On a recent visit to Seattle Children's Hospital in Seattle, WA, I learned about some of the health care challenges faced by American Indians and Alaska Natives living in both urban and rural settings in the United States. Serving as the pediatric referral hospital for Washington, Alaska, Montana and Idaho, Seattle Children's has a unique perspective on providing care to a large area with diverse populations.

Millions of American Indians and Alaska Natives living in or near cities face significant heath care disparities but are seemingly invisible to health care providers and federal and state policy-makers, according to a report released by the Urban Indian Health Commission (UIHC) entitled Invisible Tribes: Urban Indians and Their Health in a Changing World.

Many of these citizens may see an end to funding from the Indian Health Service or may be ineligible for or unable to use the health services offered. And even when urban Indians do manage to access health care, they must overcome additional barriers such as cultural misunderstandings and communication obstacles.

To make heath care more accessible for the Alaska Native children and families it serves, Seattle Children's provides language and other assistance to patients coming from various tribes-each with their own dialect. What can your facility do on a local and national level to make access to health care easier for this sector of our country's population?

In order to be eligible for the ADVANCE Hall of Fame, an individual must have at least 20 years of service in the physical therapy profession. Nominations can be submitted by anyone-a co-worker, a friend, a loved one-you can even nominate yourself if so inclined!

To enter, please send your name, phone number and e-mail address-as well as the name, phone number and e-mail address of the person you're nominating-and the reasons why this person should be the first-ever ADVANCE for Physical Therapists and PTAs hall of Famer to managing editor Rob Senior via e-mail at RSenior@advanceweb.com or by regular mail at 3100 Horizon Drive, King of Prussia, PA 19406.

Nominations the contest must be received by November 2, 2009. Good luck!

According to a July 31 press release (http://www.apta.org/AM/Template.cfm?Section=Current_Issue#article62366) from APTA, the association will partner with the Canadian Physiotherapy Association and World Confederation for Physical Therapy to host the first annual International Summit on Direct Access and Advanced Scope of Practice in Physical Therapy, October 22-24 in National Harbor, MD. The goal of this summit is to advance practice of physical therapy by exploring the current status of different nations and emerging policies on direct access. CEUs will also be available.

Programming for the event includes symposiums on direct access policy and scope of practice, poster presentations, breakout discussions and working groups. This represents an opportunity to learn the latest research supporting these policy initiatives and share strategies for implementing policy at the local, regional or national level. Interested participants can register at www.directaccesssummit.com. What are your thoughts about the decision to hold this summit and what it can accomplish?

This past Sunday, teams of professional cyclists pedaled their way through the last stage of the 2009 Tour de France and Alberto Contador was declared the winner. The race--approximately 3,500 kilometers over 23 days--attracted record-breaking crowds and inspired many to take a spin on their own bikes. Some of these same people likely realized cycling isn't as easy as it seems. But it shouldn't be painful--so long as you are properly fitted to your bike.

Physical therapists trained in bike fitting can help to minimize a patient's discomfort, increase efficiency and help prevent cycling injuries, according to the American Physical Therapy Association (APTA).

In their brochure, Bike Right, Bike Fit!, the APTA lists the following tips to avoid bike fit related injuries:

Posture Tips For Cyclists:

• Change hand position on the handlebars frequently.
• Keep a controlled but relaxed grip on the handlebars.
• Back strength is important, especially for road bike riders.
• Wear a rigid-soled shoe to avoid foot pain and increase your mechanical efficiency.

Safety Tips:

• Wear Your Helmet. Always wear a helmet when riding your bike. The straps should fit snug enough to prevent the helmet from slipping. It also should meet certain safety criteria. Look for "Snell Certified" or "Meets ANSI Z904 Standard."
• Be Visible. Wear bright clothing when riding, and use a white light on the front of your bike and a red reflector or light in the rear. Add reflective material on your clothing and bicycle when riding at night. A flag fastened to the back of your bike may be useful to increase visibility.
• Obey the Law. Ride with traffic flow, and obey all traffic controls such as stop signs, traffic signals, and one-way streets. Rules of right-of-way for motor vehicles also apply to bikes. Ride in a predictable manner and avoid quick, irregular changes of position or momentum. Ride on bicycle paths whenever possible.
• Parked Cars. Watch for cars pulling into traffic or entering the street from driveways as well as for doors opening on parked cars. Don't weave between parked cars!

Source: The American Physical Therapy Association

This caught my eye because I can completely relate! I ran in a 5k last evening in the typical Northeast summer climate-85 degrees and humid. As I crossed the finish line, I could feel the eyes on me and knew my face was as red as can be. But I was feeling good and pleased with my time. So why were the spectators looking at me-with one eye on the idling ambulance-as though I was about to face plant into the pavement?

According to Dr. Murray, "being flushed is a sign of a healthy cardiovascular cooling response." In your body's attempt to maintain a safe internal temperature, it increases blood flow to the skin, moving heat away from its core and cooling you with sweat. He says, "the fitter you become, the more heat you'll release." I am going to remember this at my next 5k!

Do any of your clients have this concern as they become fitter under your care? Do you agree with Dr. Murray's assessment? If not, how do you address this concern?

At the recent APTA annual conference in Baltimore, the APTA's Board of Delegates met to select the organization's officers for the coming term.

R. Scott Ward, PT, PhD, was re-elected to a second term as the organization's president. Joining him as vice-president will be newly elected Paul A. Rockar, Jr., PT, DPT, MS.

Aimee B. Klein, PT, DPT, DSc, OCS was reelected as a director, while Kathleen K. Mairella, PT, DPT, MA; Mary C. Sinnott, PT, DPT, Med; and Nicole L. Stout, PT, MPT, CLT-LANA, were newly elected as directors.

Back in February at CSM 2009 in Las Vegas, ADVANCE had the opportunity to interview Dr. Ward. Among the questions we asked him at the time was a query about his plans for re-election as APTA president. Dr. Ward declined to answer the question, stating that he felt doing so could provide him an unfair advantage over those who might also be interested in running for office.

This is just one example of the integrity and respect for the profession and his peers that Dr. Ward bring to the offices of APTA. ADVANCE wishes him success in his second term as president.

According to the June 26 PT Bulletin Online from the APTA, Michigan has passed legislation to license PTAs. Michigan Governor Jennifer M. Granholm signed SB 151 into law on June 25, requiring PTAs to obtain state licensure. With this move, Michigan becomes the 42nd jurisdiction to license PTAs. Thirty-nine other states, the District of Columbia, and Puerto Rico license PTAs, while 8 other states regulate PTAs through certification or registration.

"Our efforts to ensure that physical therapy patients will receive the highest quality care from PTAs have paid off," said Michigan Physical Therapy Association President Jake Jakubiak Kovacek, PT. "We're grateful that our lawmakers recognized the importance of this legislation for patient protection and passed SB 151 in its original form."        

The Bulletin further noted that the Physical Therapy Board of Licensure and Michigan Department of Community Health will move forward with the process of officially stating administrative rules, creating a limited license and distributing that license to qualified PTAs by December 31. The new law also adds term protection for "physiotherapy" and "DPT," and establishes a continuing education requirement as a condition for PT and PTA licensure renewal.

What do you think about this new legislation and how it will impact the physical therapy profession?

With the shift to warm weather, people of all ages start thinking exercise. Before your older patients take their exercise routine outdoors, The American Academy of Orthopaedic Surgeons this week advised baby boomers not to overdo it. In a press release, the AAOS offered the following tips to help boomers prevent exercise-related injuries:

• Check with your doctor before beginning any exercise program. This is especially important if you have had a previous injury.
• Always warm up and stretch before exercising. Cold muscles are more likely to get injured, so warm up with some light exercise for at least three to five minutes.
• Avoid being a "weekend warrior." Moderate exercise every day is healthier and less likely to result in injury than heavy activity only on weekends.
• Do not be afraid to take lessons. An instructor can help ensure you are using the proper form, which can prevent overuse injuries such as tendonitis and stress fractures.
• Develop a balanced fitness program. Incorporate cardio, strength training and flexibility training to get a total body workout and prevent overuse injuries. Also, make sure to introduce new exercises gradually, so you do not take on too much at once.
• Take calcium and Vitamin D supplements daily.
• Listen to your body. As you age, you may not be able to do some of the activities that you did years ago. Pay attention to your body's needs and abilities, and modify your workout accordingly.
• Remember to rest and schedule regular days off from exercise and rest when tired.

What other exercise tips do you offer older patients to keep them safe?

There's an interesting story out of Connecticut from this weekend. It involves a nursing home facing lawsuits for neglecting two patients, both of whom died. In the first, part of the argument is that the client did not receive "medically necessary physical therapy," though no physical therapists are named in the lawsuit.

The story contends that the first client, a 76-year-old man who originally came to the nursing home after a fall in 2005, died of an infection in his legs. Prior to his death, the man refused physical therapy, yet would get up from his bed unattended. Facility staff allegedly took to restraining the patient in bed so he wouldn't get up and hurt himself. Here's an excerpt:

Kyle Wininger said her father didn't want to stay in bed, so he'd ring the bell for help. When it didn't come, he'd get up even though his muscles didn't work properly.

"So he would try to get out of bed and he would fall on the floor," she said. Staff clipped a wire to the front of his shirt that went off if he moved, she said.

"They didn't particularly care for my father," Kyle Wininger said. "He was loud and he was obnoxious and I'm sure there must have been someone there that he didn't care for, because if he didn't like you, he didn't like you."

Many of you have worked with a patient at some point or another who didn't want to do physical therapy or follow instructions, regardless of the setting you're in. How do you handle patients who refuse therapy or refuse to do it as instructed? What would you have done as the physical therapist in this man's case?

Fearon walked out on stage and told the applauding audience, "I feel like a 5-year old who was waiting for Santa Claus." She borrowed a quote from Aristotle to set the tone of her lecture:  "It is the mark of an educated mind to be able to entertain a thought without accepting it."

Fearon then went on to explain that major reforms need to be made in the health care system.  Two flaws in the health care system continue to be wasteful spending within the Medicare program and provider reimbursement, she said.

She proposed to disrupt the current model in order to move a payment system that supports effective and efficient value-added care.

"Disruptive business models improve quality access and affordability by changing the way hospitals and office-based practices work," she explained.

What do you think you are worth to a health care system, she asked the audience. What do you think a payer thinks you're worth? Unfortunately, PTs collectively still have a need to communicate how the interventions chosen are related to the functions they wish to insure.

"Are we dangerously close to promoting a profession to the public and the payer that cannot yet live up to its own billing? Are we setting ourselves up for a scenario in which we are over-selling and under-delivering in an environment that is demanding more for less?" she asked.

For more on the Maley Lecture, read our conference wrap in the June 29^th issue of ADVANCE.

The Oxford Debate is held in interactive fashion with one side presenting a 3-minute case and the opposing side offering a rebuttal. Audience participation is encouraged and attendees were told to "switch sides" if they liked what they heard from the panel. It made for a lot of moving around, which made the proceedings more fun.

I love attending this debate, and the topic this year was a hot one: Should the profession of PT simply use the "PT designation and the highest-earned degree only, or should it continue to support numerous credential use after clinicians' names?

Presenting the argument for the elimination of credentials were Robert Landel, PT, DPT, OCS, CSCS; Stephen C. McDavitt, PT, DPT, FAPTA, and Robert H. Rowe, PT, DPT, DMT, MHS, FAAOMPT. Presenting the argument for using credentials were Jonathan Cooperman, PT, DPT, JD, MS; Eric Hedegus, PT, DPT, MHSc, OCS, CSCS, and Dianne V. Jewell, PT, DPT, PhD, CSCS.

That is a lot of credentials for just one panel-but each side made a convincing, impassioned and enthusiastic call for their position in the debate. "This has been an argument since I graduated," joked Charles Ciccone, PT, PhD, moderator of the debate.

The "elimination" team went first. "Our profession is defined by our advanced body of knowledge, that is how our distinction is earned," said Dr. McDavitt. "We now have a credible new brand image for PT, and the single designation provides continuity about who we are. While our post-professional development is appreciated, we believe the abbreviations are only appreciated by the profession. We advocate use of the PT designation only." Dr. McDavitt continued to make his point with the help of his panel-mates--and a hilarious reading of "Dr. Seuss' Guide to Utilization of Credentials."

Dr. Jewell rebutted: "If we agree on a uniform set of letters, it should solve the question. Designators help us tell consumers who we are and our scope of services. To whom are we directing our credentials? When I use them people can find my specialties and they know I have research training. Is there some sort of space limit we have? If we use ‘PT' as the first identifier it should clear up any confusion; patients recognize the credentials as specialties, so we need the flexibility to express them."

Dr. Rowe countered: "We obviously place a high value on post-professional training, and the initials are used to help communicate mainly to the health care community what we do and helpo the brand. So we would support a standard set of designators; anything extra just diminishes our impact, leading to confusion. Some might believe the added credentials are necessary to practice in specific disciplines. If the public is to view us as a doctoring profession, we should help them view us as they do doctors-they are first and only MDs, and this should apply to PT as well."

Dr. Hedegus responded: "The use of initials causes confusion? I say they provide clarity!" To make his point, he then read Dr. Martin Luther King's "Let Freedom Ring" speech with no credential letters included (to much applause) and concluded, "Let's use the credentials that are rightly ours in the context that we see fit."

The audience was allowed to chime in and then summations began with Dr. Cooperman for the side of using credentials-quoting Shakespeare's "Much Ado About Nothing". "We have bigger professional fish to fry! Our opposition wants you to believe this affects our profession, but we don't need any more policies from APTA on the use or non-use of credentials. To limit their use is absurd; aren't we regulated enough? The proposition here today is capricious at best and Draconian at worst! Let's allow our professionals to determine how and when to use credentials."

But the non-use argument got the last word by Dr. Landel: ‘While we acknowledge the work and training involved in earning credentials, is a string of alphabet the best way to clarify our achievements if no one knows what they all mean? Is it just for our own marketing? We say list what you have achieved under your name on cards or letterhead, as physicians do. The initials are there for you, not for an audience...let's put patients first and chose clarity over confusion."

In the end, the panel supporting the elimination of credentials--Drs. McDavitt, Rowe and Landel--were crowned the winners of the debate as a majority of the attendees sided (literally) with them. And ADVANCE's only regret is that we didn't get the entire proceedings on videotape; it was a lot of fun and sure to be a popular event at future conferences.

BALTIMORE-Adding to a plethora of activities in Baltimore, the ADVANCE staff attended a reception celebrating Kennedy Krieger Institute's newly opened outpatient center. The state-of-the-art facility was designed to improve and expand the services offered to children and young adults with developmental disabilities and spinal cord injuries.

The six-story, 115,000 square-foot building features the latest technology and is surrounded by extensive healing and therapeutic gardens. The healing garden serves two purposes, according to Laura Jaweed, PT, MS, DPT, director of physical therapy at Kennedy Krieger.

First, the garden is an area where patients, families and employees may retreat to decompress. "The garden helps families handle the stress of illness and disability," Dr. Jaweed shared with ADVANCE.

Second, the garden serves a therapeutic purpose with its many terrains and surfaces for patient navigation. The beautifully constructed area includes a labyrinth, touchable fountains and three "therapy rooms," where therapists can help patients practice real-world challenges such as maneuvering a tight ramp in a wheelchair.

The aquatic center-located on the top floor-features two pools equipped with underwater treadmills, video systems, sensory temperature controls and hydraulic lifts that raise and lower the floors for easy patient access.

The new Kennedy Krieger Institute-founded in 1937-has been in the works for nearly 15 years. The therapists and other staff were instrumental in identifying the need for standout features such as gait assessment and pressure mapping labs, sensory gyms, patient observation spaces equipped with video and audio and a floor dedicated to spinal cord injury patients.

Each floor offers dramatic views of downtown Baltimore and an opportunity to observe the therapy garden. In addition to being aesthetically pleasing, the new space is also practical and kind to the environment. Green elements were incorporated into the building's design to increase efficiency and reduce energy usage.

ADVANCE will be posting photo and video coverage of the tour as well as an exclusive interview with Dr. Jaweed on our Website soon so be sure to check back and let us know what you think!

"What is a brand?" he asked the audience. "It is a promise. It defines expectations. A good brand can be hard to create because it takes a long time to build trust. Brands can also be influenced and are not fully controlled."

Emilio J. Rouco, director of public relations and marketing, later took the podium to discuss the intensive research conducted by APTA to determine how physical therapy professionals are viewed by healthcare consumers and fellow healthcare professionals.

"The good news is that PT professionals are held in high esteem and the relevance of physical therapy is growing. But  there is also some blurriness in the differentiation between physical therapy and other healthcare professions on the part of the general public."

In addition to making it clearer to healthcare consumers exactly what physical therapy is, the APTA is seeking through its brand campaign to occupy a greater "mindshare" among the general public, noted Jennifer Rondon, associate director of public relations.

To find out more about this intriguing look into the future of physical therapy, keep an eye out for an upcoming issue of ADVANCE!

BALTIMORE--Do we really need all of the regulations Medicare and the physician fee schedule places on the PT profession-or do the regulations just make practicing PT more cumbersome and confusing?

Likely a little bit of both, according to the panelists at the 2009 Rothstein Debate, "When Does Regulation Become Over-Regulation, and When Does Under-Regulation Invite Abuse?"

The debate was held June 12, with panelists Larry Benz, PT, DPT, MBA, ECS, OCS, and Stephen Levine, PT, DPT, MSHA.

"Medicare is very complex; what we want to discuss is the concept of regulations and how they apply to us as practitioners," said Anthony J. DeLitto, PT, PhD, FAPTA, moderator for the debate.

Taking the "over-regulation" side of the debate, Dr. Benz said rules and regs are needed, but they tend to creep, and thus the profession ends up with rules on top of more rules. "This tends to demoralize; go into any clinic and you can tell which therapists are treating Medicare patients versus those who aren't. The rules are well-intended but the consequences are rarely discussed. We acquiesce to a certain number that puts a cap on our earnings. Regulation causes many therapists to act immorally," Dr. Benz said.

But Dr. Levine, taking the supporting position on regulations, responded that in essence, regs get a bad reputation that does not always apply. "There are many misconceptions about regulations and why they exist. They provide for some standardization of rules. They are very complex and don't always make sense but the result of not having them can be severe." The profession needs standardization, he said, much like speed limits on roads. "Most PTs operate in a few settings where the rules are transparent. Health care fraud and waste costs millions of dollars every year, so regulations are necessary."

The panelists addressed questions on the cost of deregulation to the PT profession, and whether the APTA and state governing bodies also do enough to influence how regulations are written and applied-and if they should be involved at all.

"The problem is there are too many regulations," Dr. Benz opined. "The pendulum should begin to swing the other way. Only nuclear power control seems to have more than our profession." Dr. Benz said another problem is that bureaucrats to make the rules are "far removed from the therapists and their patients. Autonomy in PT should unshackle practitioners from added rules."

But Dr. Levine said an overabundance of too ambitious regulations "is a myth, a misperception. We can't have things both ways. What we are paid to do is based on one-to-one care of therapist to patient. We can't be paid as if we are doing the service and also are able to use care extenders for example." Through physician-fee regulations and coding on one-to-one care and incident-to examples, others end up determining how PTs get paid, he admitted. "It's like auto insurance. But we can still define how we want to practice; APTA has a position that only PTs and PTAs can provide services."

But regulations end up limiting the profession, Dr. Benz countered. "Physicians don't limit themselves (in payment) in this respect, but PT does," thanks in essence to over-regulation.

Both panelists agreed that the profession needs to better police itself in order to mitigate some rules and that most clinicians try to do the right thing regardless of how they are governed by regs. They also concurred that in some ways, the cost to the profession of not having at least some payment/fraud regulations would be much higher than the costs of implementing regulations and teaching therapists to follow them.

The "Current Controversies: Rothstein Debate" was established annually in memory of Jules Rothstein, PT, PhD, FAPTA, Editor-in-Chief Emeritus of the Journal of Physical Therapy.

Years ago, Dr. Malone stubled upon this gender difference and wanted to find out more about it. In order to attract athletes to his study, he didn't sell the concept on the idea that he was going to prevent injury. "The emphasis was on enhanced performance," he said.

Dr. Malone chose to study ACL injuries in basketball teams across the country. He found that women were 6.19 times more likely to tear their ACL in intercollegiate basketball during a season.

Some factors to consider when comparing male to female ACL injuries:

• Strength (women's hamstrings are not as strong);
• Training;
• Posture (women have a tendency to be more comfortable when vertical);
• Stiffness;
• Hamstring tissue (male/female hamstring flexibility).

The audience was shown various photographs of men versus women in basketball playing postures. All photos showed men in a more flexed position than women. "If you keep your knees down and stay bent, you almost cannot damage your ACL," Dr. Malone told the audience.

"Women tend to demonstrate neuromuscular imbalances," added Dr. Hewett. Women and girls also tend to be more leg and quad dominant than men and boys.

Is it possible to use training and strengthening to help prevent ACL injury, Dr. Malone asked the audience. "Early results show this is possible," he answered.

For a more comprehensive summary on this session, be sure to read our conference wrap coming soon in an ADVANCE print issue.