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ADVANCE Perspective: Physical Therapy & Rehab Medicine

Therapy for Parkinson's
by Dillon Stickle
The Journal of the American Medical Association (JAMA) Neurology released a study on Tuesday which suggested that the current standard of care for early-stage Parkinson's patients may be a waste of time and money. The study said that both PT and OT offer "no improvement of quality of life" and that there were no "short or medium-term benefits."

A recent article on ADVANCE for Physical Therapy and Rehab Medicine claimed that, "Patients today are far more educated on the disease, have lots of questions, and know that physical therapy combined with prescribed exercises will impact their quality of life moving forward. Potentially, it could even slow the progression of the disease."

We shared the study with our Facebook fans via a Yahoo News article, and there seemed to be a united consensus: the study was misleading or misrepresentative of the role PT plays in the treatment of a patient with Parkinson's disease.

Here are some things PTs had to say:

"Treating injuries is not the main focus of any plan of care from a skilled PT that is treating someone with PD."

"That seems at odds with the multiple studies that have clearly shown how exercise and therapy benefit Parkinson's patients short- and long-term."

"If there was no progress or benefits for PD patients in this study, than the PTs may need a review of how to write functional goals."

"It depends on what the PT focuses on. Doing only strengthening exercises won't help. Focusing on balance, movement strategies, etc. does help. But, these have to be incorporated into daily life by the patient and family/caregiver."

Some fans pointed out the fact that balance exercises and range of motion were not part of the study, which many PTs consider their role to improve in a patient with Parkinson's. Some even argued the study was skewed because of biased healthcare providers.

What are your thoughts on the role of PT in cases of patients with Parkinson's? Let us know in the comments.

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Can Helmetless Drills Decrease Football Head Impacts?
by Brian Ferrie

The National Athletic Trainers' Association (NATA), Dallas, issued an interesting press release Dec. 18 related to the hot-button issue of head impacts in football. The release stated:

"Head impacts in football players are directly associated with brain and spine injury and have been suggested to be associated with chronic injuries, making this a topic of continued national concern. To reduce the risk of head-impact injury, researchers and others have sought ways to improve helmet technology, reduce contact during practices, and alter game rules."

A new study, "Early Results of a Helmetless-Tackling Intervention to Decrease Head Impacts in Football Players," published in the Journal of Athletic Training investigated the effectiveness of helmetless tackling to reduce head-impact exposure in an NCAA Division I football program.

"Given proper training, education and instruction, college football players can safely perform supervised tackling and blocking drills in practice without helmets," said Erik E. Swartz, PhD, ATC, FNATA, lead author of the study and professor and chair, Department of Kinesiology, University of New Hampshire. "This intervention also eliminates a false sense of security a player may feel when wearing a helmet. Younger players with less experience may require modifications to this intervention to realize a positive effect. While more research is needed, our results do show a reduction in head impacts during our one season of testing."

The results stem from the first year of a two-year study focusing on 50 NCAA Division I football players at the University of New Hampshire who were assigned to an intervention or control group. The intervention group participated in 5-minute tackling drills without their helmets and shoulder pads. Drills occurred twice per week during preseason practices and once per week throughout the competitive season. Meanwhile, the control group performed noncontact football skills with no change to their routine. All athletes were provided head-impact patch sensors worn on the skin and new helmets. At the end of the season, the intervention group experienced a 28-percent reduction in head impacts during practices and games than the control group.

"These findings elucidate the risk-compensation phenomenon and may help explain the behavior of spearing and the rise in catastrophic neck and head injuries that followed," the study authors noted. "A football helmet is designed to protect players from traumatic head injury, but also enables them to initiate and sustain impacts because of the protection it affords. While improving protective equipment in and of itself will not resolve the risk of concussion and spine injury in football, the solution may be found in behavior modification."

What are your thoughts about this study and the merits of helmetless drills to help reduce head impacts in football?

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An Unpopular Stance on POPTS
by Jon Bassett

This guest blog was written by Cary Edgar, JD, president of PT Management Support Systems.

In 2011, I published an editorial in ADVANCE explaining why the APTA's decades-long campaign against physician-owned physical therapy services (POPTS) is unfounded, misguided, and ultimately self-destructive.1 The APTA has continued its campaign against POPTS and continued to cite outdated studies as support for its argument that POPTS results in overutilization and excessive costs.2 These studies were conducted over 20 years ago, before the enactment of the Stark rules. Furthermore, these studies used questionable research methods and arrived at dubious conclusions.3

In the meantime, two more objective, comprehensive and rigorous studies have been published showing that PT provided within a physician practice actually results in lower utilization and costs than therapy provided in private practices. To date, the APTA has failed to mention either of these studies, despite the fact that it partially funded one of these studies and the other study was conducted by the GAO.

In addition, the APTA's sister organization, The Foundation for Physical Therapy, sponsored another recently published study finding that physician groups see PT patients for fewer visits per episode, units per episode and units per visit than private PT practices.4 And although the APTA announced the original grant for this study,5 it has failed to publish or even refer to the results of this study.

Beattie Study

In January 2013, the Journal of Occupational Rehabilitation published a study entitled "Differences among Health Care Settings in Utilization and Type of Physical Rehabilitation Administered to Patients Receiving Workers Compensation for Musculoskeletal Disorders."6 This was a study of workers compensation claims during 2009-2011 covering over 70,000 patients. This study found that physician-based PT averaged about 10.5 visits and 42.7 units per patient while (a) private PT practices averaged over 12 visits and 51 units per patient-which represents 16.3% more visits and 22.2% more units per patient than physician-based PT, and (b) corporate PT clinics averaged over 13 visits and close to 67 units per patient -- which represents 25% more visits and 56.3% more units than physician-based therapy.

This study was partially funded by the APTA. However, while the APTA continues to cite 1992 studies to supports its claims of physician over utilization, it makes no mention of this comprehensive study published in 2013 finding exactly the opposite.

United States General Accounting Office

At the request of Congress, the U.S. General Accounting Office conducted a study of Medicare data from 2004-2010 to determine whether physician-owned therapy resulted in higher costs than PT in other settings. The GAO compared self-referred (physician-owned) PT to non-self-referred PT and found that:

  • (a) From 2004 through 2010, the number of PT services (procedures) per 1,000 self-referred patients was generally flat while the number of services per 1,000 non-self-referred patients grew by 41%.
  • (b) From 2004 through 2010, total Medicare expenditures for self-referred PT increased by 10% while expenditures for non-self-referred services increased by 57%.
  • (c) Self-referring physicians, on average, referred fewer PT services per beneficiary than non-self-referring providers.

The GAO concluded that:

Our review indicates that PT service use and expenditures grew considerably from 2004 to 2010, despite a slight decrease in the total number of FFS beneficiaries over this period. The primary driver of this growth was growth in non-self-referred services. These results differ from our prior work on self-referral of other Medicare services-namely, advanced imaging, anatomic pathology, and intensity-modulated radiation therapy-in which we reported that self-referred services and expenditures grew faster than non-self-referred services and expenditures. One potential reason for this difference is that non-self-referred PT services can be performed by providers who can directly influence the amount, duration, and frequency of PT services through the written plan of care required by Medicare. In contrast, non-self-referred services we examined for our prior work tend to be performed by providers who have more limited ability to generate additional services or referrals; for example, radiologists generally do not have the discretion to order more imaging services or more intense imaging procedures.7

In other words, the GAO concluded that therapists in private practice largely influence the amount of PT delivered and have used that influence to increase PT visits, procedures and costs at a much higher rate than physicians and therapists providing PT within a physician group.

Mitchell Study

The APTA's foundation, The Foundation for Physical Therapy, sponsored a recent study of low back pain patients covered by Blue Cross Blue Shield of Texas.8 This study compared PT utilization rates between self-referred (physician-based) PT and non-self-referred PT. Like the GAO study, it found that therapists in private practice see patients for more services (units) per episode than therapists working within physician groups. However, the Mitchell Study actually went further and found that therapists in private practice average more visits per episode and units per visit than therapists working within physician groups. More specifically, the Mitchell Study found that PT provided within physician groups averaged 27% fewer visits per episode, 34% fewer units per episode, and 9% fewer units per visit.9 So, PT care within physician groups was actually less expensive per episode than care provided by private PT practices.

In an attempt to justify the additional services delivered by private practices, Mitchell reviewed the mix of procedures and suggested that private PT practices delivered higher quality of care because the percentage of active treatments (timed codes) were higher than those billed by therapists working with within physician groups. More specifically, Mitchell stated that:

Electrical stimulation (a passive treatment) accounted for almost 9% of the physical therapy services rendered during self-referring episodes, whereas use of this modality among non-self-referring episodes was negligible (1.4% of all physical therapy services). The 7.4 percentage point difference was highly significant.10

This conclusion is based on a count of attended electrical stimulation procedures billed under 97032. Mitchell fails to share data for or even refer to the much more common unattended electrical stimulation code billed under 97014. This failure to account for one of the most common modalities and instead base conclusions on a relatively uncommon modality begs the question of whether any practicing physical therapist actually reviewed the findings and conclusions.

The Beattie and GAO studies are rigorous and broad-based studies that clearly demonstrate that physician groups actually provide PT at lower utilization levels and costs than private PT practices. Likewise, the Mitchell Study, which was no doubt trying to find support for the APTA's assertion that physicians over utilize therapy, actually found fewer visits per episode, units per episode and units per visit in physician groups as compared to private PT practices. The APTA's continued claim that physicians are "referring for profit" is simply not supported by the evidence and disparages physicians, therapists and assistants who are delivering exemplary care.

While the APTA continues to support exclusive physical therapist ownership and operation of physical therapy services,11 the U.S. healthcare system and the vast majority of other healthcare providers are moving towards large integrated healthcare delivery systems. Congress, CMS and MedPAC have all adopted policies encouraging integrated delivery systems to both provide better quality care and control healthcare costs. These large integrated delivery systems include physicians, physical therapists, and other healthcare providers who work as a team to coordinate care so that each patient is provided the most appropriate care at the lowest cost possible without the potential impediments raised when care is provided by economically independent providers.12

The APTA may argue that therapists in independent PT practices are as capable of coordinating patient care as therapists who are members of integrated delivery systems. However, a number of factors favor integrated delivery systems, including the use of a single electronic health record system, more contact with other providers to allow for better coordination of care, and better coordination of payment mechanisms that facilitate cost savings.

The APTA's admirable vision statement includes the following principles:

The physical therapy profession will offer creative and proactive solutions to enhance health services delivery and to increase the value of physical therapy to society. Innovation will occur in many settings and dimensions, including health care delivery models, practice patterns, education, research, and the development of patient/client-centered procedures and devices and new technology applications. New models of research and enhanced approaches to the translation of evidence will more expediently put these discoveries and other new information into the hands and minds of clinicians and educators.13

The APTA and its state chapters have devoted a tremendous amount of time, energy and money in their long campaign against physician-owned therapy (and therapists and assistants who are members of physician groups) with very little to show for their efforts other than alienation of a large portion of the physical therapy profession, physicians and other providers. The APTA should follow the principles in its vision statement, recognize that exemplary care is being delivered through physician groups on a collaborative and cost-effective basis, acknowledge and agree that therapy can be effectively provided in a variety of settings, and reverse its misguided policy against providing therapy within physician groups.

References can be accessed here.

Cary Edgar is president of PT Management Support Systems, Phoenix, Ariz. Contact:

PT and PTA Student ‘Flash Action' Focuses on Congress
by Brian Ferrie

The American Physical Therapy Association (APTA), Alexandria, Va., issued an important news release on Nov. 9 related to loan repayment for new graduate physical therapists.

The release stated: "In a ‘Flash Action' effort led by students from PT and PTA education programs, supporters of legislation that would allow PTs to participate in the National Health Service Corps (NHSC) flooded Congress with more than 18,000 letters sent to Washington, DC, during an intensive 2-day drive on November 4-5.

Inclusion in the NHSC would increase access to PTs in rural and underserved areas, in part by allowing PTs to participate in the NHSC and its Student Loan Repayment Program. That program repays up to $50,000 in outstanding student loans to certain healthcare professionals who agree to work for at least two years in a designated Health Professional Shortage Area.

The campaign not only succeeded in making the voice of physical therapy heard on Capitol Hill, but also created ripples across social media. The #PTAdvocacy hashtag was used 600 times on Twitter during the days of the flash action, and the campaign's top Facebook post reached 15,826 people."

Are you interested in participating in the National Health Service Corps? What do you think about seeing this kind of PT advocacy in action?

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Proving the Value of Physical Therapy
by Brian Ferrie

This guest blog post was written by Jerry Henderson, PT, vice president of clinical community at Clinicient in Portland, Ore.

I personally believe that our profession is an excellent value. That is, our efforts provide a great benefit for the cost. Unfortunately, regardless of the conviction of my beliefs, we have an obligation to prove it to payers and, more importantly, to the consumer. Believing that we provide a great value is easy... proving it is hard.

Value is often defined as outcomes divided by costs. But measuring outcomes and, to a lesser extent, costs is difficult. Of course if we can't measure costs or outcomes, we can't prove our value.

Measuring Outcomes

Nearly every physical therapist I've ever known will tell me they provide superior outcomes. This is, of course, absurd. Not everyone is superior. I believe that many of my colleagues provide great care. But, of course, some provide only average care and there are even a small number who provide (gasp!) substandard care.

Jerry Henderson, PT

Let's compare measuring physical therapy effectiveness to effectiveness for medical problems:

For certain cancers, a crude measurement of effectiveness is based on mortality. Just studying what was done for the patients who lived compared to the ones who died provides great information on outcomes.

Type 2 diabetes is another example. Manipulating diet and drugs while monitoring lab values and controlling for demographic variables and lifestyle provides an amazing amount of useful information on morbidity.

Rehabilitation professionals do not (except in the most extreme cases) have a role in extending life. We don't treat diseases. We help our patients improve function. The absence of death is very easy to measure. The absence or improvement of disease is generally measurable.

In contrast, improvement in function can be difficult to measure. Medicare's attempt to somehow measure function is a case in point. In the absence of universally accepted objective standards for measuring functional improvement, Medicare instituted an extremely subjective process of classifying patients and rating their impairment. The current state of the art in measuring functional improvement is based on patient questionnaires, which are rough subjective indicators of functional status, not objective measurements of function.

In addition, understanding which interventions were provided in rehabilitation specialties is difficult. In medicine, it is pretty clear which drugs were prescribed. In rehabilitation specialties, it is not at all clear which procedures were performed, since there is no standard nomenclature across the professions for therapeutic exercise and manual therapy, and the procedure codes that we use for billing do little to describe what was actually done.

Measuring Cost

Surprisingly, measuring cost is also problematic, simply because healthcare records are stored in multiple, non-integrated databases. Take the example of a patient who has an elective orthopedic surgery for a knee replacement. That patient may have been seen by a family doctor for a number of years, and a physical therapist for a period of time prior to referral to an orthopedic surgeon.

Chances are good that the cost data for the treatment of that condition has already been stored in at least three different data repositories, and that's before the patient is hospitalized for surgery. On top of all that, there is nothing preventing the patient from changing insurance companies, introducing yet another data silo.

Theoretically, a payer may be able to correlate all of that information from the outpatient and inpatient providers and get an accurate idea of the cost, but there are many reasons to believe it is doubtful.

Measuring Overall Value

This article in the Harvard Business Review, "Getting Real About Healthcare Value," makes the point that comparing the true value of improvements in health status is extremely difficult. For one thing, the potential side benefits of effective treatment are not taken into account.

To illustrate with an example, many studies show that physical therapy is effective in treating and preventing chronic low-back pain, and that it saves many other immediate costs including unnecessary imaging and invasive procedures. One can hypothesize that many other conditions are potentially improved or prevented by effective treatment for that patient population, including obesity, arthritis and heart disease, creating a stunning "multiplier effect" that results in decreased healthcare costs in years to come.

We have a huge opportunity to improve on the value proposition of our profession, but we need to start with using integrated information systems that help guide our clinical decision-making, standardize our terminology, improve outcome measurements, and track our costs.

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APTA Takes Aim at SNF Productivity Controversy
by Brian Ferrie

The American Physical Therapy Association (APTA), Alexandria, Va., issued an Oct. 8 press release detailing how the organization has spoken out in The New York Times (NYT). This initiative was precipitated by recent reports that skilled nursing facilities (SNFs) are taking advantage of Medicare billing policies. The APTA states that these allegations underscore the need to replace volume-based payment systems with systems tied to value.

In a letter to the editor published today, APTA President Sharon L. Dunn, PT, PhD, OCS, responded to a September 30 NYT article titled, "Nursing Homes Bill for More Therapy Than Patients Need, US Says." That story focused on a report from the Office of the Inspector General (OIG) of the US Department of Health and Human Services alleging that Medicare payments have "greatly exceeded SNF costs for therapy for a decade."

According to the APTA press release, this OIG report and related media coverage are directly related to the pressures being placed on physical therapists, physical therapist assistants and other providers to meet productivity demands that can sometimes run counter to actual treatment needed.

"The provision of physical therapy services should be driven by patient need and the clinical judgment of the licensed physical therapist," Dunn writes in her letter. "Productivity goals that drive services toward economic incentives continue to be an issue that policymakers and professional associations have a joint responsibility to meet."

Much of the criticism of SNFs is centered on the use of ultrahigh therapy hours in billing practices, the APTA press release continued. CMS estimates this tactic provides facilities with an average of $66 a day in payments over costs. In the APTA letter to NYT, Dunn also describes APTA's collaborative efforts to address volume-based vs. value-based care, and how the association's "Integrity in Practice" campaign aims to provide PTs and PTAs with resources to support care based on patient need and clinical judgment.

"We are committed to making sure that the correct incentives are invoked in care delivery, in a manner that maintains our patients' trust," the letter states.

What are your thoughts about these developments and the issue of unethical billing practices? Share your comments below!

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Tai Chi Improves Physical Function
by Dillon Stickle
Yoga and Pilates are both well known in the therapy world and are often used as a complementary activity for patients with chronic pain and long-term conditions. Not many people, however, use Tai Chi as an example of such exercises - but maybe they should start.

The British Journal of Sports and Medicine published a systematic review on the effects of Tai Chi on four specific chronic conditions: osteoarthritis, heart failure, chronic obstructive pulmonary disease (COPD), and breast cancer. The study was put together by a team of researchers in the University of British Columbia's Physical Therapy department, located in Vancouver. The idea behind the study was to see if Tai Chi would be a successful activity for easing the symptoms and quality of life for people with one or more of these conditions.

The results were as follows: "Meta-analyses showed that Tai Chi improved or showed a tendency to improve physical performance outcomes, including 6-min walking distance (6MWD) and knee extensor strength, in most or all four chronic conditions. Tai Chi also improved disease-specific symptoms of pain and stiffness in OA [osteoarthritis]."

They concluded that Tai Chi could be used as a safe form of exercise for people with one or multiple chronic conditions, and showed a tendency to improve physical performance in those with said conditions.

PTs, have you ever incorporated Tai Chi for patients with chronic conditions? If so, how do they compare to activities such as yoga or Pilates? If you haven't, would you ever consider using Tai Chi in your practice? Share with us in the comments!

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Effective Aquatic Therapy Takes Time and Creativity
by Jon Bassett

 Editor's note: This blog post was guest written by Kelly McFarland, PT, DPT 

Any physical therapist who has chosen to get into aquatics knows how beneficial it is for patients. However, it's not always straightforward. In order to provide exceptional aquatic therapy to clients, you have to be willing to make changes along the way.

Some of my biggest tips for colleagues who are just starting out with aquatic care include:

Focus on one patient in the pool at a time. Unless you invest in a large static therapy pool that can accommodate multiple people simultaneously, don't be tempted to add more than one patient in the pool at a time. Our pool is state-of-the-art, and we have chosen to have one individual and one physical therapist in the pool for each 45-minute session. This helps us give incredibly personalized feedback and encouragement. Plus, it allows us to be inventive and progress according to the client's abilities and personal desires. This individualized approach pays off in a big way when it comes to patient satisfaction and client referrals.

Offer some special touches for clients. I love the water, and you might, too; yet there are plenty of clients who don't feel as fond about getting out of their clothes, getting into bathing suits or comfortable clothing, and then getting into the pool (even though it's warm.) Besides, even if someone usually likes the water, it can be intimidating after surgery or when someone's in pain. To build their enthusiasm and cut down on the possibility of them missing appointments, make the experience somewhat spa-like. We actually provide robes to patients when they come out of the pool, and progress them depending upon their needs during each visit. It takes a lot of energy to be patient and understanding, but it's worth it!

Never fall back on cookie cutter protocols. Every client is unique, and that means every patient's protocol needs to be just as original in design. For some people, turning on the resistance jets is the perfect way to get them working a little harder. For others, the key is to start them on gait re-training using the underwater treadmill. Certainly, some exercises overlap between patients, which is normal, but everyone in our aquatics program is case-by-case. This is why it's important to...

Invest in training for all your physical therapists. We all need to have exercises in our proverbial "back pockets" that range from very easy to very challenging. These can involve pool equipment such as specialty weights and noodles. The best way to learn what others are doing is to attend classes. Fortunately, there are free webinars where physical therapists can learn about aquatics in easy-to-watch, concise web-based events presented by professionals in the field.

Consider aquatics as an adjunct to your other practice offerings. Let's face it -- unless your patients are never going to leave the water, most of them will need to be able to transition to land-based physical therapy at some point. Aquatics needs to be a niche part of your practice, a complement to everything else you offer. It's your secret weapon! Use it to set you apart from all the competitors vying for your same clientele. Many people misunderstand aquatics and believe it cannot be aggressive or lead to incredible transformations; we know that's not true, and science backs this claim.

There are other tips to offer, of course, but these are five of the best for people who are investing in therapy pools at their practices. As long as you keep your clients' needs in mind, as well as the practicalities involved in billing insurance for aquatic therapy, you'll be on your way to setting the stage for a thriving business.

Kelly McFarland is owner of Premier Rehab Physical Therapy, with locations in Keller, North Richland Hills, and Fort Worth, Texas.

Study Reflects Poorly on Self-Referral to PT Services
by Brian Ferrie

The American Physical Therapy Association (APTA), Alexandria, Va., recently issued a press release concerning a new study. Published in the Forum for Health Economics & Policy, the study is titled "Physician Self-Referral of Physical Therapy Services for Patients with Low Back Pain: Implications for Use, Types of Treatments Received and Expenditures." It offers insight into the cost and utilization patterns of physicians who self-refer to physical therapist services for low back pain (LBP). According to the APTA, the survey builds on and fills in gaps of a previous US Government Accountability Office (GAO) study on self-referral.

The press release stated: "Two significant findings revealed that self-referring physicians refer more patients to physical therapy for LBP, but for fewer visits per episode while, on average, costing significantly more than non-self-referring providers. Patients who saw self-referring providers also received more passive treatment, which is not hands-on, does not engage the patient, and is proven to be less effective for treatment of LBP.

The study, which was funded by the Foundation for Physical Therapy and the National Institute on Aging, took an alternative approach to look at the differences in physical therapist services provided by self-referring providers and non-self-referring providers. The study's focused look at LBP allowed researchers to more accurately classify self-referring and non-self-referring providers than the GAO report could, allowing it to pinpoint whether the physical therapy given was "active," meaning hands-on and engaged with the patient, or "passive," relying on some physical agent or modality; for example, giving the patient an ice pack to place on an injury. It is important to note that "passive" treatments can be performed by a person who is not a licensed physical therapist.

Researchers found that non-self-referred episodes of care were far more likely, 52% as opposed to 36% for self-referrers, to provide "active" physical therapist services. This, according to the study's authors, suggests the care delivered by PTs in non-self-referred episodes is more tailored to promote patient independence and a return to performing routine activities without pain.

Other significant findings to come out of the study indicate that self-referring physicians were more than 2.5 times as likely to prescribe physical therapy to patients but, as previously mentioned, for less time and for more passive treatment. And on average, spending for self-referring providers was $144 per episode of care compared with an average of $73 for non-self-referring providers."

What are your thoughts about this distinctive study and its findings?

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PTs Learning from OTs
by Dillon Stickle
While there are many important differences between the physical and occupational therapy fields, it is more often than not found that each profession can learn a lot from the other.

Back in July I went to visit Phoebe Ministries, a non-profit, multi-facility organization specializing in health care, housing, and support services for seniors located in Allentown, Pa., to learn about their newest implemented therapy program, NET (Neurocognitive Engagement Therapy), which focuses on helping individuals with cognitive impairment regain their function and return to their home environment using traditional as well as nontraditional therapy methods.

Although this program seems to be more OT driven, it actually requires an interdisciplinary team, including physical therapists. In fact, the program's founder is a PT. Jennifer Howanitz, MPT and Director of Rehab Services at Phoebe Allentown, said that when she got to Phoebe with a PT background, and saw there was no unit focused solely on dementia care, she wanted to make that happen and give therapists that kind of training that they hadn't had before.

Howanitz told ADVANCE that the physical therapists at Phoebe are learning how to get more in touch with their creative side, instead of always going by the books and doing things only the way they were taught in school. "It has been more of a challenge for PT's to not be so black and white," said Howanitz. "OT's tend to be more creative naturally," she added.

Howanitz said that because of the program's overwhelming success with both therapists and patients, physical therapists are learning that they can be more creative with their patients. "The PT's are doing well because the program works. They are seeing these approaches work and it is sparking their creativity. Success breeds confidence and creativity."

Although the clinical side of PT is as important as anything, it is nice for PT's to know that they have a chance to branch away from traditional therapy for a bit - which is good not only for the patients they work with, but for themselves, too.

PTs, have you had an experience working with an OT and gained knowledge from their therapy practices? Do you think that physical therapists should start considering more nontraditional approaches? Tell us in the comments below, and click the link to read more about the NET program at Phoebe Ministries!

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Soccer Surges on the American Sports Scene
by Brian Ferrie

The explosive growth of interest in the world's most popular game -- soccer -- is perhaps the most striking development in American sporting culture over the past several years. In previous decades, as the rest of the globe worshipped the sport like a religion, the United States stubbornly held out as a nation that viewed soccer with relative apathy, fixating instead on football, baseball, basketball, and hockey.

But that tide is certainly changing, if not at the expense of those other sports, then at least in addition to them. In fact the latest ADVANCE cover story details the meteoric rise of Major League Soccer (MLS), now celebrating its 20th season with surging levels of attendance, interest, quality of play, and worldwide relevance.

What makes the enhanced interest in soccer nationwide even more fascinating is that unlike most traditional sports followed by Americans, soccer has generated significant fandom for both male and female competitions. On the men's side, in addition to the swelling popularity of MLS, the U.S. national team has clearly become a respected player on the global scene by qualifying for seven consecutive World Cups and advancing to the knockout round of the last two (2010 and 2014). Even non-soccer fans had to be impressed last summer by the fervent patriotism and enthusiasm accompanying game watches for the U.S. team at block parties and bars across the country, while the World Cup played out thousands of miles away in Brazil.

Meanwhile the U.S. women's team just routed Japan, 5-2, in their own World Cup final on July 5 to spectacularly earn the title of top female squad on the planet. That match also became the most-watched soccer game in United States history. Not just the most-watched women's game, but the most-watched game, period. Its 26.7 domestic viewers just edged out the 26.5 million who tuned in for last summer's epic World Cup men's final between Germany and Argentina.

So it's fair to say our great country is now truly recognizing what the rest of the world has long seen -- how captivating and uniting this remarkable sport can be. What do you think about soccer's surging significance in America? Have you become a more devoted fan over the past few years too? For readers who treat athletes, are you noticing more kids and adults these days who play soccer, male or female? Let us know!

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Physical Therapy at the DoD Warrior Games
by Dillon Stickle
From June 19-28, more than 240 wounded, ill, and injured service members and veterans from across the country gathered for the annual Department of Defense Warrior Games at Marine Corps Base Quantico, Virginia. Athletes represented teams from the Marine Corps, Army, Navy, Air Force and U.S. Special Operations Command. This was the first year the DoD organized the games, usually done by the United States Olympic Committee.

In his welcome letter, Major General Juan G. Ayala of the United States Marine Corps and Commander, Task Force at the Warrior Games said, "Since its inception in 2011, the DoD's Military Adaptive Sports Program has helped wounded, ill and injured Service members recover and rehabilitate for transition back into their military units or into civilian society. All of us in the Marine Corps, and across the DoD, are extremely proud to be part of an endeavor that is both beneficial and rewarding for our Nation's warriors."

According to the Department of Defense, "adaptive sports and athletic reconditioning activities play a fundamental role in recovery, rehabilitation and reintegration of service members back to their units, or as they transition into the civilian environment." Service members participated in games like wheelchair basketball, sitting volleyball, swimming, shooting, and track.

Team Army actually had a team of six physical therapists join them at the games, ensuring their safety, maintaining their health, and maximizing their performance. Army came out on top at the games, earning 162 total medals.

Did Army come out victorious because of their PT team? Do you think all the teams should have a group of therapists attend the games? Let us know in the comments!

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Developments at the NATA Annual Meeting
by Jon Bassett

"I shall not cry because it's over. I shall smile because it happened."

With a nod to Dr. Seuss, Jim Thornton, MA, ATC, CES, outgoing president of the National Athletic Trainers Association (NATA), put a stamp on his tenure at the "Changing of the Guard" ceremony during the NATA's 66th Annual Symposia and AT Expo, held in St. Louis June 24-27, 2015.

The NATA welcomes Scott Sailor, EdD, ATC, as incoming president for the next three years. Sailor, chair of the kinesiology department at Fresno State University, began his official tenure June 25.

"I'm very excited to become your 13th president," Sailor told the capacity ballroom crowd. "I believe we can accomplish amazing things. I do not take this responsibility lightly." He was elected in October 2014.

As objectives for his presidency, Sailor [pictured at right] specified ongoing misunderstandings among many policymakers surrounding what athletic trainers do, and the development of a strategic plan reflecting the modern needs and experiences of today's athletic trainer. In May 2015, the NATA's board of directors approved a mission statement and vision statement to guide the profession.

"Great opportunity lies before us," Sailor said. "I challenge each one of us to get involved." 

Position Statement on Spine Injury

In other conference news, the association released an executive summary of a new inter-association consensus statement on "Appropriate Care of the Spine-Injured Athlete." This is an update to the original 1998 consensus statement guidelines in light of recent changes in literature for pre-hospital treatment protocols and a discussion among task force and spine trauma researchers.

"These updated recommendations are critical to ensure proper and immediate care of the athlete and to reduce or prevent catastrophic outcomes," said task force chair and NATA Vice President MaryBeth Horodyski, EdD, ATC, FNATA. "The athletic trainer and other members of the sports medicine team must work together to ensure clear and immediate communication. Establishing an Emergency Action Plan for use and review by the sports medicine team is essential."

The 14-point plan, which covers immediate assessment, equipment removal, immobilization and transportation guidelines, is viewable at Also look for a full-length feature article by Horodyski in the July issue of ADVANCE.

Public Perception of Athletic Training

During J&J Day, a block of programming sponsored by Johnson & Johnson June 25, a four-member speaker panel discussed "A Patient-Centered Vision for the Future of the Athletic Training Profession." Audience members heard opinions on the way athletic trainers are viewed by patients, school administrators and politicians.

"We've got a very serious issue with the way the public perceives us," said Gary Wilkerson, EdD, ATC, professor at the University of Tennessee Chattanooga. "We've got to do more to make the public aware that we are health professionals."

Wilkerson still receives feedback that views the AT profession as "taping ankles, dispensing water, massage, and coaching." Athletic trainers must position themselves as separate from a team's coaching staff, and become the managers of the full spectrum of health needs for a specific population, said Wilkerson. He pointed to such differentiators as concussion management, cardiac issues, asthma and lifting and training technique to underscore the value of ATs as healthcare providers.

"We have to be the protectors of the welfare of our student-athletes," he said.

Athletic Training Moves to a Master's

Finally, the NATA held an open discussion with membership regarding the proposal to transition the athletic training profession to an entry-level master's degree. More information can be viewed at


PT Day on Capitol Hill
by Brian Ferrie

The morning of June 4 started very early for more than 1,000 dedicated attendees at the American Physical Therapy Association's NEXT 2015 Conference & Exposition in National Harbor, Md. These hardy souls awoke before the sun, donned their professional best and headed downstairs by 6 a.m. for a quick breakfast before boarding shuttle buses bound for nearby Washington, D.C. The much-anticipated PT Day on Capitol Hill had arrived!

Despite the early hour, their energy and enthusiasm abounded. Led by Michael Matlack, APTA director of grassroots and political affairs, the attendees disembarked from their shuttle buses in front of the Capitol Building and paraded to a nearby lawn. The light drizzle couldn't dampen spirits as they anticipated their opportunity to march into the Capitol and talk with legislators about the pertinent issues impacting the PT profession.

A succession of speakers addressed the attendees while they waited until 9 a.m. to make their move. Among them was APTA Past President Paul A. Rockar Jr., PT, DPT, MS, who said, "Our goal today is to communicate the value and importance of physical therapy in healthcare, and the way that it transforms lives. I've learned a lot of lessons about advocacy over the years, and one of the most important is we can't take for granted that our role in educating legislators will be done by somebody else. We need to do it. From sharing with them the real-life patient stories about the harmful impact of the therapy cap, to reminding them about the vital role physical therapists play in treating concussions and our job as the number-one resource in physical therapy. We're all equally accountable in finding a role to ensure our success."

Rockar was followed at the podium by Rep. Xavier Becerra of California, an important ally of the profession who has co-sponsored HR 775. This bill, the "Medicare Access to Rehabilitation Services Act," would repeal the outpatient therapy cap.

Congressman Xavier Becerra, a member of the U.S. House of Representatives for California's 34th congressional district.

"I want you all to know that many members of Congress are with us on this," he told the audience. "Including my friend Rep. Charles Boustany from Louisiana, the principal co-sponsor along with me of HR 775, which will undo this fits and starts way of providing the best care to a lot of Americans who have paid for it under Medicare. We want to say thank you for their support. Shout out nice and loud so everybody in the Capitol Building over there can hear you, we're ready to make sure HR 775 becomes the law of the land!"

Finally, Matlack himself spoke, looking proudly out on the eager group he had played such a vital role in assembling.

"I want to share with you one of my favorite quotes when it comes to advocacy," he said. "These are the words of Thomas Jefferson: ‘We in America do not have government by the majority, we have government by the majority who participate.' You're participating, and I really appreciate that. All of you came to D.C. to do this. Now we need to tell our colleagues back home. Because it's not just one time you're here to advocate. You need to continue to do that. Today you're participating for your profession, patients and colleagues. Are you ready to share with your members of Congress and their staffs how physical therapy can provide the answers and savings for the healthcare system? Today is our opportunity to highlight the benefits of rehabilitation and the services we provide. Let's make history!"

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‘It's a Calling to Be a PT'
by Brian Ferrie

NATIONAL HARBOR, MD -- The APTA Annual Conference & Exposition, which was rebranded last year as "NEXT," just celebrated its 2015 incarnation in this inviting little town on the Potomac River outside Washington, D.C. The conference drew thousands of excited physical therapy professionals and advocates from all over the country, kicking off the night of June 3 with a memorable opening event.

Replicating last year's well-received format, APTA CFO Rob Batarla served as host of a "Tonight Show"-style presentation, in which APTA leaders gave their thoughts on the profession and entertained the crowd in a variety of ways.

The first guest was APTA CEO Michael Bowers, who was asked by Batarla to talk about the organization's goals. "I couldn't be more excited to be working with the members that we have," Bowers responded. "The focus of the APTA is to transform society, which can be a very large task. We have to make sure the profession is ready to do transformational work through education, research and practice."

Bowers was followed on stage by APTA Past President Paul A. Rockar Jr., PT, DPT, MS, and newly elected APTA President Sharon L. Dunn, PT, PhD, OCS, who both drew laughs from the audience by playing a lighthearted trivia game about Rockar's recently completed three-year term in office.

For the final question, "What does Paul Rockar most regret about his presidential tenure?" he earned cheers by saying, "I regret nothing, and I can't wait for Sharon to experience that same feeling."

But the highlight of the night was Keynote Speaker Billie Jean King, the legendary women's tennis player and social rights advocate who charmed the audience with tales of her playing career, and efforts to spread the cause of feminism both on and off the court.

"The thing about tennis, like soccer, is that it's really a global sport, which has given me a great opportunity to make a difference," she said.

King also paid tribute to the impact physical therapy has made on her.

"I've given you a lot of employment in my life," she said with a laugh. "You not only take care of us physically but you help with the emotional part too. It's a calling to be a PT. I don't think it's just a job. You're very special people, so give yourselves a pat on the back."

The night ended with a spectacle few will soon forget, as King took out a tennis racket while "Philadelphia Freedom" began playing through the speakers. Elton John actually wrote this song about King almost 40 years ago and named it after the tennis team she played for at the time. While delighted attendees danced to the popular tune and cheered the charismatic icon before them, King wound a path up and down the aisles, hitting souvenir tennis balls all around.

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