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ADVANCE Perspective: Physical Therapy & Rehab Medicine

Early PT Cost-Effective for Low-Back Pain
by Brian Ferrie

The American Physical Therapy Association (APTA), Alexandria, Va., issued a press release on April 9 detailing the results of a recent study published in the scientific journal BMC Health Services Research. The study demonstrated that early and guideline-adherent physical therapy following an initial episode of acute, non-specific low-back pain (LBP) resulted in substantially lower costs and reduced use of healthcare resources over a two-year period.

The press release continued: "Physical therapist researchers John D. Childs, PT, PhD, et al analyzed 122,723 patients who went to a primary care physician following an initial LBP episode and received physical therapy within 90 days. Of these, 24% (17,175) received early physical therapy (within 14 days) that adhered to guidelines for active treatment. During a two-year time period, these patients made significantly less use of advanced imaging, lumbar spinal injections, lumbar spine surgery, and opioids than did patients in other combinations of timing and adherence."

Early PT patients also had 60% lower LBP-related costs, compared with 33.5% (23,993) of patients who had delayed and adherent physical therapy (between 14 and 90 days). Patients received physical therapy within the Military Health System, one of the largest single-payer systems in the United States.

"Physical therapy as the starting point of care in your low-back pain episode can have significant positive implications," Childs explained. "Receiving physical therapy treatment that adheres to practice guidelines even furthers than benefit."

Clinical guideline recommendations in military and civilian settings are to avoid opioids and advanced imaging procedures as a first-line of treatment. However, research done mainly in civilian settings has revealed clinical practice is inconsistent with these recommendations. Childs noted that the study's results extend the findings from civilian settings by demonstrating an association between early guideline-adherent care, costs, and use of healthcare resources in a single-payer health system.

According to American Physical Therapy Association President Paul Rockar Jr., PT, DPT, MS, "Given the enormous burden of excessive and unnecessary treatment for patients with low-back pain, cost savings from physical therapy at the beginning of care has important implications for single-payer health care systems."

What are your thoughts about the findings of this study, and how do you think it may impact the public perception of physical therapy?

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Cutting-Edge Collaboration
by Brian Ferrie

PHILADELPHIA -- When the National Soccer Coaches Association of America (NSCAA) Annual Convention came to this country's birthplace last week, ADVANCE made sure to be on the scene. Held in conjunction with the 2015 Major League Soccer (MLS) draft, the conference is billed as "The World's Largest Annual Gathering of Soccer Coaches," drawing more than 10,000 attendees for live field demonstrations and lecture sessions.

The City of Brotherly Love played host to the 2015 National Soccer Coaches Association of America Convention.

This year for the first time, US Soccer and MLS also partnered to conduct a trailblazing two-day Medical Symposium during the convention. Featuring healthcare professionals from both organizations, it focused on player health and safety issues related to youth, amateur and professional soccer.

The event provided an opportunity for the soccer community to review the latest research, identify best practices, develop additional strategies for enhancing safety and reducing injuries, as well as chart a course to further understand soccer-related medical issues.

Of particular interest to ADVANCE was the session, "Lower Extremity Injuries in the Sport of Soccer," presented by John Gallucci Jr., MS, ATC, PT, DPT, president of JAG Physical Therapy in New Jersey and medical coordinator of Major League Soccer.

Also the former head trainer for the league's New York Red Bulls, Gallucci now coordinates the medical care of more than 500 professional soccer players in MLS.

"For this presentation, I've tried to take all my years of experience as a physical therapist and athletic trainer, to bring you the common-sense concepts of where we stand today in preventing and treating soccer injuries," Gallucci told the attentive audience. "Being dual-degreed, it's great that I can help athletes from the start of their injury all the way to returning to full participation."

He pointed out that soccer is among the fastest-growing team sports in the United States, with an estimated 15.5 million participants, and that 50-80 percent of all soccer injuries are to the lower extremity.

"You as coaches and administrators can be advocates for your injured players," emphasized Gallucci.

One of their most important roles is to enforce sensible practice schedules to help prevent overuse injuries, which are responsible for nearly half of all sports injuries to middle and high school students, he noted.

How do overuse injuries occur? "Too much, too often, too quickly, and with too little rest and recovery," said Gallucci. "Most overuse injuries can be avoided with common sense and good training programs."

Coaches need to understand the requirements of their athletes, which can vary based on sport, position, and level of competition.

"Every exercise is not appropriate for every athlete!" he added.

Speaker John Gallucci Jr., MS, ATC, PT, DPT, medical coordinator of Major League Soccer.

When soccer players do get injured, Gallucci stressed that coaches should be patient during rehabilitation and respect the process.

"To return to sport, an athlete must have no pain, range of motion within normal limits, 5/5 strength, ability to perform sport-specific drills in a clinical setting, and graded return-to-play progression," concluded Gallucci. "You can't take a player straight from a treatment session to a 90-minute game."

For more information about the 2015 NSCAA Annual Convention and US Soccer/Major League Soccer Medical Symposium, check out http://www.nscaa.com/.

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APTA Applauds Groundbreaking AARP Action
by Brian Ferrie

The American Physical Therapy Association (APTA), Alexandria, Va., issued a press release on Tuesday supporting a groundbreaking action taken last week by the American Association of Retired Persons (AARP). The APTA statement reads, in part:

"On Dec. 11, 2014, the AARP, in a letter of support addressed to Rep. Jackie Speier (D), became the first consumer organization to publicly endorse tightening restrictions on physician self-referral by eliminating the in-office ancillary services (IOAS) exception for four specific services, including physical therapy, under the Stark law. In a significant win for the U.S. healthcare system and the patients it serves, the 38-million-member AARP has thrown its considerable weight behind the legislation sponsored by Speier, commending her work to improve healthcare and reduce spending.

"The APTA wholeheartedly applauds AARP for this bold move. Removing these services from the IAOS exception would transform healthcare to save the country billions in unnecessary treatments and protect patients from being used as pawns for profit. The Stark law prohibits a physician from making referrals for certain Medicare health services to an entity with which he or she, or an immediate family member, has a financial relationship -- unless an exception applies. The IOAS exception is intended for the delivery of services that could be quickly administered for patient convenience, such as routine lab tests or X-rays.

"However, physicians' expansive use of the IOAS exception to include therapy services, in a manner outside the spirit of the law, undercuts the law's very purpose and substantially increases costs to the Medicare program and its beneficiaries. The Office of Management and Budget concluded that closing the loophole for these services would save just over $6 billion over the 10-year budget window, a number to which AARP directly referred in its letter of support."

APTA President Paul A. Rockar Jr., PT, DPT, MS, added, "APTA continues to urge Congress to take action to close this loophole, which threatens the integrity of the Medicare program. We'd like to see patients put back in the driver's seat, receiving treatment because they need it to be healthy, not because of the profit it will generate. It is time to take action. It is time for Congress to pass the Protecting Integrity in Medicare Act (PIMA) (H.R. 2914) and close the loophole. We are pleased to see AARP join the fight, and we stand behind them 100%."

The APTA has long viewed referral-for-profit as a hot-button issue, and in fact the organization is a founding member of the Alliance for Integrity in Medicare (AIM), a consortium of organizations that advocates for Congress to address the IOAS exception loophole.

However, some individual PT professionals might have different perspectives on the issue, including current employees of physician-owned physical therapy services (POPTS). What are your thoughts about referral-for-profit and the recent stance taken by AARP on the subject? Do you agree or disagree with the APTA's perspective?

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Errorless Learning for Memory Impairment
by Brian Ferrie

Post written by ADVANCE guest blogger Rachel Wynn, MS, CCC-SLP

Let's start with a story that takes place in a SNF where I worked. The tight quarters of a small therapy gym and rehab wing allowed for easy co-treating and observation of my fellow therapists' treatment, which I found incredibly valuable as a new graduate. I noticed when a very gentle occupational therapist worked with a patient (with memory and cognitive impairment) on training safe ADLs, she often corrected with "no," "don't do that," or "uh uh."

Despite the constant correction, this patient was continuing to make the same "mistakes" (or not complete targeted behavior). I had a hunch about what was holding this patient back from making progress; after all she was physically able to complete the task. I went home and did a little research (since then I have read a lot of research). Sure enough, I found evidence to support my hunch. Because the patient was doing the wrong thing, she was making the undesired pattern stronger.

What is Errorless Learning?

Errorless learning is a strategy or philosophy with the goal of reducing errors. We aren't trying to reduce errors for the sake of improved accuracy during therapeutic trials. We are trying to reduce errors so patients are practicing the desired information or process correctly (even if that means they need more assistance during trials). This in turn results in improved accuracy of task completion.

When you are working with a patient with dementia, it is easy to set a goal for improved accuracy (e.g. transfers, ambulation with walker etc.); however, it is much more challenging to obtain improved accuracy. Errorless learning is a well-researched dementia communication strategy.

Errorless vs. Errorful Learning

If focusing on correction of tasks isn't ideal (due to creating an errorful learning situation), then how do we get patients to complete therapy tasks in an errorless environment? The first thing we need to do is separate task-training accuracy and independence goals for patients with dementia or cognitive impairment.

An errorless learning environment relies on the patient receiving all the cues (verbal, visual, and tactile) required in order to complete tasks without error. If the goal is learning a task accurately, then we need to remove the independence aspect, until the task has been mastered.

Evidence-based dementia communication strategies, such as spaced-retrieval therapy and vanishing cues, pair nicely in facilitating an errorless learning environment. As tasks are being mastered, these strategies support our goals for patient independence.

Using dementia communication strategies may be the missing component to helping your patients achieve their goals. Co-treatment requires scheduling and extra effort, but disciplines working together have more tools to use. Collaborate with the SLP on your team to design individualized plans using dementia communication strategies, so you and your patients can meet goals even when dementia or other cognitive impairment is a factor.

Rachel Wynn, MS, CCC-SLP, is a speech-language pathologist specializing in elder care. As the owner of Gray Matter Therapy, she provides education to therapists, healthcare professionals, and families regarding dementia and elder care. She is an advocate for ethical elder care and improving workplace environments, including clinical autonomy for therapists. She is presenting at an upcoming webinar "Dementia Communication Strategies to Improve Therapy Outcomes" with Gawenda Seminars.

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An OT Goes to Atlanta
by Jon Bassett

There's an occupational therapist in Georgia who's running for a seat in the State Senate.

Bikram Mohanty, OTR/L, who owns Innovative Rehab Solutions, with two outpatient clinics in Waycross and Valdosta, Ga., is the Democratic candidate for Georgia's 8th Senate district, which encompasses six counties in the south central part of the state.

Mohanty ran in the 2012 race for District 8 and captured almost 40% of the vote. While he lost to Republican incumbent Tim Golden, Golden announced in March that he will not be running for re-election, so Mohanty is confident that he can capture the seat come November.

"I came to this country in 1995," Mohanty told me. "I had $50 in my pocket and the clothes on my back." Following his education at the National Institute of Orthopedics in Calcutta, Mohanty pursued the dream of many OTs in that country, making his way west. He settled in South Georgia, and began practicing with Aegis Therapies and then South Georgia Medical Center. In 2002, he opened his own practice, which at one point had more than 50 employees.

"This country has inspired me to reach higher," he said of his decision to open his own business. "I consider every challenge an opportunity."

If elected, Mohanty will split his time between the business and serving his constituents. State legislators must be in the capital from January through April. Mohanty ran unopposed in the Democratic primary; Republican candidate Ellis Black defeated John P. Page in a runoff primary election July 22 and will face Mohanty in November.

Mohanty decries a severe shortage of rehabilitation professionals in political positions -- which does patients a disservice, he said. It's a mission he hopes to bring to Atlanta. "Imagine having a PT, OT and a speech-language pathologist in every State house," he said. "Think what that would do for our patients. I'm running for their dream."

Mohanty uses the example of a proposed state bill that would prohibit insurance companies to halt coverage for children who have autism when they reach a certain age - a common policy among insurers. Effectively the bill -- which has passed with universal support in the Senate but is stalled in the House -- would ensure lifetime coverage for people with autism.

"OTs see autistic children all the time," said Mohanty. "Imagine what this bill could do for families, and for OT practitioners." Another example is the Medicare therapy cap. "In all practicality, think what would happen to that cap if there were more therapists in Congress. I want to reach out to every OT, PT, and speech-language pathologist and tell them this task is critical."

But Mohanty pledges to bring more than just a therapist's perspective to office. His flagship issue is education. After learning that many teachers in his district pay for school supplies out of their own pockets, Mohanty has pledged to improve school funding, and promises to accept only $1 in Senate salary, donating the rest to his district's teachers.

To accomplish his objectives, Mohanty declares he will sidestep ideological divides and work together to arrive at real solutions for his constituents.

"The principle that I go by is that political opponents can be friends," said Mohanty, alluding to the current atmosphere of deadlocked government in which innovative ideas are not allowed to flourish. "Idealism is fine, but we have to find a way to not pull each other down."

The election will be held November 4.

Moving to a Master's?
by Jon Bassett

INDIANAPOLIS -- In December 2013, the National Athletic Trainers Association (NATA) released a white paper titled "Professional Education in Athletic Training," a 23-page document that examined the issue of moving the profession of athletic training from a bachelor's to an entry-level master's degree.

The document, the result of a work group composed of experts and representatives of the Committee on Accreditation of Athletic Training Education (CAATE), summarized that "it is the conclusion of this group that professional education in athletic training should occur at the master’s degree level."

But the document has not been met with universal acceptance among members of the profession, and the issue has been fraught with conflicting opinions. A spirited discussion titled "The Appropriate Professional Degree for the Professions of Athletic Training" was held Thursday afternoon June 26 at the Indiana Convention Center in Indianapolis in an effort to hear comments from the work group and the audience.

Lennart Johns, PhD, ATC, professor and chair of the sports medicine and athletic training department at Quinnipiac University in Connecticut, and James Scifers, DScPT, LAT, ATC, director of the School of Health Sciences at Western Carolina University in Culowhee, NC, presented a point-counterpoint session debating the findings in the white paper and the potential effects on the athletic training profession.

"We tried to objectively analyze the data" while keeping emotions out of the debate, said Johns, making the point that currently, roughly 50% of instructional hours are devoted to athletic training instruction in 4-year programs -- the rest being comprised of general education courses. Since most master's level programs are an additional two years, instructional hours devoted to athletic training principles would effectively double, should the profession make the shift to master's-level entry. 

Panel speakers and audience members in support of the move cited increased retention, elevated respect, improved patient perception, and potentially higher pay as reasons to shift to an entry-level master's. Several educational programs, such as the University of Montana (according to one member of the audience), is phasing out its undergraduate athletic training degree in favor of an entry-level master's. 

However, cost was cited by many commenters as a serious obstacle, particularly given low salaries in the profession.  Starting salaries among those with a bachelor's degree across all disciplines averages around $45,000, Scifers said, and athletic training remains below that. "We need to get our graduates to that level," he said.

Bill Prentice, PhD, ATC, PT, FNATA, professor in the department of exercise and sports science at the University of North Carolina Chapel Hill, thanked the panel members for the open dialogue and looked forward to more discussion. "It doesn't have to be us vs. them," Prentice said.

The issue is still in the discussion phase and no plans to implement the recommendations of the panel have yet been announced. 

'The Power of the Human Spirit'
by Brian Ferrie

CHARLOTTE, NC -- Jimmy Fallon isn't down here for the APTA's 2014 NEXT Conference and Exposition, but he was about the only thing missing from the "Tonight Show"-style opening event last night. APTA CFO Rob Batarla served as master of ceremonies, with the homage including everything from a comical monologue to interview couch, succession of guests and even a house musical act, the Doug Burns Band. Fittingly the first guest was APTA President Paul A. Rockar Jr., PT, DPT, MS, who excitedly announced the "fantastic news" that Michigan had just become the 50th state with direct access. He geared additional comments toward PT students, emphasizing they can be "game changers for the profession."

New APTA CEO J. Michael Bowers then took his turn on the couch and was asked about his impression of PT professionals since taking the job in February. "I love you guys," he said with a broad smile, eliciting enthusiastic applause from the packed auditorium. When the discussion turned to APTA goals, Bowers added, "We want to be as large and strong an organization as we can be, continuing to expand our reach."

Other PT dignitaries who took the stage to offer comments on the profession included Skye Donovan, PT, PhD, OCS, program chair of the conference work group, and Cole Galloway, PT, PhD, professor and interim chair of the department of physical therapy at the University of Delaware.

But the star of the show was keynote speaker Captain Mark Kelly, an American astronaut, bestselling author and retired US Navy pilot who flew 39 combat missions during the Gulf War. Kelly's own accomplishments would have been more than enough to justify keynote status, but his presence carried even greater relevance because he's also the husband of former US Congresswoman Gabrielle Giffords. Kelly has served as Giffords' primary caregiver and most ardent supporter during her continuing recovery from a gunshot wound to the head that miraculously did not take her life at a 2011 community outreach event in Arizona.

The inspirational speaker captivated attendees with stories about his rise from troublemaking teen in New Jersey to decorated Gulf War veteran, before ultimately becoming an astronaut who made four trips into space and commanded the final mission of space shuttle Endeavour.

"I firmly believe we all learn at different rates," he said. "How good you are when you first try something isn't the only indicator of how good you can become at it."

He emphasized that life has taught him the power of having a goal, a plan to reach it and working hard toward that end. Kelly related how applicable this philosophy is to physical therapy in general and his wife's recovery in particular. The powerful presentation even included a short video of Giffords herself addressing the audience about her progress and continuing determination to overcome the effects of traumatic brain injury.

"The power of the human spirit is an incredible thing, and physical therapists get to see it every day," Kelly emotionally stated. "It's really amazing what you all do and I want to thank you for it."

What's NEXT? The 2014 APTA Annual Conference
by Brian Ferrie

The American Physical Therapy Association's yearly summertime showcase is celebrating significant changes in 2014. Traditionally known as the "APTA Annual Conference & Exposition," it has been rebranded as "NEXT." In addition, this year's event will be hosted by a city not typically seen among the organization's rotation of conference sites -- Charlotte, N.C.

As the APTA website states, the new title represents a new attitude. "It's a name change, but more than that it's a commitment to making APTA's June conference about looking into the future of physical therapy. ‘NEXT' isn't an abbreviation, but it does stand for something: It's a name thematic of where this conference and profession are headed."

From June 11-14, the reenergized spectacle will unfold at the Charlotte Convention Center. But attendees should also find many familiar elements from past annual conferences.

"Like all those ‘PT' conferences before it, NEXT will continue to offer the visionary McMillan and Maley lectures and the lively Oxford Debate," according to the APTA. "It will still provide an intimacy to networking that can be a challenge at CSM. It will still occur immediately following APTA's House of Delegates. And it will look to build on the energy of 2013's opening event. But NEXT will also be a conference that evolves over time, in exciting and engaging fashion."

For prospective attendees who want to learn more about Charlotte, it's the largest city in North Carolina and among the top 20 in the country with a population of about 775,000. Charlotte is also a major U.S. financial center, with both Bank of America and the East Coast operations of Wells Fargo headquartered there. It's nicknamed the "Queen City" in honor of Charlotte of Mecklenburg-Strelitz, who was queen consort of Great Britain at the time of the city's incorporation in 1768.

You can count on ADVANCE to be there covering all the action at NEXT, informing our readers of breaking developments through blog posts, photo galleries and social media, so stay tuned! Of course we can't truly capture the essence of the event without sampling a little Carolina barbecue too, right?

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A Charming Good Time
by Danielle Bullen
It's that time of year again! From April 3-6, over 5,000 OTs, OTAs and OT students will descend on Baltimore for the 94th AOTA Annual Conference and Expo. "Charm City" promises to be a gracious host for those rehab professionals.

After a day of intense pre-conference workshops on April 2, the event kicks into full swing.

The schedule is packed with short courses, long courses, research presentations, and poster presentations. From children and youth to mental health to work and industry, there is sure to be a category of event that fits your professional goals.

On April 3, at the opening keynote, "The Wounded Warrior and the Art of Independence," three wounded service members will share their personal occupational therapy success stories.  Newly elected AOTA president Virginia Stoffel will present the annual Presidential Address on April 4: "Attitude, Authenticity, and Action: Building Capacity for Occupational Therapy."

Each year, a highlight of the AOTA conference is the Eleanor Clarke Slagle lecture.  The award honors an occupational therapist who has contributed to the body of knowledge of the profession. This time, Maralynne D. Mitcham, PhD, OTR/L, FAOTA, of the Medical University of South Carolina, will speak on "Education as Engine."

The annual meeting is a time for occupational therapy professionals to honor their own. The awards ceremony on Saturday, April 5 will highlight the best and the brightest from both the AOTA and the American Occupational Therapy Foundation. Who will win the Award of Merit, the Writers' Awards, the Roster of Honor Award, and the AOTF Meritorious Service Award?

Yet it's not all lectures and classes. OT students can mingle at Students Unconferenced on Thursday night. Early birds can partake in a free Friday morning Pilates session or a Saturday morning 5K around the Inner Harbor. And put on your dancing shoes and raise a glass Friday night at the AOTA gala at the American Visionary Art Museum.

And of course, the exhibit hall is a major part of the conference. Approximately 350 exhibitors will be presenting their products and services, so be sure to carve out some time to walk through. ADVANCE will be in booth 218, so stop by to renew your magazine subscription, pick up the latest issue and purchase one-of-a-kind OT gear from the ADVANCE Healthcare Shop. You might even run into staffer Danielle Bullen.

Yes, ADVANCE for Occupational Therapy Practitioners will be on site in Charm City. Be sure to visit the ADVANCE Outlook blog during and after the conference and keep up with us on Facebook and Twitter to get the latest news from the Inner Harbor.

See you there!

Gutsy Openmindedness
by Danielle Bullen
LAS VEGAS, NV--One of the highlights every year at the Combined Sections Meeting is the Pauline Cerasoli lecture. Named in honor of Cerasoli, a highly respected physical therapist who suffered a brutal attack at the 1996 meeting, the lectureship is awarded to a PT who has made significant contributions to physical therapy education.

This year's awardee certainly fit that bill. Leslie Portnoy, PT, DPT, PhD, FAPTA, is dean of MGH Institute of Health Professions. Portnoy opened her talk, "Choosing a Disruptive Path Toward Tomorrow," by reflecting on some of the themes of past lectures. She noted, "Change is the overriding theme." Physical therapists in academia, especially, must face change on a constant basis, as both the profession and higher education at a whole are altering rapidly.

She admitted, "Change is not something most of us like, bit it is happening." She quoted the very first Cerasoli lecturer, Katherine Shepard, PT, PhD, FAPTA, who encouraged physical therapists to "generate ideas that sound strange."  Portnoy expanded on that challenge, calling for "gutsy openmindedness" when it comes to the future of physical therapy education. Don't ask how, she urged, but ask what if?

"We must move academic physical therapy forward and exercise leadership as guardians of our profession's future." That was the challenge Portnoy issued the crowd. She raised several what if scenarios to move the profession ahead.

Does clinical experience drive education or vice versa? Many students receive conflicting info from their CI and what they learned in the classroom. What if there was a more seamless connection of education, practice, and research?

Beyond the physical therapy classroom, she noted, "Higher education is in crisis and can't survive without significant changes." Online education is the most talked about of those changes. What if PT education more fully embraced this model, which places faculty in the role of mentors, encouraging students as they learn at their own place?

A shortage of qualified professors is a problem across the health disciplines. 1/3 of PT faculties are over age 55. "What are we doing to groom physical therapists to become faculty?" asked Portnoy.  "What incentives are there to move into academia?" What if there were more combined DPT/PhD programs to prepare young physical therapists for the demands of teaching?

"We need a diverse community to generate new ideas," Portnoy said. Currently, 1/2 of PT programs have no minority faculty members. "Only by diversifying our student bodies will we change our future faculties."What if physical therapy schools broadened the profile of their students and looked beyond the typical profile of an admitted PT student when filling out new classes?

Changing the future of physical therapy education is a tough road. PTs must be willing to take chances and learn from their mistakes, to embrace disruption. Yet, Portnoy said, "I have tremendous optimism for our future."

Land and Sea
by Danielle Bullen
The mechanics of running, swimming and cycling and the injuries sustained from each sport were the focuses of today's Combined Sections Meeting talk, "Tuning Up the Triathlete." Speakers were Janice Loudon, PT, PhD, ATC, CSCS, Shefali Christopher, PT, PhD, ATC, SCS, and Rob Butler, PT, DPT, PhD.

While each phase of a triathlon has its own considerations for physical therapists treating participants, some common themes emerged. Generally speaking, triathletes injure their lower extremities more often than their upper extremities, race-day injuries tend to be more traumatic than training injuries, and injuries occur most often in the running phase. One study placed the rates of injury at 50% running, 43% cycling, and 7% swimming.

Although swimming ranks on the low end, injuries can still occur. Unlike the other phases, there is a high occurrence of UE injuries in swimming. Shoulder impingements are the number one reason triathletes injured while swimming seek physical therapy treatment. PTs can modify the swimmer's stroke to correct the impingement. This can be done by encouraging less internal rotation at the point of the hand entry into the water; encouraging bilateral breathing; and shortening the follow-through on the stroke.

Two problems seen in swimmers are hypo- and hypermobility. With hypomobility, there is limited internal rotation and tight posterior structures in the upper extremities. Yet there is relative flexibility. As Loudon explained, "The body takes the path of least resistance." Posterior shoulder stretches are a recommended intervention. Hypermobility tends to occur among very high-level swimmers, as a high degree of range of motion is needed to compete at an elite level. There needs to be a balance between shoulder laxity and shoulder stability, however.

Scapular stability and mobility are two areas commonly addressed by PTs treating swimmers. Other treatment focuses include core strength, proprioception, and muscle fatigue

When treating cyclists, PTs must pay attention to both  the interface between the rider and bicycle, and the reaction forces between the rider and the bicycle. When cyclists are in an extreme crouch position, it can benefit aerodynamics, but it can also cause hip injuries.

"Part of our job is realizing fit  principles and applying them to patients to treat injuries," said Christopher. For example, optimal knee flexion when the pedal is at bottom dead center is 25-30 degrees. A slower cadence equals more time loading the joints, raising injury risk.

The angle of the bike seat affects comfort, efficiency and power. Cyclists have optimal cardiovascular response between 73-90 degrees. A low seat angle can cause the quads to cramp during the running phase of the triathlon.

There are other connections between the different legs of the race. Cycling for 30 minutes at 12-24 RPE cause an increase in anterior pelvic tilt cycle during the running phase.

While running, the hip goes into extension, the knee gives a little bit, and the ankle is in dorsiflexion.There is less dorsiflexion of the knee and ankle among triathletes versus pure runners. During mid-stride, bones are aligned so muscles don't work as hard. This causes microtraumas on the bones, which are not designed to carry that load.

One tricky matter of studying triathletes is measuring the effects of exertion, as all runners don't run at the same speed. Physical therapists are still working on the best answer to that problem.







Cancer Crusaders
by Danielle Bullen

LAS VEGAS, NV--"Physical therapy has positive effects for children with leukemia in many areas," says Kristin Brown, PT, MS, DDT, PCS, Hasbro Children's Hospital, Providence, Rhode Island. That was the main takeaway at this morning's Combined Sections Meeting talk, "An Evidence-Based Approach to Physical Therapy for Children with Leukemia."

Brown and Debra Seal, PT, DPT, DCS, NTMTC specifically focused on physical therapy for children diagnosed with acute lymphoblastic leukemia (ALL). It is the most common form of childhood cancer yet one of the most beatable. The five-year survival rate with medical treatment is over 90%.

 In ALL, leukemia cells crowd out normal blood cells, causing, among other things, anemia, brusing, increased ris of infection, and bone marrow failure. Weakness, fatigue and fevers can be some of the first signs of ALL.

 After several rounds of blood and platelet transfusions, children begin chemotherapy in three distinct phases. The firsr--remission induction--aims to kill of the primary cancer cells. The second--consolidation--occurs when the cancer is in remission. It is an intense six-to-nine month cycle of chemo to kill off any remaining cellls to prevent replase. Kids are frequently hospitalized during this cycle. The third--maintainance phase--is when they receive a lower chemo dose, sometimes orally, and can last for up to two years.

Every body system is affected by ALL and chemotherapy. "These kids have a lot of  pain," noted Brown. Besides pain, both during and after treatment, these patients show deficits in balance and cardiovascular pulmonary function; fatigue; decreased range of motion; and impaired motor performance. Some of those side effects can continue even into adulthood. And this is where physical therapy comes into play.

Brown explained at her hospital, physical therapy begins soon after diagnosis, before chemotherapy even starts. Yet most of the research cites the effects of PT during the maintainance phase of threatment only.

Physical theraphy interventons showed improved across several functional areas. Ankle ROM increased with skilled PT. Home exercise programs showed an increased distance in the nine-minutre walk test. A three times per week strength training program in the maintainacne phase increased the kids' strength. And a six-week home-based exercise program was shown to lower fatigue.

One of the challenges faced by PTs with this population is patient fatigue. "Fatigue impacts our therapy so much because they don't want to participage," Brown said. Another barrier to treatment is "roid rage," the negative effects the heavy doses of steroid medication have on the children's behavior. At times, Brown will skip a few PT sessions when she realizes the child will be non-compliant because of his or her attitude.

Overall, the resarch has found there are no adverse effects of physical therapy for children with leukemia.


What is Physical Therapy’s Value Proposition?
by Danielle Bullen
LAS VEGAS, NV--Each year at CSM, the Linda Crane Lecture acknowledges an individual who has made outstanding contributions to the field of physical therapy. This year, that honor went to Dianne Jewell, PT, DPT, PhD, a 25-year veteran of the profession, founder of The Rehab Intel Network and program director of the Health Policy Certificate program at Arcadia University. Jewell's lecture was called "More Than White Hats: Making the Case for Physical Therapy's Value Proposition."

Jewell began her lecture by admitting that she never knew Crane personally; she did, however, "know her as a trailblazer," She defined trailblazer as someone who forges ahead in the face of great uncertainty. Physical therapists, Jewell explained, must serve as trailblazers in the healthcare industry.

To do that, PTs must address three assumptions that both the public and the PTs themselves hold about their roles.

 1. Our "white hat" reputaton is integral to who we are but it is incomplete

Physical therapists have an easy message to sell to both the public and the policymakers. They are about recovery and restoration. They are the "white hats" of healthcare, riding in to save the day.  "We can leverage our knowledge and skills to prevail against the evils of chronic disease and disability," said Jewell, illustrating the "white hat" mythology.

 Yet different stakeholders-- the insurance companies, employers, legislators, patients themselves--are starting to demand more evidence for physical therapy interventions. As healthcare costs rise, all invoiced parties need to work to reduce costs and improve outcomes of care. Just being that hero coming to save the day is no longer enough.

2. Demonstration of our value is an exercise in data analysis, not persuasion.

 "Let's be clear about what we can and cannot do," Jewell encouraged her fellow PTs. "The need for reliable data cannot be understated."

Value is an abstract concept though. What is valuable to a patient is different from their therapist is different from the service payor. Everyone needs to consider the fundamental costs of their decision making. For some physical therapists, that is a shift in mindset.

Measuring quality is not as easy as it sounds. Clinicians need to analyze the existing data and ask themselves, how will this info be used?

 3. Our ability to demonstrate our value will cause stakeholders to "see the light"

This, as readers may be acutely aware, is untrue. Simply showing value does not always convert various stakeholders to the power of physical therapy. Value is interpreted by different people in the conversation, who each filter it through their own expectation. "If people come at value from different perspectives, we become stuck," said Jewell.

Physical therapists need to focus on their value proposition--a statement that summarizes why a consumer should buy a particular product or service and why that product or service serves their needs and adds more value than a competitor. PTs must make purposeful efforts to reach out to audiences with their unique value proposition.

"It's going to be more than just making patients better," explained Jewell. "We need to be willing to step out there."



Issues at the Statehouse
by Jon Bassett
LAS VEGAS, NV -- A small but committed group of PTs gathered for “Physical Therapy Issues in the State Legislatures: Challenges and Opportunities to Making Vision 2020 a Reality,” a session at the APTA’s Combined Sections Meeting held Tuesday afternoon Feb. 4 in the Venetian Sands Expo Center in Las Vegas.
APTA Director of State Affairs Justin Elliott, well-known as a state legislative affairs guru and known for his “Jeopardy”-style presentations at APTA, brought attendees up to speed on legislative hot topics such as dry needling, direct access, title protection and the encroachment of other disciplines on PT treatments and scope.
Here is a brief rundown.
Medicaid expansion. Elliott’s co-presenter Angela Chasteen, APTA’s senior specialist of state affairs, relayed that the Supreme Court’s decision on the Affordable Care Act was a game-changer for state Medicaid programs, essentially leaving it up to states to implement their own programs. As a result, 26 states have moved forward on expanding their Medicaid services, said Chasteen. And a state’s government is not always a good predictor of how Medicaid will be implemented in that state.
Case in point is Arizona, where Republican Governor Jan Brewer has availed itself of federal dollars to expand the Medicaid program for its residents. This is good news for PTs working with patients covered by the program, Chasteen said.
“If it can happen in Arizona, there’s a distinct possibility it can happen in most any state,” Chasteen said. Florida and Pennsylvania are other big-population states that may be expanding their programs in 2014 or 2015.
Dry needling. Calling it “one of the hottest issues in terms of scope of practice issues in the states,” Elliott outlined state-level efforts to bring dry needling under the scope of PT practice. Acupuncturists continue to battle the APTA on this issue -- cease and desist letters were received in Arizona, Indiana, and North Carolina, and lawsuits have been threatened in Washington and Wisconsin.
APTA’s stance is that dry needling is a “shared intervention” and not owned by a particular discipline, and APTA will continue lobbying efforts to educate state legislatures in that regard. “2013 was a very busy year on the issue of dry needling,” said Elliott. “2014 is going to be just as busy.”
Athletic trainers. Currently regulated in 48 states, athletic trainers have in the last few years looked at their practice acts and have begun state-level legislative efforts to expand their practice scope language beyond sports medicine and athletic training services. An excerpt of NATA’s profile of athletic trainers makes reference to the fact that in other countries, “athletic therapist” and “physiotherapist” are similar titles.
It becomes a matter of reimbursement. “They’re looking for third-party payment,” said Chasteen, adding that proposed bills in Vermont and Indiana would mandate payments for interventions that fall under the state’s practice act for athletic trainers.
Direct access. All 50 states now allow PT evaluation without physician referral -- a “big milestone for the profession,” according to Elliott. Now, the association turns its attention to an all-50-state policy for PT treatments -- Oklahoma and Michigan are the two remaining holdouts, but 2014 lobbying efforts are underway.
Eighteen states currently have unrestricted PT treatment, meaning no physician referral is required following a given timeline or number of treatments – what Elliott called the “gold standard” practice act. Another 18 plus the District of Columbia have direct access treatment with provisions, and 12 have “limited” direct access.
So though the 50-state milestone was reached, direct access is “still a priority for the association,” said Elliott, adding that future efforts in this area will be directed toward federal (Medicare) direct access and tying quality of outcomes to physical therapy direct access.
“We’re trying to pivot the conversation,” he said.
Other legislative fronts include the South Carolina lawsuit regarding physician self-referral, rising PT co-pays, and encroachment of other disciplines including massage therapists, chiropractors and occupational therapists.

"Real-World" Rehab
by Danielle Bullen

LAS VEGAS, NV--"It's normal physical therapy in a unique environment." That's how Christopher Rabago, PT, PhD, Center for the Intrepid, Brooke Army Medical Center, defined virtual reality rehab. This morning at CSM 2014, Rabago was a co-presenter at "Virtual Reality-Based Rehabilitation For Injured Service Members," speaking before a packed ballroom at the Venetian in Las Vegas. He and his physical therapy counterparts at Walter Reed Army Medical Center and Naval Medical Center San Diego explained how immersing wounded warriors in simulated environments aids their recovery process.

Therapists measure how patients maneuver through their virtual environment and how they react to stimuli in that environment. They can assess kinematics and assess data for future use. One goal of VR-based rehab is to engage all the senses, stimulating as close to real-world scenarios as possible. The PTs at these military medical facilities have access to high-end simulators. The Computer Assisted Rehab Environment, aka CAREN, projects scenarios onto a movie screen 180 to 300 degrees in radius.

The patient is on a motion platform with built-in treadmill in front of the screen. The platform itself in the CAREN moves or the PT can set the platform steady and have the surrounding environment appear to move. Both of these help the patient improve their balance.

Depending on the goal of rehab, patients are placed in different settings. For example, a soldier rehabbing to return to duty could be on a simulated Afghan street, practicing dismantling IEDs and differentiating between insurgents and civilians when shooting. A patient rehabbing to return to civilian life could use the CAREN to engage in sports, like skiing. "We use all of our resources to make their transitions as smooth as possible," said Allison Pruziner, DPT, ATC, Walter Reed Army Medical Center.

Fire arms simulators allow the injured service members to manipulate their weapons. Those situations also test their cognitive and emotional readiness in terms of potential return to action. These fire arms simulators are great for training patients with new lower limb prosthetics to re-establish their proprioception. The scene can be adjusted to react to their movements.

One of the biggest advantages of virtual reality-based rehab is that it doesn't feel like rehab, which increases compliance rates. A study of mild TBI patients at Naval Medical Center San Diego showed that wounded warriors who had VR-based vestibular rehab self-reported a better sense of balance versus those who had regular physical therapy.

Of course, not everyone has access to these multi-million dollar machines. Out-of-the box products, like the Wii or Microsoft Kinnect can be programmed to meet the needs of such patients. The PTs at today's talk explained how they prescribe Wii or Kinnect home exercises for the patients to continue after discharge.

Whether high-end or low end, virtual reality has proven to be useful adjunct to traditional physical therapy in helping these service members return to as close to normal lives as possible.





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