [physical therapy].”






Unlike other sports where athletes do a lot of cutting and twisting, in lacrosse the element of constant running is combined with the contact similar to what might occur in football.

“so you get the injuries from moving all the time. then there’s so much rotation involved when you throw—in lacrosse you rotate your whole upper body—and almost every time you throw you’re also running in 1 direc-tion or switching directions,” Mchorse explains. the exception, he adds, is goalies: “you don’t really see the over-use stuff. Abrasions or contusions are more common in the goalies.”

For kids with overuse injuries, Mchorse says rehabilitation is a 2-step process. First, take care of the underlying prob-lem. then figure out why the player ended up in a situation with a lack of flexibility and a lack of core strength.

With lacrosse rising in popularity, chil-dren are starting to play the game at ever younger ages. hettler says it’s im-portant that young athletes participate in multiple sports throughout the year and focus on strengthening programs appropriate for their age groups.

PREvENTIvE METhODSWhen it comes to lacrosse, preven-tion is key to successful seasons and careers, the Pts interviewed for this article said. Fatigue commonly plays a large role in lacrosse injuries. For that reason, they say, a program should be developed based on individual findings to address neuromuscular control issues, length-tension issues, and compensatory patterns.

“Although contact injuries cannot be prevented, we can have a positive effect on noncontact injuries and over-use injuries,” hettler says. “A proper screening for each player should be done to look at mobility at each joint, isolated strength testing, trunk en-durance, and dynamic motions. these same dynamic tests should also be looked at after the athlete is fatigued.”

Meanwhile, cody levine was a star player at cornell when he suffered a herniated disk in his lower back, during his senior season in 2013. With effective rehab, he was able to get on the field for the World Games this past summer.

levine advises, “it’s extremely import-ant to consult a Pt because it only takes the slightest movement in the wrong direction to rein-jure yourself. coming back too early from an injury could cause even more

whEN IT COMES TO LACROSSE, PREvENTION IS KEY TO SuCCESSFuL SEASONS AND CAREERS

damage,” he says. “As a midfielder, i run all game long and need my entire body in top shape. i would tell any [la-crosse] player to see a sports Pt to get proper eyes on your injury and work to get healthy the right way.”

Keith loria is a freelance writer.

reFerenCes

1. 2013 Participation Survey uS Lacross. http://www.uslacrosse.org/Portals/1/documents/pdf/about-the-sport/2013-participation-survey.pdf. Accessed November 19, 2014.

2. bach bR, McCulloch, PC. Injuries in Men’s Lacrosse. Orthopedics. 2007;30(1).

3. Xiang J, Collins CL, Liu D, et al. Lacrosse injuries among high school boys and girls in the united States: academic years 2008-2009 through 2011-2012. Am J Sports Med. 2014;42(9):2082-2088.CODY LEvINE suffered a herniated disk in

his lower back while playing in college. he advises, “it’s extremely important to consult a pt because it only takes the slightest movement in the wrong direction to reinjure yourself.”






HeALtH CAre teCHnoLogY toDAyBy Don Tepper



NASAL CELLS uSED IN SPINAL CORD TRANSPLANTscientists have reported that cell transplants combined with other interventions have enabled a man with a severed spinal cord to walk again.

the case involves a 38-year-old man who sus-tained traumatic transaction of the thoracic spi-nal cord at upper vertebral level th9. there was an 8-mm gap between the spinal cord stumps. the stumps remained connected only by a 2-mm rim of spared tissue. At 21 months after injury, the patient presented symptoms of a clinically complete spinal cord injury (American spinal injury Association class A-AsiAA).

researchers removed 1 of the patient’s olfactory bulbs and used it to derive a culture containing olfactory ensheathing cells and olfactory nerve fibroblasts. Following resection of the glial scar, the cultured cells were transplanted into the spi-nal cord stumps above and below the injury. the 8-mm gap was bridged by 4 strips of autologous sural nerve. the patient underwent an intense pre- and post-operative neurorehabilitation program.

During the first 8 months after the operation, the patient did not show any improvement. however, the scientists report, in the period from 9 to 11 months after surgery “there was an evident improvement in the technique of exercise performance and an in-crease in the values of the loads in exercises requir-ing high degree of voluntary function of abdominal

and back muscles, gluteal muscles, adductors and abductors, hip flex-ors, and knee extensors.”

the scientists continued to see progress: “starting from 14 months the patient was able for the first time to ambulate with walker, long braces, and the assistance of one person. Additionally, in the last months of observation the patient started to walk both in parallel bars and with a walker with short braces, locked only at the ankles.” At 19 months postop, the patient had improved from AsiA A to AsiA c.

the researchers noted that because they provid-ed multiple types of treatments, “it is difficult to determine which aspects of the interventions con-tributed to the observed neurological recovery.” however, they added, “each single intervention had its importance but in our opinion could not be in itself sufficient, if applied without the others.”

reFerenCe

Tabakow P, Raisman g, Fortuna w, et al. Functional regeneration of supraspinal connections in a patient with transected spinal cord following transplantation of bulbar olfactory ensheathing cells with peripheral nerve bridging. Cell Transplantation. Published ahead of print. http://dx.doi.org/10.3727/096368914X685131.

RESEARChERS MODIFY SKIN CELLS FOR bRAIN TREATMENTresearchers at Washington University school of Medicine in st louis have described a way to convert human skin cells directly into a specific type of brain cell affected by huntington disease, a fatal neurodegenerative disorder. Unlike other techniques that rely on one cell type turning into another, the new process does not pass through a stem cell phase. the converted cells survived at least 6 months after injection into the brains of mice and behaved similarly to native brain cells.

the investigators produced a specific type of brain cell called medium spiny neurons, which are involved in controlling movement. the research involved adult human skin cells, rather than more commonly studied mouse cells or even human cells at an earlier stage of development.

to reprogram the cells, the researchers put the skin cells in an environment that closely mim-ics the environment of brain cells. From past research, they had determined that exposure to 2 small molecules of rnA could turn skin cells into a mix of different types of neurons. the

researchers then started to modify the chem-ical signals, exposing the cells to additional molecules called transcription factors that they knew were present in the part of the brain where medium spiny neurons are common. When transplanted into the mouse brain, the converted cells demonstrated morphological and function-al properties similar to native neurons.

the investigators now are taking skin cells from patients with huntington disease and reprogram-ming them into medium spiny neurons. they also plan to inject healthy reprogrammed hu-man cells into mice with a model of the disease to see what effect that will have on the symptoms.

reFerenCe

victor Mb, Richner M, hermanstyne TO et al. generation of human Striatal Neurons by MicroRNA-Dependent Direct Conversion of Fibroblasts. Neuron. October 2014;84(2):311–323. DOI: http://dx.doi.org/10.1016/j.neuron.2014.10.016.



‘gAME ChANgINg’ NEw DEvICES INCLuDE gAIT, PRESSuRE wOuND MONITORINg SYSTEMSnever mind the latest iPhone 6—how about an insole than can gather and transmit motion data, or a monitoring system that can provide detailed assessments of wounds to help thwart the development of pressure ulcers?

recently, Medscape published a list of 15 “game changing” wireless health technology devices selected by cardiac electrophysiologist David lee scher, MD, clinical associate professor of medicine at Penn state University, director of a digital health consulting firm, and chairman of the healthcare information and Management systems society (hiMss) Mobile health roadmap task Force. While cardiac, records, and medications monitors made up much of the list, scher also included several devices that could be of special interest to physical therapists and physical therapist assistants.

Woundrounds combines a special app with a dedicated device that allows providers to record the state of a wound over time and share

that information with other providers. though intended for use in facilities, the device and app also can be used in home care settings.

moticon is a removable device that its devel-opers describe as the world’s “first integrated sensor insole.” once slipped into a wearer’s shoe, Moticon wirelessly transmits data on gait to a special smartphone app and, according to scher, even could help providers track when a patient is experiencing a growing risk for falls.

GrandCare systems is a tablet-like device de-signed for elderly patients. the software interface includes medication schedules and reminders, as well as lifestyle assessments and care coordina-tion notes that wirelessly allow family members and health professionals to exchange information. the tablet mates with a variety of wireless devices including a scale, pulse oximeter, glucometer, blood pressure cuff, thermometer, motion sensors, and pressure sensors. the portal also enables us-ers to video chat, play games, and listen to music.

http://www.medscape.com/features/slideshow/wireless-devices?src=wnl_edit_specol; www.woundrounds.com; http://moticon.com/en/; www.grandcare.com



www.indego.com

RObOTIC EXOSKELETON COMINg FROM INDuSTRIAL EquIPMENT MANuFACTuRERAccording to a recent Wall Street Journal article, the latest developments in robotic lower limb orthoses are coming from a manufacturer “whose components have long helped propel construction equipment, factory ma-chinery, and airplanes” for companies such as caterpillar and boeing.

the article describes how Parker han-nifin corporation developed a proto-type set of robotic leg braces designed to allow individuals with paraplegia to walk. the new device, named indego, is now undergoing trials with 40 peo-ple at 5 rehabilitation centers.

indego is an exoskeleton device that weighs in at 26 pounds. Users control walking speed by leaning forward and backward, while “tiny gyro-chips

commonly used to rotate images on cellphones” help users keep from veering off-course, and serve as part of a vibration-based alert system for changes to speed and position.

Parker hannifin is seeking FDA approval for the device, which the company says could come as soon

as 2015. if successful, indego would be only the second device to receive FDA approval for a robotic orthosis for home use by people with lower-body paralysis. the company estimates a $69,500-$100,000 pricetag for the device.




$

hhS ISSuES LIST OF TOP MANAgEMENT ChALLENgESthe office of inspector General (oiG) of the De-partment of health and human services (hhs) has prepared a summary of the most significant management and performance challenges facing hhs. these reflect what oiG says are continuing vulnerabilities as well as new and emerging issues. oiG is required to prepare the summary annually.

Among the challenges that hhs is facing, according to oiG, are the following:

The meaningful and secure exchange and use of electronic Health Information. issues involved include the following:

\Medicare and Medicaid EHR incentive programs. oiG said, “Although program interest has been high among those eligible, recent data suggest that not all those currently participating will continue in the program. challenges in program oversight also leave the ehr incentive Programs vulnerable to inappropriate payments to participants that do not meet program requirements.”

\ Interoperability. oiG said that health information still is not commonly exchanged between groups of health care providers who use different ehr products.

\ Protecting sensitive information. oiG said, “During our audits of hospitals and covered entities, we identified weaknesses that included inadequacies in access controls, patch management, encryption of data, and website security vulnerabilities.”

Addressing what needs to be done, oiG said, “Given the magnitude of the investment in ehrs and other health it programs, it will become in-creasingly important to demonstrate and measure the extent to which ehrs and health it have actually achieved the Department’s goals, which include improved health care and lower costs.”

ensuring effective Financial and administrative management. issues cited by oiG include the following:

\ Financial statement audits. oiG said: “For Fy 2013, independent auditor ernst & young

identified a material weakness in the Depart-ment’s financial management systems related to it security and a significant deficiency in its financial reporting systems, analyses, and oversight. specifically, ernst & young recom-mended that the Department bolster it securi-ty in its financial management systems.”

\ Improper payments. oiG observed, “improper payments cost federal programs billions of dollars annually. For Fy 2013, the Department reported improper payments totaling almost $50 billion in the Medicare program and $65 billion overall.”

Among oiG’s recommendations was the follow-ing: “the Department should continue to leverage technology to further prevent improper payments and ensure responsible program stewardship.”

Fighting Waste and Fraud and Promoting Value in medicare Parts a and b. this includes:

\ Reducing improper payments. cMs reported an error rate of 10.1% for Medicare fee for service, corresponding to an estimated $36 billion in improper payments in Fy 2013, according to oiG.

\ Preventing and responding to fraud. oiG said, “cMs’s contractors play a key role in fighting Medicare fraud. however, cMs is not realizing the full potential of this oversight tool.”

\ Fostering economical payment policies. oiG said, “Medicare pays significantly different amounts for the same services for similar patients in different services for similar patients in different settings.”

Addressing what needs to be done, oiG said, “cMs needs to better ensure that Medicare makes accurate and appropriate payments. When improper Medicare payments occur, cMs needs to identify and recover them in a timely manner. cMs must also implement safeguards, as needed, to prevent recurrence. cMs relies on contractors for most of these crucial functions; therefore, ensuring effective contractor performance is essential.”

http://oig.hhs.gov/reports-and-publications/top-challenges/2014/2014-tmc.pdf




TIPS TO CONTROL TEChNOLOgY vENDOR DEMOSAn article in Physician’s Practice by cheryl toth recently listed 5 ways to control technology vendor demos. she wrote, “ever notice that most technology vendors don’t know much about your practice or your specialty when they give you a demo? that they go full steam ahead through a rote presentation without asking any questions about your needs or practice operations?” With some preparation, a practice can avoid wasting time and can keep the demo more relevant, toth wrote.

here’s a brief summary of 2 of the tips:

\Create a “Top-10 Must-See Features” list. Different people and different functional areas may have different priorities and interests. toth writes: “Get input from everyone in the practice to create this list, and tell the vendor you want these features covered.”

\Give the vendor an “Off Limits” list. toth suggests, “telling a vendor what you don’t want to see during the demo is as important as telling what you do want to see … Drive the conversation by telling the vendor what your priorities are.” she suggests terminating the demo if a vendor begins addressing items on your “off limits” list.

http://www.physicianspractice.com/technology/five-ways-control-technology-vendor-demos

MAYO CLINIC TESTS TELEhEALTh KIOSKSthe Mayo clinic is testing a workplace-based telehealth delivery system—the Mayo clinic health connection—that allows patients to con-nect with Mayo clinic and Mayo clinic health system providers through a private walk-in kiosk that provides high-definition videoconferencing and interactive, digital medical devices.

the kiosks allow patients to walk up to the kiosk without scheduling an appointment and be treated for minor, common health conditions such as colds, earaches, and sore throats. the system uses the healthspot platform, which combines cloud-based software with a private walk-in kiosk.

http://mayoclinichealthsystem.org/local-data/press-releases/austin/ mayo-clinic-health-connection?year=0



gOvERNMENT INvESTIgATINg ThREAT OF MEDICAL DEvICE hACKINgthe Us Department of homeland security is investigating about 2 dozen cases of cybersecurity flaws in medical devices and hospital equipment that officials believe could be exploited by hackers, according to a story distributed by reuters. the products include an infusion pump and implantable heart devices.

Meanwhile, Kaiser health news reports, “concern about the vulnerability of medical devices like insulin pumps, defibrillators, fetal monitors, and scanners is growing as health care facilities increasingly rely on devices that connect with each other, with hospital medical record systems, and—directly or not—with the internet.”

Jay radcliffe, a medical security expert, demonstrated in 2011 how vulnerability of an insulin pump could allow an attacker to manipulate the amount of insulin pumped to produce a potentially fatal reaction. radcliff now is warning of another threat—medical identity theft. he estimates that medical identify information on the black market is worth 10 times more than credit card information—$5-$10 per record. thieves could use the information to apply for credit, file false claims with insurers, or buy drugs and medical equipment that can be resold.

some institutions, including the Mayo clinic, have begun writing security requirements into their procurement contracts, according to Kaiser health news.

http://www.reuters.com/article/2014/10/22/us-cybersecurity-medicaldevices-insight-idusKCn0Ib0DQ20141022http://kaiserhealthnews.org/news/pacemakers-get-hacked-on-tv-but-could-it-happen-in-real-life/




IOM: PhYSICAL ACTIvITY MEASuRES ShOuLD bE AMONg STANDARD ‘SOCIAL AND bEhAvIORAL’ DOMAINS TRACKED ON EhRSthe institute of Medicine (ioM) has recommended that future electronic health records (ehrs) include patient “social and behavioral data”—including data on physical activity—acquired through a set of 12 measures.

the 300-plus page report, “capturing social and behavioral Domains and Measures in electronic health records,” urges the centers for Medicare and Medicaid services (cMs) to include the measures as part of the ehr certification and meaningful use regulations.

Data on 4 of the domains—alcohol use, to-bacco use and exposure, race/ethnicity, and residential address—already are being widely collected, the report states. but additional domains should be included, each with its own measures—education, financial resource strain, stress, depression, physical activity, social connections/isolation, exposure to violence/intimate partner violence, and neighborhood compositional characteristics.

the ioM report describes “a large body of empirical evidence” around the dose-re-sponse relationship between physical activity and improved physical and mental health throughout the lifespan, with “little evidence that an upper threshold exists.” Authors write that not only is the relation-ship strong enough to be worth collecting data, the very act of obtaining this infor-mation from patients at outpatient visits

is associated with “significant, yet small, changes in patient weight loss and [plasma glucose concentration] levels compared [with] those who were not asked about their physical activity levels.”

the report recommends that 2 “exercise Vi-tal signs” questions from the Us centers for Disease control and Prevention’s behavioral risk Factor surveillance system be used as the standard measures for physical activity in ehrs. the 2 questions are:

\on average, how many days per week do you engage in moderate to strenuous exercise (like walking fast, running, jog-ging, dancing, swimming, biking, or other activities that cause a heavy sweat)?

\on average, how many minutes to you engage in exercise at this level?

the report noted that the additional do-mains would likely add to costs, and that these costs would largely be incurred by providers. however, the report asserts, the long-term benefits would be significant.

“the Us health system has achieved tech-nological advances but lags behind other countries in population health outcomes,” write the report’s authors. “standardized use of ehrs that include social and behavioral domains could provide better patient care, improve population health, and enable more informative research.”

http://www.iom.edu/reports/2014/eHrdomains2.aspx

APtA offers several resources on information technology and ehrs, including a webpage devoted to the use of ehrs. Additionally, APtA has long supported the promotion of physical activity and the value of physical fitness, and is involved with the national Physical Activity Plan. (nPAP), where the association has a seat on the nPAP Alliance board. the association also offers several resources on obesity, including continuing education on childhood obesity, and a prevention and wellness webpage that links to podcasts on the harmful effects of inactivity.

http://www.apta.org/ehr/

http://www.physicalactivityplan.org/

http://www.apta.org/courses/text/Pediatric/childhoodobesity/




Health Care Employment Rose 29,000 In november, 261,000 in Past 12 Monthstotal nonfarm payroll employment increased by 321,000 in november, and the unemployment rate was unchanged at 5.8%, the u.s. Bureau of Labor statistics has reported. Job gains were widespread, led by growth in professional and business services, retail trade, health care, and manufacturing.

Health care added 29,000 jobs over the month. employ-ment continued to trend up in offices of physicians (+7,000), home health care services (+5,000), outpatient care centers (+4,000), and hospitals (+4,000). Over the past 12 months, employment in health care has increased by 261,000.

within health care, ambu-latory health care services contributed 24,000 jobs in november, after an identical gain in october. Ambula-tory health care services has added 207,000 jobs in 2014, accounting for approximately 80% of employment growth in health care over the same period. Year to date, hospitals added 33,000 jobs. nursing and residential care facilities added 19,000 jobs.

employment in profes-sional and business services increased by the civilian labor force participation rate held at 62.8% in November and has been essentially unchanged since April.

http://www.bls.gov/news.release/empsit.nr0.htm

DAtAPoInts

average annual Wages of Physical Therapists Metro Areas With highest Pt employment levels

economy at a

Glance

CHAngE In PAyRoll

EMPloyMEnt

UnEMPloyMEnt RAtE

243,000321,000

5.8%5.8%

Con

sUM

ER P

RICE

InDE

x

-0.3%0.0%

(All items)

0.2%

-0.2%

PRoDUCER PRICE In

DEx

(Finished Goods)

EMPloyMEnt Cost InDEx

0.7%(Civilian workers)

All figures from October to November 2014, except Employment Cost Index reflects 2nd quarter to 3rd quarter change.

source: Bureau of Labor statistics, department of Labor. www.bls.gov/eag/eag.us.htm

PT employment Trends 2012-2022: offices of physical, occupational, and speech therapists

* Employment figures roundedSource: Bureau of Labor Statistics, Department of Labor. www.bls.gov

54.3% change

2012 66,700*

2022 102,800*

ny

$84,

670

Il

$76,

630

CA

$88,

010

MA

$80,

710

PA

$78,

580

Us

$82,

180

0.7%

source: Bureau of Labor statistics, department of Labor. Available at www.bls.gov.

professional pulse

Income/ Employee

Revenue/ Employee

Asset turnover

Receivables turnover

Current Ratio

HLs 6,178 98,980 0.89x 8.75x 1.77

THc -424 154,580 0.96x 7.41x 1.26

UsPH 6,664 104.920 1.25x 8.47x 2.44KnD -961 79,470 1.26x 5.01x 1.66

InD. AVG. 118,774 1,685,870 1.75x 12.91x 1.30

HLs: Healthsouth | THc: tenet Healthcare | UsPH: us physical therapy Inc | KnD: kindred HealthcareAll data are ttm (trailing twelve months). Information updated: 12/12/14 * Last 4 quarters + Rounded to nearest dollar

Source: Fidelity Investments: www.Fidelity.com

operating metrics of selected Health Care Companies

source: Bureau of Labor statistics, department of Labor. Available at www.bls.gov.

ny new York-white plains-wayne, nY-nJ MA Boston-Cambridge-

Quincy, mA

Il Chicago-Joliet- naperville, IL PA philadelphia, pA

CA Los Angeles-Long Beach-glendale CA

Us national/All


http://www.bls.gov/eag/eag.us.htm




professional pulse


number of Hospitals Penalized for Readmissions growsthe Us centers for Medicare and Medicaid (cMs) has added about 400 hospitals to its list of facili-ties that will be penalized in 2015 for having what cMs says are excessive numbers of patients re-turning to the hospital fewer than 30 days after being discharged. the list of 2,610 hospitals covers readmissions for heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, total hip replacements, and total knee replacements.

thirty-nine of the most recently listed hospitals will face the max-imum 3% reduction in Medicare reimbursements. cMs calculated readmission rates on discharg-es for all 5 categories that had occurred from July 1, 2010, through June 20, 2013. it took into account the severity of the illness, the age of the patient, the patient’s additional medical con-ditions, and other factors. states with the highest percentage of hospitals penalized were new Jersey (98%), connecticut (88%), and Delaware (86%). the high-est hospital penalties occurred in Kentucky (1.21%), Arkansas (1.02%), and Virginia (0.97%).

the readmissions penalty pro-gram began in 2013 as part of a quality improvement effort in the Patient Protection and Affordable care Act.

selected states readmission Penalties perCent of hospitals penalized average hospital penalty

More info: http://www.cms.gov/Medicare/Medicare-fee-for-service-Payment/AcuteInpatientPPs/Readmissions-Reduction-Program.html http://kaiserhealthnews.org/news/medicare-readmissions-penalties-by-state/

47%1.02%

86%0.22%

66%1.21%

9%0.44%

30%0.14%

80%0.73%

4%0.18%

56%0.52%

98%0.82%

ArkAnsAs

montana

north dakota

64%0.41%

California

kentucky

new jersey

texa

s

delaware

new york

oregon



Fewer Believe that obesity Is a Medical ProblemIs obesity a medical problem, a community problem, or a matter of personal choice? recently, the opinions of health care professionals and the general population have swung away from “medical problem” and toward “com-munity problem.”

Specifically, in February 2013, 34% of health care professionals considered obesity predominantly a medical problem. That figure steadily declined to 24% in september 2014. similarly, 18% of the general popula-tion in February 2013 had

considered it a medical problem. That figure shrank to 15% in september 2014.

on the other hand, during the same period, health care professionals ranking obesity as a community problem grew from 26% to 33%. The general population ranking rose from 24% to 30%.

In 2014, younger and higher-income respondents more likely viewed obesity as a community problem. older respondents more likely viewed it as a medical problem.

rebecca puhl, phd, deputy director at Yale university’s rudd Center for Food policy & obesity, commented, “these trends are encour-aging because they suggest a shift away from simplistic, biased views that focus on personal blame. the more that people recognize shared risks for obesity, the more likely they are to support evi-dence-based approaches to reducing obesity’s impact.”

The findings were presented at a session of the obesity society Annual meeting at obesityweek 2014 in Boston.

the study is based on an online survey of a represen-tative sample of 54,111 us adults and 5,024 health care professionals. responses were collected in 5 time peri-ods ranging from February 2013 to september 2014.

More info: http://www.obesity.org/news-center/americans-view-on-obesity-is-changing-fewer-adults-see-it-as-a-personal-problem-of-bad-choices.htm

HEAltH CARE HEADlInEs

More info: http://www.cms.gov/Medicare/Medicare-fee-for-service-Payment/AcuteInpatientPPs/Readmissions-Reduction-Program.html http://kaiserhealthnews.org/news/medicare-readmissions-penalties-by-state/




professional pulse

Patients Mistrust US Physicians, But Are Satisfied With Treatmentthe us ranks near the bottom among 29 countries in level of trust in the overall medical system, but near the top in satisfaction with individual care, according to a recent study. the study, published in the New England Journal of Medicine, reports a dramatic drop in Amer-icans’ confidence in the medical profession between 1966 and 2014. In 1966, nearly 3 quarters (73%) of Americans expressed “great confidence in the leaders of the medical profession,” but that rate has fallen to 34%.

Americans’ level of confidence puts the us near the bottom of 29 countries surveyed from 2011 to 2013. It’s tied for 24th place with Croatia in terms of the percentage of respondents who agreed with the statement, “All things consid-ered, doctors [in your country] can be trusted.” A total of 58% of Americans agreed, putting the us behind countries such as Lithuania, slovakia, the philippines, turkey, and portugal. switzerland ranked highest in this category, with an 83% rate of agreement.

only Chile, Bulgaria, russia and poland scored lower than the us.

But in a shift that authors describe as “unique among the surveyed countries,” Americans rate their satisfaction with their own medi-cal treatment higher than all but 2 other countries, with 56% of American respondents reporting that they were “completely” or “very” satisfied with their last visit to a physician. switzerland had the highest rate (64%), followed by Denmark (61%). Lithuania (13%) and russia (11%) were at the bot-tom of the list. Authors note that the rate of institutional trust and personal satisfaction tends to be similar in nearly all countries, and that the us is an “outlier.”

Authors of the study warn that the lack of trust in the medical institution puts physicians at risk of losing political clout as the future of us health care is shaped. “If the medical profes-sion and its leaders cannot raise the level of public trust,” they write, “they’re likely to find that many policy decisions affecting patient care will be made by

others, without consideration of their perspective.”

Authors suggest that public trust could be improved “if the med-ical profession and its leaders deliberately take visible stands favoring policies that would improve the nation’s health and health care, even if doing so might be disadvantageous to some physicians.”

Other findings in the study:

\ mistrust of the medical profes-sion is higher among low-in-come families (47% rate of trust) compared with families not considered low-income (63% rate of trust). However, individual satisfaction was relatively stable across the groups.

\ men tended to express more trust than women (63% vs 54%).

reFerenCe

blendon RJ, benson JM, hero JO. Public trust in physicians—uS medicine in international perspective. N Engl J Med;371(17):1570-1572.

HEAltH CARE HEADlInEs






professional pulse


5 Myths About Bullying In the WorkplaceJennifer Green-Wilson, PT, EdD, MBA

Bullying is a prevalent and contempo-rary topic of interest that is surrounded by countless myths and misperceptions. Workplace bullying is defined as recur-rent, health-damaging mistreatment of 1 or more persons (“the targets”) by 1 or more perpetrators. According to the workplace Bullying Institute, it is driven by a perpetrator’s need to control the targeted individual(s). the institute defines workplace bullying as behavior that is threatening, humiliating, or intim-idating and that interferes or sabotages performance at work.

Bullying in the workplace is started by bullies who choose their targets, timing, and methods. For example, bullies withhold resources, such as information, and/or do things to others especially when no one else is around. researchers say that 35% of workers have experi-enced bullying directly. other statistics from the workplace Bullying Institute show that: the majority (68%) of bullying is same-gender aggravation; 62% of bul-lies are men; 58% of targets are women; and women bullies target women in 80% of cases.

myth #1: bullying is just robust managementgood managers manage people; bad managers bully others, says Bullyonline. Bullies intimidate and torment others to hide their own weaknesses and inad-equacies, and to divert attention away from their own incompetence, accord-ing to Bullyonline.

myth #2: bullies are just being assertiveAssertiveness is typically supported by integrity. people who are assertive tend to recognize and respect other peo-ples’ boundaries and values; whereas, bullies lack integrity and are aggressive, demanding, and violate others’ bound-aries regularly. (Bullyonline.org)

myth #3: It takes 2 …Bullies choose to bully. Bullying is behavior, and behavior is a choice. regrettably, bullies abdicate responsi-bility for choosing their own behavior. (Bullyonline.org)

myth #4: Targets are not team playersIndividuals who become the targets of bullying are often independent, resourceful, self-motivated, and inno-vative! Yet, bullies work hard to isolate, exclude, and disempower their targets and then falsely accuse them as “not being a team player.” (Bullyonline.org)

myth # 5: Targets are just oversensitiveAccording to the workplace Bullying Institute, the targets of bullying are iden-tified as: compassionate and kind (37%), cooperative (19%), agreeable (22%), and aggressive (15%). targets can detect malicious intent but, unfortunately, this ability often is perceived as being oversensitive.

Bottom line? preventing or controlling workplace bullying is a murky challenge but one that needs to be addressed. Change requires heightened awareness and organizational factors to be explic-itly reshaped.

More Info: Workplace Bullying Institute. http://www.workplacebullying.org/ Bullyonline.org. http://www.bullyonline.org/


3 tips for starting a Blog for your Practiceone element of many web-sites—one that’s useful to attract new visitors and to improve search engine opti-mization—is a blog. don’t be intimidated. It can be easy to start and grow an effec-tive blog. daniel ruscigno of Clinicsense offers these suggestions:

How often to blogthe golden rule of blog-ging is to keep your blog up-to-date with new content. ruscigno suggests posting at least once every couple of weeks, which should only

take 1-2 hours and doesn’t necessarily have to be done in 1 sitting.

What to Write aboutBeing a physical therapist makes you a movement expert. write about what you know best. remember: Blogging is not a school assignment. You only need to write a few hundred words. And keep it casual: most health care termi-nology will go over your patients’ heads. patients and clients love to read about health advice from

practitioners, so write about what they can do to keep healthy.

How to spread the Wordpublicize your blog. Add your web address to all of your brochures and busi-ness cards. spread the word on twitter, Facebook, and LinkedIn. For each blog post, send a tweet/post/update with your blog title and a link to your post. You also can include hash tags (such as #backpain or #bar-iatrics) to help reach your audience.

Adapted with permission from http://clinicsense.com/blog/2014/09/03/3-tips-starting-blog-clinic/.

BUsInEss sEnsE





AssoCIAtIon REsoURCEs

professional pulse




Encouraging healthy, active lifestyles is central to the physical therapy profes-sion’s ability to transform society. Keep up with the latest resources at APTA’s Prevention and Wellness webpage at http://www.apta.org/PreventionWellness/.

More Information, opportunities Available for International Congress

time marches on—and so do the prepa-rations for the 2015 world Confed-eration for physical therapy (wCpt) Congress. the world’s largest interna-tional physical therapy gathering is set for may 1-4 in singapore. the meeting will include 25 focused symposia, 33 networking sessions, 11 discussion pan-els and debates, more than 15 seminars and presentations of more than 2,000 abstracts. the following activities and resources are already available:

\ the preliminary program for Con-gress 2015 is posted.

\ An art and health competition has been launched, and work of the final-ists will be displayed in a special art and health exhibition in singapore.

\ singapore Airlines has been desig-nated as the official airline partner of Congress 2015. Congress attendees can get preferential rates through online booking. For more details and other options visit the Congress travel page at http://www.wcpt.org/congress/travel.

registration for the Congress is open. AptA is a member of wCpt. For more information, contact rene malone at [email protected].

More info: http://www.wcpt.org/congress.





professional pulse

‘Well to Do’ Column joins PT in Motion’s online-only lineupIn recognition of the growing emphasis on physical therapy’s role in prevention, wellness, and fitness, PT in Motion magazine adds “well to do,” a new col-umn on the topic, to its lineup of online-only content.

Longtime contributor Brad Cooper, pt, mspt, mBA, mtC, AtC, CwC, writes the monthly column, which began with the november 2014 issue. the articles will be posted along

with the ahead-of-print content in each issue.

Cooper’s november column notes that during the same 8-day period in october that marked the death of an American from the ebola virus and diagnosis of 2 others, 13,144 Americans died of heart disease and 3,491 of lung cancer. “we can impact these other—far more prevalent—causes of death in both our lives and the lives of those around us,” Cooper writes.

More info: http://www.apta.org/ptinmotion/2014/11/welltodo




professional pulse REsEARCH

RoUnDUPArthritis Medicine May Contribute to stroke DeathCommonly prescribed drugs for arthritis and pain may increase the risk of death from stroke, according to a recent study. the drugs exam-ined in the study, CoX-2 inhibitors, include older drugs diclofenac, etodolac, nabumeton, and meloxi-cam, as well as newer drugs includ-ing celecoxib and rofecoxib. CoX-2 inhibitors are selective nonsteroidal anti-inflammatory drugs (NSAIDs). the study also looked at non-se-lective nsAIds, which include pain relievers such as ibuprofen and naproxen.

researchers reviewed records of 100,243 people hospitalized for a first stroke in Denmark between 2004 and 2012 and deaths within 1 month after the stroke.

overall, people who were current users of CoX-2 inhibitors were 19% more likely to die after stroke than people who did not take the drugs (10.4% versus 8.7%). new users of the older CoX-2 drugs were 42% more likely to die from stroke than those who were not taking the drugs. those taking etodolac were 53% more likely to die from stroke.

the researchers found no link between the non-selective nsAIds and increased stroke death. study author morten schmidt, md, writes, “our study supports stepping up efforts to make sure people with a higher risk of stroke are not pre-scribed these medications when other options are available.”

reFerenCes

Schmidt M, hováth-Puhó E, Christiansen CF, et al. Preadmission use of nonaspirin nonsteroidal anti-inflammatory drugs and 30-day stroke mortality. Neurology. 2014:Nov 5. doi: 10.1212/wNL.0000000000001024Neurology 10.1212/wNL.0000000000001024. [Epub ahead of print]

research-related stories featured in PT in Motion Professional Pulse 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 say More Attention should Be Paid to Bone loss in MenCritical opportunities are being lost by not focusing more attention on bone loss and fracture risk in older men, according to a new study from Beth Israel deaconess medical Cen-ter (BIdmC) in Boston. “given that the prevalence of fragility fractures among men is expected to increase threefold by the year 2050, adequately evaluating and treating men for osteoporosis is of paramount importance,” writes lead author tamara rozental, md.

rozental examined 5 years of data from 127 men and 394 women over the age of 50 who had been treated for a distal radial fracture. “we know that a distal radial fracture can often be an early indi-cation of bone loss. we typically see this type of fracture 10 to 15 years before we might see a hip fracture,” she writes.

the study found that, following a wrist fracture, 53% of women received dual X-ray absorptiometry to measure bone

mineral density, compared with only 18% of men. Additionally, 21% of men versus 55% of women initiated treat-ment with calcium and vitamin d sup-plements within 6 months of injury.

rozental writes, “treating men for bone fractures, but not the underlying cause, places them at a greater risk for future bone breaks and related complications.” the researchers suggest that men over the age of 50 with fractures of the distal radius should undergo further clinical assessment and bone density testing.

the study results appear online in The Journal of Bone and Joint Surgery.

reFerenCe

harper CM, Fitzpatrick SK, Zurakowski D, et al. Distal Radial Fractures in Older Men: A Missed Opportunity? J Bone Joint Surg Am, 2014 Nov 05;96(21):1820-1827. http://dx.doi.org/10.2106/JbJS.M.01497.




professional pulse

Pre- and Post-AClR Rehabilitation shows Benefits 2 Years After SurgeryA study of individuals who undergo anterior cruciate lig-ament reconstruction (ACLr) shows that patients who participate in both pre- and postoperative rehabilitation not only get a head start on recovery, but also experience markedly better outcomes than patients receiving usual care even 2 years after surgery. the study was e-published ahead of print in the British Journal of Sports Medicine.

researchers compared knee Injury and osteoarthritis out-come scores (koos) of 84 patients who participated in progressive pre- and postop-erative rehabilitation between 2007 and 2011 with 2,690 patients who received usual care between 2006 and 2010.

patients completed the KOOS—a knee-specific

self-assessment instrument of injuries linked to posttrau-matic arthritis—preoperatively and again 2 years after recon-struction surgery. research-ers found that patients who underwent a 5-week preoper-ative rehabilitation program, followed by a yearlong pro-gressive rehabilitation pro-gram after surgery, reported what authors describe as “sig-nificantly better” scores than their usual-care counterparts at both measurement points.

patients in the rehabilitation cohort were recommended to achieve 90% quadriceps strength, hamstring strength, and hopping performance prior to surgery. the postop-erative rehabilitation varied by surgical circumstances and patient functional status, and was divided into 3 phases that began with quadriceps

contractions and range-of-motion exercises and pro-gressed to heavy resistance strength training, plyometric exercises, and sport-specific drills. Authors did not include a description of usual-care.

researchers found that the rehabilitation program not only set the stage for better short-term outcomes, but also showed positive results long afterwards. “Compared to usual care, [the rehabili-tation cohort] had superior preoperative patient-re-ported knee function, and still exhibited superior … function 2 years after the sur-gery, with 86–94% of patients scoring within the normative range in the different koos subscales,” authors write.

Authors recommend that treatment strategies that include progressive pre- and postoperative rehabilita-tion for ACLr patients “be considered in the standard treatment protocol,” but acknowledge that more research needs to be con-ducted to identify which parts of the rehabilitation programs are most responsi-ble for the improvements.

reFerenCe

grindem h, granan LP, Risberg MA, et al. how does a combined preoperative and postoperative rehabilitation programme influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in the Delaware-Oslo ACL Cohort and the Norwegian National Knee Ligament Registry. Br J Sports Med. 2014;Oct 28. pii: bjsports-2014-093891. doi: 10.1136/bjsports-2014-093891. [Epub ahead of print]



REsEARCH RoUnDUP

Preoperative Physical Therapy Beneficial for Patients Undergoing Hip or Knee Replacement As few as 1 to 2 sessions of preoperative physical therapy can reduce postoperative care use by 29% for patients undergoing total hip or knee replacement, adding up to health care cost savings of more than $1,000 per indi-vidual, according to a recent study.

researchers in ohio reviewed 4,733 medicare cases involving total hip or knee replacement from a combination of 169 rural and urban hospitals with wide geographic distribu-tion. they found that 79.7% percent of patients who did not receive preoperative physical therapy required postacute care services. that

rate dropped to 54.2% for patients who received even a small number of physical therapy sessions before surgery. the study was pub-lished in the Journal of Bone and Joint Surgery.

the study’s authors esti-mated a 29% reduction in postoperative care use among the preoperative physical therapy group, which translated into adjusted cost reductions of $1,215 “driven largely by reduced payments for skilled nursing facility and home health agency care.”

researchers believe that the benefit of preoperative physical therapy was derived

mostly from the way it pre-pared patients for postoper-ative rehabilitation. In most instances studied, preoper-ative physical therapy was limited to 1 or 2 sessions, suggesting that “the value of preoperative physical therapy was primarily due to patient training on post-operative assistive walking devices, planning for recov-ery, and managing patient expectations, and not from multiple intensive training sessions to develop strength and range of motion.”

“our study demonstrates a significant reduction in postacute care use associated with the use of physical ther-apy during the preoperative

period for total joint replace-ment surgery,” authors write.

“As payments in health care move from a fee-for-service basis to more global pay-ments that require some risk sharing by providers,” authors write, “the ability to manage populations across the continuum to high-quality outcomes at low cost will be imperative.”

reFerenCe

Ruhil vS, vogel K, McShane M, et al. Associations between Preoperative Physical Therapy and Post-Acute Care utilization Patterns and Cost in Total Joint Replacement J Bone Joint Surg Am. 2014 Oct 01;96(19):e165. http://dx.doi.org/10.2106/JbJS.M.01285





RoUnDUP

surgery for spinal stenosis All over the Mapwhen it comes to surgical interven-tions for spinal stenosis, patients are subject to an “accident of geography” that makes spinal decompression surgery more than 8 times as likely in tacoma, washington, than the Bronx, new York, and spinal fusion surgery 14 times more frequent in tyler, texas, than Bangor, maine.

the wide variation not only begs further study into the effectiveness of both surgical and nonsurgical approaches but underscores the need for a more standardized shared decision-making process that better educates patients on risks and out-comes, according to the latest install-ment in the dartmouth Atlas of Health Care series.

the dartmouth Atlas report on spinal stenosis looks at medicare records from 2001 to 2011 for treatment of the condition, which is thought to affect about 30% of people 65 and older. Authors found “dramatic” variations in the 2 most prevalent surgical interven-tions and an overall increase in the use of spinal fusion surgery, which they describe as a “controversial” proce-dure whose effectiveness “has not been clearly established.”

the rate of more traditional decom-pression surgery—the removal of tissues compressing the spinal nerves—has decreased as spinal fusion surgery has increased, according to the study,

but still accounted for 80 procedures per 100,000 Medicare beneficiaries across the us in 2011. But the over-all rate masks significant variation in usage across the country, where some areas reported fewer than 35 proce-dures per 100,000 Medicare benefi-ciaries, and others—topped by mason City, Iowa, at 216.7 per 100,000—exceeded a rate of 180 per 100,000 beneficiaries.

Between 2001 and 2011, spinal fusion surgery witnessed a 67% increase, to 52.7 per 100,000 Medicare benefi-ciaries. this intervention shows even more dramatic regional variation, according to the study, with a low of 9.2 procedures per 100,000 in Bangor, maine, to a high of 89.2 per 100,000 in mason City, Iowa—a region that also reported a highest rate of decompres-sion surgeries.

Authors of the study write that the general lack of definitive research sup-porting one intervention over another, coupled with the risks involved in surgery and the wide regional varia-tion in approaches, make it extremely important for patients to participate in a careful decision-making process. “In ideal settings, patients should be informed about these options and given the opportunity to participate in shared decision-making,” they write, “allowing their values and preferences to guide them to the best decision for them.”

http://www.dartmouthatlas.org/downloads/reports/spinal_stenosis_report_10_29_14.pdf







professional pulse

For Patients With Meniscus tear, Exercise therapy outperforms surgery in key Muscle strength Measureexercise therapy can improve cer-tain functions not possible through arthroscopic surgery for middle-aged patients with degenerative meniscus tears, according to a danish study. researchers believe the improvement in function through exercise—more than 16% greater than improvement experi-enced by the surgery group—may lead to better long-term outcomes.

A total of 82 patients with a degenerative meniscus tear and mild to no oA were placed into 2 groups—1 group underwent arthroscopic partial meniscectomy (Apm), and the other was assigned to a 12-week supervised exercise therapy program. Males made up 65% of the study group.

the 12-week exercise program con-sisted of 2–3 sessions per week, each session lasting 60 to 80 minutes. A phys-ical therapist individually supervised sessions once per week. the Apm group received “written and oral instructions for simple home exercises” to be per-formed 2 to 4 times daily.

researchers assessed isokinetic knee muscle strength, lower extremity perfor-mance, and self-reported global rating of change 3 months after intervention.

While researchers noted no significant differences between the groups in performance tests—knee bends, one-leg hop for distance, and a 6-meter timed

hop—or in self-reported assessments of change, a significant improvement occurred in the areas of knee extension total work and knee flexion peak torque. The mean difference of just over 16% reflected improved quadriceps muscle strength that authors write “is effective in relieving pain and improving physical function in patients with knee oA, which could also apply to patients at earlier stages of the degenerative disease.”

Although both the nonsurgical and surgical groups reported about the same levels of self-assessed change after 3 months, researchers speculated that “more invasive procedures are associated with greater placebo effects,” which might explain the perceived improvement even in the absence of improvement in muscle strength for the surgical group.

Authors note that their findings are sta-tistically significant enough to support the role of exercise therapy for patients with degenerative meniscus tear.

reFerenCe

Stensrud S, Risberg MA, Roos EM. Effect of Exercise Therapy Compared with Arthroscopic Surgery on Knee Muscle Strength and Functional Performance in Middle-Aged Patients with Degenerative Meniscus Tears: A 3-Mo Follow-up of a Randomized Controlled Trial. Am J Phys Med Rehabil. 2014;Oct 8. [Epub ahead of print]

“Alternative” Programs, Better Payment needed to Close CR Care gapA recent survey of cardiac reha-bilitation (Cr) centers across the us has found that even if current facilities were able to expand modestly, more than half of the us patients in need of Cr would remain unserved—a care gap that can only be filled through alternative delivery models and significant changes to reimbursement policies, according the study’s authors.

the study, published in the Journal of Cardiopulmonary Rehabilitation and Prevention, is based on survey results from 252 Cr programs asked to assess their current utilization, current capacity, and potential expansion capacity. the bottom line: most were not running at capacity and could increase services by about 33% without having to expand—and by 68% “if they were given reason-able resources to expand.”

As unlikely as such expansion may be, authors write, the real issue is that even in the rosiest of scenarios in which staffing, facility, insurance copay, and other obstacles resolve themselves favorably, a full 33% of patients in need of Cr would still go without due to lack of capacity. “As currently structured and staffed, center-based Cr programs simply do not have the capacity, by them-selves, to provide services to all eligible patients—even in the setting of perfect referral and enrollment,” authors write.

Authors believe that the current underutilization of Cr has more



REsEARCH RoUnDUP

to do with the structural and financial barriers encountered by the programs, and not patient behavior. these bar-riers, which include high copays, low reimbursements, and a limited range of conditions for which insurance compa-nies will cover CR, make it difficult for the programs to make even marginal progress in addressing current gaps.

still, authors write, changes to when and at what level insurance companies cover Cr won’t themselves cover the short-fall in care—there simply isn’t enough

capacity. one solution? the develop-ment of alternative Cr programs.

“our data suggest that alternative models of Cr delivery will need to be explored and implemented to sub-stantially increase national Cr partic-ipation rates,” they write, suggesting “group-based Cr programs in commu-nity centers, home-based programs, and web-based methods” to provide the care. Combined with changes to

reimbursement policy, authors believe better participation rates could be achievable.

reFerenCe

Pack qR, Squires Rw, Lopez-Jimenez F, et al. The current and potential capacity for cardiac rehabilitation utilization in the united States. J Cardiopulm Rehabil Prev. 2014 Sep-Oct;34(5):318-3 26. doi: 10.1097/hCR.0000000000000076.

More info: http://www.ncbi.nlm.nih.gov/pubmed/25098437




RoUnDUP

Australian study: Physiotherapists Demonstrate “Weight stigma”A new Australian study asserts that like other health care professionals, physiotherapists stigmatize patients who are overweight and obese, and that this stigma “has the potential to negatively affect physiotherapy treatment.”

The findings were based on a 2-part survey in which physiotherapists commented on 3 case studies and then completed the Anti-Fat Attitudes questionnaire, a 13-item instrument designed to measure explicit weight stigma.

the case studies presented a mix of patient characteristics that included weight, and directed participants to read the case studies and respond to questions about attitudes and recommendations—a measure of implicit stigma, accord-ing to the authors. results were published online in the Journal of Physiotherapy.

After analyzing 265 questionnaires and 520 case study responses, authors found that the physiothera-pists demonstrated both explicit and implicit weight stigma.

As a group, the physiotherapists responding to the questionnaire showed overtly negative attitudes in all 3 areas measured—the char-acterization of individuals who are overweight as lacking sufficient will-power, an overall dislike of individu-als who are overweight, and a fear of becoming overweight oneself.

of the 3, Australian physiotherapists demonstrated the highest stigma when it came to an attitude that individuals who are overweight lack willpower.

still, they write, 59% of responses mentioned weight management

as part of a treatment or referral strategy, and within that subset, researchers identified common the-matic threads that they believe “indi-cated implicit weight stigma:” use of negative language when describing patients, a “focus on weight man-agement to the detriment of other important considerations,” the assumption that weight is “individ-ually controllable,” the preference for directive or prescriptive—rather than collaborative—responses, and a failure to recognize the complexity of weight management.

“the most common responses were simplistic, implicitly negative, and prescriptive advice,” authors write. “It was rare for responses to indicate a more complex consideration of weight or explicitly negative/ste-reotyping attitudes. These findings align with literature about other health professionals.”

though the study is focused on Australian pts, Lisa Culver, pt, dpt, mBA, AptA senior specialist in clin-ical practice, says that the findings underscore an important point for the profession in general. “It’s clear from many studies that overweight and obesity stem from much more than diet and exercise,” she said. “there are many contextual factors at work here beyond just the individ-ual, and it is important that physical therapists and physical therapist assistants have a positive impact as a motivator and advocate for change for our patients and clients.”

reFerenCe

Jenny Setchell J, watson b, Jones L, et al. Physiotherapists demonstrate weight stigma: a cross-sectional survey of Australian physiotherapists. Journal of Physiotherapy. Published online 01 August 2014.

More info: http://www.journalofphysiotherapy.com/article/s1836-9553(14)00088-5/abstract





RoUnDUP

Acupuncture no Better than sham for Chronic knee Pain in Adults 50+regardless of whether it’s delivered traditionally or through a more high-tech laser version, acupuncture doesn’t appear to have any benefit over sham procedures when it comes to reducing moderate-to-severe knee pain in adults 50 and over, according to a study in the Journal of the American Medical Association (JAmA).

researchers in Australia studied treatments of 282 patients who were 50 or older and had been experiencing moderate to severe knee pain on most days for a period of time longer than 3 months. the patients were divided into 4 groups: a needle acupuncture group, a laser acu-puncture group, a sham laser acupuncture group, and a control group. Acupuncture treatments were conducted 1 to 2 times weekly for 12 weeks. neither acupuncturists nor patients knew if they were involved in the sham or actual laser treatment, but there was no sham treatment used in the needle-based acupuncture group.

when the researchers compared self-reported knee pain and function at baseline, 12 weeks, and after 1 year, they found “no significant differ-ences in primary outcomes between active and sham acupuncture at 12 weeks … or 1 year.”

“Although needle and laser acupuncture improved pain after treatment compared with control, improvements were not sustained at 1 year and were of clinically unimportant magnitude,” authors write. “Improvement in … physical function with needle acupuncture relative to control at 12 weeks was of a clinically irrelevant magnitude and did not persist at 1 year. Furthermore, this improvement was not different from sham laser.”

“Among patients older than 50 years with moderate to severe chronic knee pain, neither laser nor needle acupuncture conferred benefit over sham for pain or function,” they concluded. “Our findings do not support acupuncture for these patients.”

However, they caution that the findings “likely only apply to patients with clinically diagnosed osteoarthritis and moderate or severe pain … and may not be generalizable to end-stage radiographic disease.”

http://ncbi.nlm.nih.gov/pubmed/25268438

Exercise Programs likely to Help People With lower limb Amputations A new systematic review of the effects of exer-cise programs on gait performance in people with lower limb amputations points to some positive connections—even if specifics were hard to come by.

the review, published in Prosthetics and Orthotics International, found 623 article citations for studies of gait among people with lower limb amputations and eventually whittled acceptable research down to 8 stud-ies involving 199 participants. these studies allowed researchers to compare self-selected gait speed among patients who received spe-cific functional exercise programs, but in the end they did not reveal a single exercise pro-gram or combination that could be deemed most effective.

Authors focused on self-selected gait speed as “the only consistent measure of gait perfor-mance” among the studies.

the actual degree of improvement difference was difficult to pin down, authors wrote. Still, they said, “the combined evidence suggests that a variety of different types of exercise can improve self-selected gait speed,” and that “improvement in gait performance was seen throughout whether participants were in their third or seventh decade, and whether only men or men and women were combined.” no study focused on women only.

the range of exercises in the studies included activities targeted at supervised walking, specific muscle strengthening, balance, gait training exercise, and functional training focus-ing on coordination exercises “beyond walking and stair negotiation.”

“Little evidence consistently differentiated which type of exercise was most benefi-cial,” authors write, although improvement occurred “whether most exercise was per-formed as an unsupervised home exercise program, in focused daily treatments pro-vided within a single week, or in regular sessions spanning months.”

http://ncbi.nlm.nih.gov/pubmed/25261490



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oPtP Issues Mobilization Belt DvDs optp has issued a series of dVds, mobilization Belt techniques for manual therapy, covering mobilization techniques for the cervical, thoracic, and lumbar spine, as well as the shoulder, elbow, hip, knee, and ankle joints. each mobilization is demonstrated by Yousef ghandour, pt, and includes patient positioning, belt

placement, and mobilization technique. the dVds show how manual therapy tech-niques can be enhanced using mobiliza-tion belts by supporting the patient’s body and/or heavy limbs, stabilizing adjacent body parts, creating fulcrum points, free-ing up the therapist’s hands to treat joints or muscles, and more.

WebPt Acquires Weboutcomeswebpt has acquired weboutcomes, an online outcomes tracking tool that webpt says allows physical therapists to enhance patient care and demonstrate their clinical per-formance to insurance carriers and referral sources. weboutcomes features a library of evidence-based tests that are familiar to the health care community.

Havig named sCIFIt Controller Adam Havig has been named sCIFIt controller, where he will manage the company’s account-ing, finance, and information technology. Havig spent the last 12 years as controller of us operations at Bs&B safety systems, a manufacturer of pressure-relief safety products. sCIFIt designs and manufac-tures commercial fitness and rehabilitation equipment.






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For product information from these advertisers, visit www.apta.org/freeproductinfo.


OnHand: The Physical Therapy Clinician’s KitFrom the American Physical Therapy Association and GNR Orthopaedic & Rehabilitative Products.

OnHand is the convenient and practical way for you to stay organized while saving time, money, and energy—no matter what your practice setting!

The 12" x 17" x 4" water-repellent black Cordura® nylon case has sturdy handles and a comfortable shoulder strap. OnHand unzips and lays flat to reveal 28 fitted compartments for everything from a Buck hammer to a sphygmoma-nometer and has additional pockets for your case files, clipboard, cell phone, wallet, business and appointment cards, and other items you want to keep on hand!

Price: $169.99*Add $20 for shipping and handling.

Clinician Bag onlyPrice: $42.95*

Add $11 for shipping and handling.

*Plus applicable sales tax in Florida and North Carolina.

We’ve thought of everything! The standard OnHand kit includes a professional carrying case and a complete set of 13 standard, high-quality instruments used most often by physical therapists:

• 3M Littman Lightweight Stethoscope• Buck Neurological Hammer• Omrom Aneroid Sphygmomanometer• Retractable 6' Tape Measure• 60" Cloth Gait Belt• Lister 5 ½" Bandage Scissors• 180˚ Goniometer (6")• 360˚ Goniometer (8")• Allen Wrench Set• Adjustable 6" Wrench• 4-in-1 Screwdriver• Thera-Band® Prescription Pack• Pen Light

Get your hands on OnHand:Call GNR toll-free at 800/523-0912Fax your order toll-free to GNR at 800/523-0912E-mail your order to: [email protected]

“I’ve been working in home health

for over 13 years. With OnHand, I’m much

more organized and I know that I’ll always

have the right instruments when I need them.”

David Herrington, PTSta-Home Health Agency

Jackson, Mississippi










OnHand: The Physical Therapy Clinician’s KitFrom the American Physical Therapy Association and GNR Orthopaedic & Rehabilitative Products.

OnHand is the convenient and practical way for you to stay organized while saving time, money, and energy—no matter what your practice setting!

The 12" x 17" x 4" water-repellent black Cordura® nylon case has sturdy handles and a comfortable shoulder strap. OnHand unzips and lays flat to reveal 28 fitted compartments for everything from a Buck hammer to a sphygmoma-nometer and has additional pockets for your case files, clipboard, cell phone, wallet, business and appointment cards, and other items you want to keep on hand!

Price: $169.99*Add $20 for shipping and handling.

Clinician Bag onlyPrice: $42.95*

Add $11 for shipping and handling.

*Plus applicable sales tax in Florida and North Carolina.

We’ve thought of everything! The standard OnHand kit includes a professional carrying case and a complete set of 13 standard, high-quality instruments used most often by physical therapists:

• 3M Littman Lightweight Stethoscope• Buck Neurological Hammer• Omrom Aneroid Sphygmomanometer• Retractable 6' Tape Measure• 60" Cloth Gait Belt• Lister 5 ½" Bandage Scissors• 180˚ Goniometer (6")• 360˚ Goniometer (8")• Allen Wrench Set• Adjustable 6" Wrench• 4-in-1 Screwdriver• Thera-Band® Prescription Pack• Pen Light

Get your hands on OnHand:Call GNR toll-free at 800/523-0912Fax your order toll-free to GNR at 800/523-0912E-mail your order to: [email protected]

“I’ve been working in home health

for over 13 years. With OnHand, I’m much

more organized and I know that I’ll always

have the right instruments when I need them.”

David Herrington, PTSta-Home Health Agency

Jackson, Mississippi



by Crystal Morris, PTAptas today

Crystal Morris, PTA, a delegate to the PTA Caucus, is employed at Fayetteville

Orthopaedics & Sports Physical and Occupational

Therapy in Fayettevillle, North Carolina.

Why am i a member of APtA? because of a passion for the profession of physical therapy that was instilled in me as a first-year student in the PtA education program at Fayetteville technical community college in north carolina. My instructors found great value in the association. they considered it important to teach students the history of physical therapy and about APtA’s integral role in ensuring its ability to optimally meet the needs of patients and clients.i was hooked from the time i attended my first north carolina Physical therapy Association (ncPtA) fall conference with my class-mates. We were welcomed with open arms. every chapter member we met—physical therapists (Pts) and PtAs alike—was happy and eager to share his or her knowledge, offer us

encouragement, and urge us to seek his or her help in securing employ-ment after graduation.

ncPtA members informed us, too, about volunteer opportunities within our communities to deepen our learning process and instill in us the value of service for its own sake.

During my second year of school, i attended APtA’s national student conclave, where i was personally wel-comed by the association’s then-president, ben Massey, Pt, MA, a fellow north carolinian who greeted me as a colleague.

these interactions assured me that i was traveling down the right career path. i renewed my membership upon graduation and continued to attend all of the state-level and district meetings that i could. A few years into my career, then-ncPtA President Dee Daley, Pt, DPt, felt it was time for me to play a more formal role in the state chapter. i was nominated to serve as my state’s representative to the PtA caucus. in that role, i’ve acquired some of the best mentors and friends that i possibly could have.

i learned so much in my first year as a caucus

Partners in the Profession’s FutureThe importance of membership and participation in APTA.

editor’s note: this is part of an occasional series

of essays by physical therapist assistants

(PtAs) on why they value membership in APtA.



representative alone— not only from individuals within my own chapter, but from other states’ caucus representatives. their skills, knowledge, and dedication made me want to do even more for my profession. it wasn’t until i joined the PtA caucus that i truly appreciated the countless hours of work that go into protecting our profession and ensuring its brightest possible future in service to patients and clients.

Why do i donate so much of my time to APtA-related activities? if i don’t, who will? that’s how i often answer that question. APtA is the backbone of our profession, and the association cannot do all of the things that it can and must do without having the support of thousands of volunteers who freely give of their time. the Vision statement for the Physi-cal therapy Profession is “transforming society by

optimizing movement to improve the human experi-ence.” that truly describes what Pts and PtAs do on a daily basis for patients and clients. but it’s import-ant to note that this work starts behind the scenes. it’s the product of clinical guidelines and standards of practice that have been established by APtA and are ever-changing and ever-evolving. From deter-mining the areas in which research is most needed and how best to implement its findings, to monitoring legislation and ensuring that optimal access to physical therapy services is ensured, volunteers are needed in so many areas.

Whether Pts and PtAs work in clinical practice, education, or health policy and administration, everyone has a slightly different but equally valuable perspective to offer. Physical therapy is

a single profession with a single vision. PtAs work side-by-side with Pts in the clinic. We collaborate. We educate one another. We focus together on patients’ needs, and team up to provide them with optimal care. it’s important that we carry over that sense of teamwork to membership and involvement in APtA.

PtAs serve in an array of roles across the country.

We are educators. Managers. leaders in our communities. Many of us have higher degrees. Many of us, too, come into physical therapy as a second career and carry with us unique perspectives and abilities born of our varied experiences. We are assets to practice, education, and advocacy. show your colleagues in APtA that you share my passion for the vision, and the key role of PtAs in helping to fulfill it.



defining moment by Adele Levine, PT, DPT, OCS, CSCS

Adele Levine, PT, DPT, OCS, CSCS, is the author of Run,

Don’t Walk: The Curious and Chaotic Life of a Physical

Therapist Inside Walter Reed Army Medical Center.

i went into physical therapy because of the good job outlook, relaxed wardrobe, and what i anticipated would be a career free of stress and emotional drama. but i ended up working with combat casualties at Walter reed Army Medical center in Washington, Dc. it was located across the street from my new apartment. When i saw the sign out front, i sent in my resume—naively equating an easy commute with an easy job. i was completely unprepared for what i would see when, filled with optimism, i walked across the street and past the armed guards.

the wardrobe was relaxed, all right, but the hours were long and the stress was con-stant. All of my patients were either double or triple ampu-tees, and they had the kinds of major orthopedic injuries you get when you cross paths with a bomb—pelvic fractures, open abdomens,

complicated lower extremity fractures. i found myself flung far down a rabbit hole, in which my colleagues and i treated 150 combat ampu-tees a day from the wars in Afghanistan and iraq.

Across town, my friend sta-cey was an emergency-flight nurse. she spent her work-days in a helicopter deliv-ering people with serious injuries to the hospital. the rest of my friends all were lawyers. that’s how it seems

to be in Washington—most everyone either is a lawyer or a politician.

i kept telling my friends that i was going to leave Walter reed and find a new job with less stress and better hours. As the years went by, though, i never got my feet underneath me long enough to leave.

My lawyer friends were fun and interesting. but when happy hour dissolved into talk of law briefs, corporate accounts, and new associates, i would drift over to stacey. “they’re waving their resumes around.” i would say. stacey would laugh appreciatively.

she and i never talked about our jobs. i knew only the most basic details about what she did, and vice-versa. but i figured that she, like me, had nights where she lay awake, trying to tune out that day’s grim movie, playing on a continuous

Defining Moment spotlights a particular

moment, incident, or case that either led the writer

to a career in physical therapy or confirmed why he or she became a Pt or PtA. to submit an essay or find out more, contact

Associate editor eric ries at [email protected].

Coming CleanWhen housekeeping reveals more than just dirt.



loop. We weren’t about to relive it at happy hour.

While our friends were busy dissecting their careers, stacey and i would sit together at the end of the bar and invent jobs for each other—ones that did not involve playing roles in other people’s nightmares.

“i’ve got the perfect one for you. Are you ready for this? renting towels at rehoboth beach.”

“shut up! i’m starting a fund to send you to pet-groomers school.”

During happy hour one night, stacey brought a colleague—nancy, a nurse in an intensive care unit. she’d put herself through nursing school by cleaning houses, and she still ran a small cleaning company on the side.

As usual, there was much resume-waving and jobs-related chatter going on

among us. this trickled down to talk of new associates, law clerks, and, finally, cleaning ladies. in the process, nancy’s cleaning company got hired to clean the house of one of the lawyers, christa, over the christmas holidays.

soon after that, our lawyer friends left town for christmas. stacey and i spent the holidays working, meeting occasionally for breakfast on our days off.

“has nancy’s crew cleaned christa’s house yet?” i asked stacey one morning over a cup of coffee.

“thursday.”

“What do you mean thursday? christa’s coming back tomorrow!”

stacey burnt her tongue on her cup of coffee.

“i am not joking!”

stacey blanched. she had given nancy the wrong dates. now the nurses were going to be humiliated in front of the lawyers.

i was surprised that stacey had gotten the dates confused, because at work she juggles life-and-death details all day long. but she recovered quickly, and packed me into her car. We flew through stoplights and sped to christa’s house at what seemed like 90 miles an hour. nancy met us there in hospital scrubs, armed with an industrial vacuum and a sack of cleaning supplies. “i really owe you,” she said.

At first, cleaning christa’s house was kind of fun. We felt like we were pulling a fast one.

“can you believe it?” we laughed. “christa thinks she’s paying for some fancy cleaning crew, and she’s really just getting us!”

but our mirth and good cheer evaporated as the hours began to stack up. i morosely chased an elusive hair around christa’s shower and started to question my life. What was i doing?

stacey and i had cleaned barely half of the house when, late that afternoon, christa called stacey’s cell phone. i was in the living room in my bare feet, vacuuming and dusting simultaneously. stacey signaled frantically for me to turn the vacuum off. We sank down into the couch while stacey waited a few rings before answering.

“hello? oh, hey! how’s your vacation going? Uh huh. hmmm. yeah. oh. Me? nothing. Just hanging out.”

i glanced over at stacey as she talked to christa. there was a smudge of dirt on her cheek. her hair was matted and plastered in sweaty clumps to her forehead.



defining moment

stacey hung up the phone. We looked at each other for a long second before run-ning back to our respective chores. We were 2 dedicated medical professionals clean-ing a lawyer’s house. it was the one career we’d never made up for each other.

stacey and i would never again invent new professions for each other.

i can’t speak for stacey, but the saturday i spent cleaning christa’s house was a turning point for me. i had

unhesitatingly jumped in to bail out a fellow medical provider because she and i were in similar foxholes. We had hard jobs. Jobs we couldn’t really describe to anyone else because they were so emotionally messy. but every day at work, we did something that really mattered.

My patients all had terrible injuries. Perhaps if the hard cases had been more isolated, i would have been more reflective about my

role. As it was, i viewed my job simply as stressful and difficult. but, there on my hands and knees, meditatively scrubbing christa’s floor, i realized that i actually was part of something much larger than myself. For better or for worse, i was a part of a team of people who literally were getting service members with crippling injuries back on their feet again.

christa never did find who cleaned her house.

stacey, who for years had toyed with the idea of finding an easier job, ultimately admitted to me that, “i’m a lifer, i guess.”

i stayed at Walter reed for 9 years. When the war casualties stopped coming, i finally left. i remain a physical therapist, but i don’t lie awake at night anymore. stacey is still a nurse.

We are in the right places.





By the numbersBy the numbers

1.25 BIllIon

the percentage of American adult smartphone or tablets owners who would be extremely or very interested in using a mobile app to check their blood pressure. Percentage who would be extremely or very interested in using a mobile app for a stool sample test: 19%.

reFerenCeAmericans to Eat 1.25 Chicken wings for Super

bowl XLvIII. National Chicken Council. http://www.nationalchickencouncil.org/americans-eat-1-25-billion-chicken-wings-super-bowl/

Fried Chicken wings Nutrition. Livestrong.com. http://www.livestrong.com/article/326259-nutritional-facts-of-fried-chicken-wings/.

Estimated number of chicken wings eaten during Super Bowl XLVIII.

A wing averages about 100 calories, depending on preparation.

That’s enough to put 572 wings on every seat in all 32 NFL stadiums.

6%the rate of patient no-shows for appointments scheduled 1 day in advance.

Another 17% are cancelled by the patient.

reFerenCegetting your practice “in the zone”: 7 tips for

achieving and sustaining financial health. whitepaper. Athenahealth. www.athenahealth.com.

reFerenCeNational health Interview Survey. Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/nhis.htm.

Adults aged 18 and over in the Us in 2014 who met the 2008 federal physical activity guidelines for aerobic activity through leisure-time aerobic activity.

48.6%

lowest, 19.8%, was for females over the age of 75.

highest percentage, 67.4%, was for males 18-24.

reFerenCeNutriStrategy. based on data from Medicine and

Science in Sports and Exercise, published by the American College of Sports Medicine.

Calories burned per hour by a 155-pound person snow skiing.

Patients who accessed their information online who perceived the access as “very useful.”

reFerenCeIndividuals’ Access and use of their Online

Medical Record Nationwide. ONC Data brief No. 20. http://www.healthit.gov/sites/default/files/consumeraccessdatabrief_9_10_14.pdf.

60%

reFerenCeebizMbA ranking August 2014.

50 million

estimated unique monthly visitors to the national Institutes of Health website. that ranks it second among popular health websites.

reFerenCeAmericans May be Ready for a brave New world of healthcare. harris

Interactive. www.harrisinteractive.com.

48%




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