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ADVANCE Perspective: Physical Therapy & Rehab Medicine

Utah State of Mind
by Brian Ferrie

SALT LAKE CITY -- For the first time ever, the APTA has brought its Annual Conference and Exposition to Utah, and ADVANCE is here to cover all the action. Coincidentally, this is also my first trip to Utah, and specifically Salt Lake City. For those wondering what the place is like, here's a quick rundown. The scenery is beautiful -- Salt Lake City sits in a valley surrounded by towering mountains. It's also hot. Real hot. The temperature is expected to reach triple digits all four days of the conference. But as they say, it's a dry heat -- and noticeably different from the muggy mid-Atlantic summers I'm used to. Finally, there's a very laid-back vibe to the whole town -- with friendly residents and quiet streets.

Last night's opening ceremonies though were certainly not laid-back. The APTA made a concerted effort to deviate from its traditional format of a succession of podium speakers comprising a lengthy lead-in to the keynote speaker. This year's ceremonies, modeled after the increasingly popular TED (Technology, Entertainment, Design) Talks, featured APTA board members and Utah chapter representatives addressing the audience in quick bursts from the front of the stage. This presentation combined with short pre-taped segments to put an emphasis on fun and entertainment. Keynote speaker Dave Barry then took the stage and drew many laughs throughout his irreverent 45-minute presentation. A well-known humor columnist and author, his work has been syndicated in more than 500 newspapers in the United States and abroad. Barry began by joking how little he actually knew about physical therapy.

"In fact," he said, "you might even get a couple CE credits deducted because you attended this speech."

The Miami-based humorist related tales about the hazards posed by hurricane season in Florida (which "lasts from June until about the following June") as well as the dangers presented by having so many retirees living in the area. He also touched on his own status as an aging Baby Boomer and later brought the house down with his thoughts on the difficulties men and women face in relating to each other. Tongue planted firmly in check, he concluded, "So those are my thoughts on the challenges facing physical therapists in the 21st century," and left the stage to a rousing ovation.

It was a great start to what all attendees hope will be a fun and informative conference. Are you in town for PT 2013 too? Feel free to leave some comments below about your thoughts on the conference so far.

In Vegas at NATA
by Jon Bassett

With temperatures soaring well into the triple digits this week (and a potential to break the all-time record high this weekend), NATA President Jim Thornton, MA, ATC, PES, kicked off the 64th Annual Meeting and Clinical Symposia of the National Athletic Trainers' Association (NATA) the morning of June 25 by moderating a press event to release the association's new Best Practice Guidelines for preventing sudden death in secondary school athletes.

Announcing "significantly record-breaking" conference attendance numbers upward of 15,000 -- which shattered previous numbers in St. Louis and New Orleans the last two years -- Thornton reported that the new guidelines will be published in the July issue of Athletic Training, the association's professional journal.

"This is the most important moment for me professionally," said task force chair Doug Casa, PhD, ATC, FACSM, FNATA, chief operating officer of the Korey Stringer Institute (KSI) and director of athletic training education at the University of Connecticut. The recommendations serve as a roadmap for policy consideration regarding the safety of secondary school athletes. They address the leading causes of sudden death in this population -- head and neck injuries, exertional heat stroke, sudden cardiac arrest and exertional sickling.

LaQuan Phillips, a local football player who sustained a spinal contusion during a 2008 game and who became partially paralyzed from the injury, was on hand to help introduce the new guidelines. Phillips, who was injured as a senior linebacker for Green Valley (Las Vegas) High School, credits the school district's athletic trainer Jeremy Haas for saving his life, keeping him calm during the event and preventing further damage. Phillips underwent surgery and nine months of rehabilitation, and walked at his own graduation the following June.

"That was a very humbling, very gratifying moment," Phillips told the audience.

The full guidelines can be viewed here.

The NATA conference is taking place this week at the Mandalay Bay Convention Center in Las Vegas the week of June 24-27. Stay tuned to updates and comprehensive coverage from ADVANCE!

Swarming to the Beehive State
by Brian Ferrie

Two weeks from today, the APTA's annual conference & exposition will kick off, making its first-ever appearance in the state of Utah. From June 26-29, PT 2013 is scheduled to convene in beautiful Salt Lake City. The exclusive ADVANCE preview article detailing city attractions and conference highlights can be found here.

According to Curtis Jolley, PT, MOMT, president of the Utah Physical Therapy Association, "The conference will come at a beautiful time of year here. There could still be a little snow on top of the mountains. It's only about a half-hour drive from downtown to famous ski resorts like Park City and Snowbird. For any attendees who come from parts of the country that don't really have mountains, I definitely recommend going up there to see how pretty it is."

Salt Lake City has much to offer beyond the natural scenery as well.

"There are all kinds of wonderful restaurants downtown, including a section called Trolley Square, which is a gathering of shops and places to eat," Jolley added. "A huge new indoor/outdoor mall called City Creek Center also just opened. There's been a great resurgence in the downtown area over the past few years, including enhanced mass transit. A light rail line now runs from the airport straight downtown, so conference attendees who fly in can just take the train to within a block or so of the convention center. We're excited to showcase Utah along with its physical therapy profession and we encourage people to come here and enjoy our state,"

Will you be attending the conference? Have you ever been to Salt Lake City before? What are you most looking forward to about it?

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That Makes 50!
by Brian Ferrie

The American Physical Therapy Association (APTA), Alexandria, VA, announced in an April 30 press release that Indiana Gov. Mike Pence has signed HB 1034, granting Hoosiers direct access to evaluation and treatment by a physical therapist without a physician referral. Ensuring a patient's choice of which healthcare professional to see and when has been a longtime goal of the APTA and its state chapters.

Passage of this bill signifies a landmark moment for the profession in that all 50 states and the District of Columbia now allow patients to be evaluated by a physical therapist without a referral. With enactment of HB 1034, 48 states and DC also allow some level of treatment by a PT without a referral. The new law takes effect July 1.

"We are thrilled that Indiana has become the latest state to offer patients the choice of direct access to physical therapist services. Ensuring patient access is a cornerstone of APTA's vision and mission," said APTA President Paul A. Rockar Jr., PT, DPT, MS. "I congratulate our colleagues in the Indiana Chapter for their resilience and dedication in enacting this vital legislation after many years of tough battle. I also want to thank Rep. David Frizzell for authoring the bill and Sen. Patricia Miller for sponsoring the bill in the Senate."

The bill, which was promoted by the Indiana Chapter of APTA, permits patients to be evaluated and treated by a physical therapist for 24 calendar days without a referral from a physician or other provider. However, referrals will continue to be required for spinal manipulation and sharp debridement. After 24 days, the PT must obtain a referral from another, authorized provider to continue treatment. Prior to passage of the new law, a referral was required for all physical therapist services, both evaluation and treatment.

As APTA celebrates this legislative success in Indiana, it will continue to work toward improved patient access across the country. While all states now allow patients to be evaluated by a physical therapist without a referral, there are still significant restrictions in many states that continue to impede patient access to physical therapist services. Only 17 states currently enjoy unrestricted patient direct access.

"We'd like to see unrestricted patient access to physical therapists in all 50 states," Rockar said. "Unrestricted patient access is considered the 'gold standard' for patient care as it does not include arbitrary restrictions, such as time or visit limits."

What do you think about this milestone and the APTA's mission to pursue unrestricted direct access in every state? How has direct access impacted your practice?

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The Volunteer Spirit
by Lisa Lombardo
Are you looking for an opportune time to volunteer overseas? Judging from the number of reports I receive from ADVANCE readers, and from organizations who are continually looking for therapists to join their travel groups, the demand-and desire-for lending a PT hand in parts unknown is growing. Some recent reports:

Michael Tabasko, PT, MSPT, OCS, has been active with HVO since 2006 and has volunteered in Vietnam, Peru and Bhutan. He is currently practicing at Capitol Orthopaedics & Rehabilitation in Rockville, MD.

In "Why We Volunteer," published this month in ADVANCE, Michael wrote: "My assignment through Health Volunteers Overseas (HVO) in Thimphu, Bhutan, focused on teaching physiotherapy technician students, as well as educating and consulting with my local counterparts. We met some wonderful people along the way too, but I wanted to know that my donated time was successful, that it was worth something tangible. 

"We're told the value lies in acknowledging your privileged position in this world by helping a less-privileged one. It's supposed to make you feel good--better, in fact, than if you'd been compensated to do it. Whether it's a weekend helping out in a rough neighborhood or an overseas commitment, at some point all volunteers question how much their presence has actually mattered... Maybe specific outcomes have very little to do with the individual's impact, and the real result is the experience itself, a simple interaction and greater understanding amongst cultures."

I was also recently contacted by Chandi Edmonds, DPT, who presented to a group on training she did in Port au Prince, Haiti several months ago. As a volunteer with Project Medishare, Edmonds trained local physical therapy techs to work with patients, many still suffering with injuries from the 2010 earthquake. Edmonds reported that the nation's only critical care hospital is inadequately staffed and supplied. The facility is small and treatment areas and patients are exposed to sometimes harsh elements.

In her two weeks there, Edmonds witnessed the indomitable spirit of the proud Haitian people, as well as the abject need that resulted in children dying. Chandi plans to continue promoting awareness of Project MediShare and the vast need in Haiti.

Therapy Volunteers Needed in Haiti

And more recently, this request from Donna Hutchinson, PT, co-founder of Global Therapy Group: "We are a 501c3 non-profit, all volunteer organization providing therapy services in the Port au Prince area. We are in need of PT, OT, and ST volunteers for 2013 and wondered if you might assist us in getting the word out?

"Global Therapy Group is seeking physical therapy, occupational therapy and speech therapy volunteers at our clinic in Port au Prince, Haiti, for rotations of two weeks or longer.  Global Therapy Group was created in 2010 to bring sustainable rehabilitation services, therapy education, and employment opportunities to Haiti following the earthquake. Our clinic is staffed with a Haitian clinic manager, a Haitian rehab tech, and PT, OT and ST volunteers from around the world. Our patient population includes children and adults, orthopedics, cerebrovascular accidents, developmental disabilities, trauma and injuries. We arrange for guest housing, transportation and all in-country support."

If you are interested, contact Donna at dhutchinson@globaltherapygroup.org or visit http://www.globaltherapygroup.org/ for more information. Photos courtesy of Chandi Edmonds, DPT.

Care Amid Chaos
by Brian Ferrie

The American Physical Therapy Association, Alexandria, VA, put out a press release yesterday detailing the role that therapy professionals and students played in helping victims of the tragic bombing at the Boston Marathon. The release stated:

"A team of 70 members of APTA's Massachusetts Chapter, stationed at the Boston Marathon finish line on April 15 when tragedy struck, stepped in despite a chaotic scene to help injured people. These volunteers, led by Dave Nolan, PT, DPT, OSC, consisted of physical therapists and physical therapist students from Northern University, Simmons College, and Boston University. Nolan said, ‘All are physically OK but are certainly dealing with tremendous emotional challenges right now. I am proud of how each member reacted in the face of catastrophe to provide exceptional care for the critically injured.'

Massachusetts Chapter President George Coggeshall, PT, DPT, reported that no APTA members who were runners, spectators, or volunteers were hurt in the blast; however, there are members whose family and loved ones were among the more than 170 injured people. Coggeshall expressed sincere thanks to those who aided the victims and everyone who reached out to the Massachusetts Chapter. ‘Thank you for your many emails and calls expressing your concerns, caring, compassion and love,' Coggeshall said. ‘We will do our best to follow the footsteps of those chapters who have survived adversity and tragedy.'

If you are interested in helping people affected by this tragic event, Massachusetts Governor Deval Patrick and Boston Mayor Tom Menino have announced the formation of The One Fund Boston."

How have you been impacted by this shocking attack at one of America's greatest community events? Do you have any suggestions about other ways that PT professionals can help?

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Knee Injury--The PT Alternative
by Lisa Lombardo

Last month, my mom, who is 67, had surgery on a torn meniscus in her right knee. She's not even sure how she tore her meniscus, and it was a very light tear; could have been something as simple as planting her foot wrong or her foot coming lose from her shoe, causing the twist. I wouldn't consider her particularly "active;" she has a full-time desk job but does walk for about 20 minutes a day at lunch when weather permits.

Before her surgery, I did some investigating on whether surgery was necessary, and what she could expect to be able to do once her treatment was complete. I asked her if her doctor had suggested physical therapy as an option, rather than the surgery. She was told the surgery, done in an outpatient office, was very non-invasive and with some rest and proper pampering of her knee, she'd be fine in a few weeks. And she now is, having recently returned to work. Other than the exercises she was told to do every day after she got home, she was told post-op physical therapy would not be needed.

It turned out that her surgeon removed some arthritic cartilage too, so perhaps the surgical intervention was the best option, in her case. But it did make me wonder if physical therapy was even put forth as a viable alternative to having the surgery. Perhaps the doctor took a look at the tear and decided surgery would be minimal enough to go right to the source. And when my mother first experienced the tear, she was in a great deal of pain; at the outset the combination of the tear and arthritis formed in the knee made walking near to impossible.

New research from Brigham and Women's Hospital (BWH), suggests that physical therapy may prove just as effective as surgery for some patients. These findings were presented this month at the annual meeting of the American Academy of Orthopedic Surgeons and simultaneously published online in the New England Journal of Medicine.

Researchers at seven major universities and orthopedic surgery centers around the U.S. assigned 351 people with arthritis and meniscus tears to get either surgery or physical therapy. The therapy was nine sessions on average plus exercises to do at home, which experts say is key to success.

After six months, both groups had similar rates of functional improvement. Pain scores also were similar.

Thirty percent of patients assigned to physical therapy wound up having surgery before the six months was up, often because they felt therapy wasn't helping them. Yet they ended up the same as those who got surgery right away, as well as the rest of the physical therapy group who stuck with it and averted an operation. The research was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health.

Should my mom have been encouraged to opt for physical therapy rather than the surgery? It might have saved her time off from work, but would it have prolonged her pain when walking? Can patients assume doctors do consider PT as an option, but decide on a patient-by-patient basis who needs surgery and who can heal just as well without it? I'd be interested to know what readers think.


Therapy Team
by Brian Ferrie

Last month saw a unique occurrence for ADVANCE. In an effort to highlight interdisciplinary collaboration, we scheduled a staff-written article to be the cover story of two different publications, ADVANCE for Occupational Therapy Practitioners (Feb. 4) and ADVANCE for Physical Therapy & Rehab Medicine (Feb. 18).

That article focused on JAG Pediatric Therapy in West Orange, NJ, which just opened last fall and treats children with a variety of conditions such as cerebral palsy, developmental coordination disorders, fine-motor delay, gross-motor delay and Marfan syndrome. This clinic is staffed by the two-person, PT/OT team of Megan Acquaro, PT, DPT, and Kathleen Kane, MS, OTR/L. Both talked extensively with ADVANCE about how their services complement each other, how they worked together to launch the clinic and how they continue to team up in growing the practice. In addition to the cover story itself, we produced an exclusive ADVANCE video of Megan and Kathleen on the job.

Do you interact frequently with OT practitioners during the course of your workday? How do you believe that OT/PT collaboration can be enhanced to provide the best outcomes for patients?

CSM 2013: PT Autonomy: What the Future Holds Under Health Care Reform
by Lisa Lombardo

SAN DIEGO--There's a popular saying that goes in this vein: There really is no such thing as luck; it is what you do with the situations you are confronted with that determines your own fate.

PTs who are in private practice or who are contemplating such a venture would be wise to adopt this strategy for the foreseeable future, according to the therapists who spoke at CSM June 23 on "Health Care Reform and Professional Autonomy: The Good, the Bad and the Opportunities."

Making the most of navigating the impending health care insurance law changes can make or break how PTs can practice autonomy, and while many of the new rules seem restrictive, it doesn't have to mean that PTs give up autonomy in their practices altogether. The profession would be best served, autonomy-wise, by seizing the opportunity to rethink how PT as a profession approaches the health care bureaucracy table.

"The Affordable Health Care Act pushes development of new health care models and prevention strategies for chronic diseases and improving public health, which overall is a positive thing," stated speaker Ira Gorman, PT, MSPH. Prevention of chronic conditions is a big opportunity for the PT profession, Gorman stressed. "We're great at that secondary and tertiary care, after the problem has begun," he said. "We should start looking more at primary preventive care; often this is not appreciated and as we know it often is not paid for."

The key is keeping the autonomy of the PT profession respected within the health care bureaucracy, which will end up determining standards of payment and how outcomes are achieved, added  Robert Sandstrom, PT, PhD. "Stats show more doctors are joining hospitals and health systems rather than go into private practice. It's an interesting and sobering idea of the effect that added bureaucracy can have on an autonomous profession." At the core is the doctor/clinician-patient relationship that remains valued; could moves toward ACOs and the like put an effective end to this relationship?

"Things like joining ACOs don't have to mean a threat to our autonomy outright, for either physicians or for physical therapists in practice. We can help steer and initiate new payment reforms that give clinicians more flexibility within those [rules]," Gorman said.

Gorman, Sandstrom and Stacey Ziegler, PT, DPT, outlined what they called the "good, the bad and the opportunities" for the PT profession in lieu of the coming changes. The good: the ACA is aimed at adding 32 million more health care consumers nationwide; more patients of baby boomer age-between ages 55-70-are now opting for more and better care options and are a huge patient population; and insurance reforms are beginning to focus on outcomes-oriented accountability and evidence-based practices-areas that are PT's stronghold.

The "bad": the development of an Independent Payment Advisory Commission (IPAC); no payment reprieves for outpatient therapy under the cap and no updates yet on fee schedule cuts; market cuts to home health and some other settings, and more regulatory activism under MPPRs, RAC enrollments and a Corporate Practice of Medicine doctrine.

But with the good and the bad come opportunities, the speakers stressed. PT's role in new models of care can open doors for the profession that were previously closed, particularly in primary care aspects and prevention and wellness initiatives.

"More than 90 percent of health care consumers surveyed have a positive impression of PT," Ziegler said. "We have both opportunities and challenges in front of us in participation in ACOs; we are going to have to come to the table to demonstrate to the public our knowledge, expertise and value as a component of integrated care," she said.

As of now, 300 ACOs are operating within 48 states, she said, so the time is now. "As Thomas Paine once said, we need to lead, follow or get out of the way," she said. "These can either be rules that are happening TO us, or they can be opportunities that present us with taking the mess and finding the message."

New Technology is a Pipe Dream for Small Clinics
by Brian Ferrie

The following post was written by ADVANCE guest blogger Brian Knutsen, OTR/L, CHT, president of Buzzards Bay Hand Therapy LLC, located in Marion and Lexington, MA.

SAN DIEGO -- In the CSM session, "Emerging Technologies for Enhancing Post-Stroke Arm Rehabilitation," speakers Mindy Levin, PT, PhD, and Michelle Harris-Love PT, PhD, discussed two specific examples of emerging technologies for the treatment of UE deficits post-stroke: virtual reality (VR)/robotics and transcranial magnetic stimulation (TMS).

VR and robotics are designed to incorporate motor learning into rehab through an interactive learning process using highly repetitive movement activities. TMS is a non-invasive method to stimulate the brain. The speakers went into detail about these techniques and explained that existing research sends mixed signals. Some studies show promise regarding the effectiveness of these technologies, but many others have yet to prove or validate that effectiveness.

Despite my fascination with these technologies (who doesn't want more "toys?!"), I couldn't help but think how far off/unrealistic these tools are for me and my small private practice. Costing thousands and thousands of dollars each, these tools are certainly not in my budget. The use of these modern technologies is generally limited to large facilities with substantial budgets for capital equipment.

These technologies, along with many demonstrated in the exhibit hall, are intriguing to say the least, but just not possible for many clinics with smaller budgets. Each year, the number of papers written on these technologies continues to increase dramatically. Hopefully as more studies show/prove the effectiveness of these tools, the price tags will drop, making the technology more of a reality for smaller practices.

Third-Party Payers and You
by Brian Ferrie

The following post was written by ADVANCE guest blogger Brian Knutsen, OTR/L, CHT, president of Buzzards Bay Hand Therapy LLC, located in Marion and Lexington, MA.

SAN DIEGO -- In the CSM session, "Practice, Coding, Documentation and Reimbursement," Nancy Beckley, MS, MBA, CHC, shared a quick Medicare update to start. The audience then launched into a brief discussion about how confusing and downright inconsistent Medicare billing standards have become in the practice of hand therapy.

It was comforting for me to hear other clinicians from around the country explain their frustrations and scenarios that paralleled those in my own small practice in Massachusetts. Being a small clinic owner with only one employee (myself), I complete all the billing and coding on my own. It's apparent to me now that similar issues occur in larger clinics and facilities that have an entire department dedicated to billing issues.

Despite our frustrations with Medicare and other private payers, we learned that we must work hard to be as compliant as possible in order to protect ourselves legally, as well as ensure we are paid appropriately for the care we provide our patients. Lynn S. McGivern, JD, LLM, shared helpful specifics regarding standards for good compliance for DME in rehab clinics. I'll be sure to check out the Palmetto website for detailed information about DME standards and review my own compliance policies when I return home from the conference.

Bridget Morehouse, PT, MBA, touched on coverage and reimbursement as they relate to varying commercial payers. Although I would have much rather attended a session relating to clinical practice, this session was imperative for me to attend. The information is vital for clinicians striving to remain updated and compliant with coding and billing requirements. Ultimately if we don't keep abreast of these requirements, despite our frustration with third-party payers, we'll lose the reimbursement we all deserve and possibly open ourselves up to legal issues.

What does your clinic do to ensure compliance?

Forearm Compartment Syndrome Can Kill
by Brian Ferrie

The following post was written by ADVANCE guest blogger Brian Knutsen, OTR/L, CHT, president of Buzzards Bay Hand Therapy LLC, located in Marion and Lexington, MA.

SAN DIEGO -- The CSM session "Athletic Injuries to the Forearm, Wrist and Hand," presented by Kevin J. Lawrence, PT, DHS, OCS, was well attended with standing room only. I was particularly pleased to see the large number of students in the audience and their interest in this topic.

This talk was an excellent review for me. The most common upper-extremity athletic injuries were summarized, many of which I see often in my clinic. I was especially interested to hear the emphasis on recognizing forearm compartment syndrome. Compartment syndrome is usually caused by blunt trauma, penetrating injury, crush injuries, fractures, burns, arterial injuries and overuse injuries. Severe edema in the flexor or extensor compartments of the forearm and hand results, along with increased pressure in enclosed fascial space. Dr. Lawrence explained that this affects the blood supply to muscles and nerves. He reviewed the "5 P's" in recognizing this condition: pain, paresthesia, paresis, pallor and pulses.

I don't see this condition often in my small clinic but was aware that it's a serious complication of forearm injuries. I didn't realize, however, that if the condition goes undiagnosed, it can be fatal. Dr. Lawrence explained that the irreversible damage to muscle can lead to necrosis and eventual renal failure and death. This permanent damage can result if treatment isn't started within four hours after injury. Immediate fasciotomy in these cases is critical.

Have you had experience with this diagnosis in your clinic?

Therapeutic Maestro Post-Stroke
by Brian Ferrie

The following post was written by ADVANCE guest blogger Brian Knutsen, OTR/L, CHT, president of Buzzards Bay Hand Therapy LLC, located in Marion and Lexington, MA.

SAN DIEGO -- In the "Assessment of Upper Extremity Impairment, Function, and Activity Following Stroke" session at CSM, Catherine E. Lang, PT, PhD, shared the foundations for clinical decision-making. Dr. Lang, an associate professor at the Washington University program for physical and occupational therapy in the department of neurology in Saint Louis, MO, based her talk on an article she wrote for an upcoming special issue of Journal of Hand Therapy.

Dr. Lang opened her talk by relating the cortico spinal system to an orchestra, in which our muscles are the musical instruments and our movements are a song played by those "instruments" and coordinated by the conductor (our brain). In order for movement patterns to be conducted properly, all aspects of the orchestra must work together to coordinate the desired function and play the "song." I found this analogy useful and plan to share it with my patients when educating them about the effects of stroke.

Following a stroke, our instruments (muscles) may still be able to play some notes, but they aren't always able to play the notes at the appropriate time, rate or volume. The effect is a jumbled song or in the case of a patient post-stroke, lack of movement or coordination of movement.

The primary focus of the talk was the importance of effectively assessing paresis and loss of fractional movement. In her article, fractional movement is defined as "the ability to voluntarily move one segment independently of other segments." She noted some useful time-saving tips for post-stroke assessments.

The assessment of paresis, for example, can be used to gain insight into other areas of deficit. Assessing paresis is more important for the patient's function than focusing on deficits such as light touch, tactile discrimination, vibratory sense and joint position. Therefore if a patient has a paresis deficit, we can assume those other areas will also have deficits and may not need to be formally assessed. Dr. Lang felt that frequent administration of standardized tests can be helpful to the patient, therapist and physician by providing objective and definitive assessment of progress.

Dr. Lang also advocated the use of accelerometers. Accelerometers are wrist watch-like devices that record movement of a limb or limbs over a long period of time. They can be used with patients post-stroke, much like a pedometer is used in gait training. Accelerometers help therapists measure and compare the total movement or lack of movement of the affected and unaffected limbs.

CSM 2013: APTA Steps Up Advocacy on Federal Affairs
by Lisa Lombardo

SAN DIEGO--In a two-part session to accommodate a wide range of topics on Medicare and federal health care law changes, APTA presented "Emerging Issues in Medicare and Federal Affairs: What Every PT Needs to Know" to a packed audience on Wednesday at CSM. The first point the speakers felt attendees needed to know was that its government affairs office was more than ready to increase its advocacy efforts on behalf of the profession given the impending changes to health care insurance law.

Mandy Frohlich, director of advocacy efforts for APTA, said the last-minute negotiations on the fiscal cliff agreement out of Congress resulted in a last-minute package for Medicare, resulting in a 26.5 percent fee schedule cut, expansion of the current therapy cap extensions until Dec. 31, 2013, and a short-term fix on sequestration to March 1, 2013.

Frohlich said grass-roots efforts are focusing on "the number 1 priorities" of the Medicare Fee Schedule and the Multiple Procedure Payment Reduction (MPPR) that awaits determination in Congress. APTA has headed comment letter and coalition letter campaigns, attended more than 60 Hill meetings, organized PPS Lobby Days and more efforts to make sure that the decision on the MPPR in particular was not going to be offset for 2013, Frohlich said.

She listed the next steps APTA planned to take prior to the April 1, 2013 decision on MPPR, which affects future changes to therapy cap extensions: Redoubling efforts to find a way out of the cycle of yearly extensions on the cap; preparing for the next series of votes to introduce language changes on cap reform; and gearing up for overall payment reform efforts. Action alerts are already out this month, she noted. "Our grass-roots attempts are aimed at fixing the MPPR within the context of larger legislation," Frohlich stressed.

The Impact of MPPR

Gayle Lee, JD, explained the impact of the MPPR as it would relate to PT and other disciplines. It would apply across the board to all disciplines in all outpatient therapy settings with the exception of critical access hospitals. CMS has identified a list of CPT codes to which MPPR would apply; work costs and malpractice insurance costs would not be reduced under the measure, Lee said.

The larger impact on the profession depends on practice patterns, Lee pointed out, and said APTA has developed a calculator to help PTs determine, based on their own practice billing, how low their cuts will be after the April 1, 2013 deadline. Website instructions are listed on the APTA website.

Cap Decisions Loom

Frohlich noted that the cap on outpatient therapy, in effect since 1997, got yet another extension as a result of the last-minute budget deal last month. But she warned, "this exceptions process is not a given anymore, where it is just renewed for another year every year. We're in a different budget environment now; Congress is confronted with coming up with $1 billion to extend the cap in this budget environment. Congress has always shown a willingness to work with us--but we need to be smarter about our approach to this.

"If this profession isn't smart, we will find ourselves in a position where the caps will go into effect [permanently], that is just the budget reality now. We are working on the language needed to possibly repeal it altogether, but realistically we don't see [Congress] coming up with the $10 billion to repeal it. Congress can work with us, though, to find modifiers to offset any continued extensions," she stressed.

The cap on outpatient physical therapy for both PT and speech therapy is $1,900, and for OT singly is the same, up from $1,880, under the latest extension, Lee said. Claims exceeding $3,700 in exceptions are subject to mandatory medical reviews, and APTA is still awaiting guidance from CMS on what that means for 2013. Manual audits could revert to electronic ones, she said. And advance approval on exceptions doesn't guarantee payment without an audit later, she noted. In addition, clinicians collecting money out-of-pocket must first send the beneficiary a notice of such out-of-pocket payments.

One attendee asked if any possibility remained to separate PT and speech therapy in the cap limit. It is possible, Frohloch said, but this would require a change to the Medicare statute, at a huge cost to the government to change. "We have always believed the real answer is to get out from under these caps altogether," she said, and APTA has directed its advocacy efforts in that direction.



Infant Brachial Plexopathy Treatment is not 'Cookie Cutter'
by Brian Ferrie

The following post was written by ADVANCE guest blogger Brian Knutsen, OTR/L, CHT, president of Buzzards Bay Hand Therapy LLC, located in Marion and Lexington, MA.

SAN DIEGO -- One of Tuesday's hand rehab sessions, "Infant Brachial Plexopathy: Nonsurgical and Surgical Management," presented by Susan V. Duff, PT, OTR/L, EdD, CHT, Gregory G Heuer, MD, PhD, and Jamie Berggren, OTR/L, discussed the mechanism and etiology of a brachial plexus injury.

Brachial plexopathy is a unilateral traction injury of the brachial plexus caused by forced lateral flexion of the neck (separation of the head from the shoulder) either during gestation or delivery. The most frequent cause is shoulder dystocia either when the anterior shoulder is trapped behind the symphysis pubis or when the posterior shoulder is caught on sacral promontory of the mother.

The return of bicep function is the most important factor when determining prognosis and ultimate need for surgery vs. non-surgical treatment. The timeline when bicep function returns seems to guide the surgeon's decision making process as to when /if surgery is indicated. If bicep function is restored by two to three months, then conservative therapy has an excellent-to-good chance of being effective.

There are formal tests to evaluate bicep function; however one test I found interesting is the "cookie test." This test simply involves having a child attempt to bring a cookie to his mouth while observing for compensation. Dr. Heuer explained that this simple test is most helpful in determining the indications for surgery. He described protocols and treatment options following surgery and placed special significance on the importance of physician/therapist communication to ensure the best possible functional outcome.

The presentation featured videos depicting children with various degrees of brachial plexus pathology. It was interesting to see the movement patterns each child demonstrated and how they related to the severity of brachial plexus injury as well as the decisions to elect for surgical options.

Some of the video clips included the child's parent assisting with positioning during attempts to elicit certain movement patterns. I was pleased to see the clinician incorporating the parent in the therapeutic treatment of the child because these patients need care beyond the clinic. Parent involvement and proper positioning instruction for both active and passive movement is critical to ensure the best possible chance for success.



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