physical combat - apta.org · 4 ptinmotionmag.org / april 2018 ©2018 by the american physical...

FOR MEMBERS OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION APRIL 2018

Putting the “Fun” Into Functional Recovery

Practicing Ethically in Today’s Health Care Environment

COMBATATHLETES

PHYSICAL THERAPISTS TREAT

http://link.argifocus.com/5XU-1

2 PTinMOTIONmag.org / April 2018

26 PRACTICING ETHICALLY IN TODAY’S HEALTH CARE ENVIRONMENTEthical challenges always have been present in the practice of physical therapy. But the evolution of health care has put increasing pressure on PTs, PTAs, and students. It’s not always simple to “do the right thing”— nor is the right path always clear.

34 PUTTING THE “FUN” INTO FUNCTIONAL RECOVERYDo some of your patients resist exercise? Try making it joyful.

Vol 10 No 3 APRIL 2018

DEPARTMENTS

4 QUOTED

6 VIEWPOINTS

42 PROFESSIONAL PULSE

+ Data Points

+ Health Care Headlines

+ Research Roundup

+ Update on Opioids

+ Association Resources

56 MARKETPLACE+ Career Opportunities &

Continuing Education

+ Products

57 ADVERTISER INDEX

64 BY THE NUMBERS

WORKING WITH COMBAT ATHLETESSports that involve fighting are among the most challenging and stressful—not to mention dangerous—competitions. PTs who work with these athletes need to be on top of their own games.

8 COMPLIANCE MATTERS

MIPS and APMs: Where we are now.

12 ETHICS IN PRACTICE

A student’s uneven performance at a hospital reflects his practice preferences.

62 DEFINING MOMENT

Extending a patient's coverage also extended her horizons.

16

COLUMNS

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©2018 by the American Physical Therapy Association (APTA). PT in Motion (ISSN 1949-3711) is published monthly 11 times a year, with a combined December/January issue, by APTA, 1111 N Fairfax St, Alexandria, VA. SUBSCRIPTIONS: Annual subscription, included in dues, is $10. Single copies $20 US/$25 outside the US. Individual nonmember subscription $117 US/$137 outside the US ($197 airmail); institutional subscription $147 US/$167 outside the US ($227 airmail). No replacements after 3 months. Periodicals postage paid at Alexandria, VA, and additional mailing offices. POSTMASTER: Please send changes of address to PT in Motion, APTA Member Services, 1111 N Fairfax St, Alexandria, VA 22314-1488; 703/684-2782. Available online in HTML and a pdf format capable of being enlarged for the visually impaired. To request reprint permission or for general inquires contact: [email protected].

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DISCLAIMER: The ideas and opinions expressed in PT in Motion are those of the authors, and do not necessarily reflect any position of the editors, editorial advisors, or the American Physical Therapy Association (APTA). APTA prohibits preferential or adverse discrimination on the basis of race, creed, color, gender, age, national or ethnic

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APTA Board of DirectorsOFFICERS

PresidentSharon L. Dunn, PT, PhD

Vice PresidentLisa K. Saladin, PT, PhD, FAPTA

SecretaryRoger A. Herr, PT, MPA

TreasurerJeanine M. Gunn, PT, DPT

Speaker of the HouseSusan R. Griffin, PT, DPT, MS

Vice Speaker of the HouseStuart Platt, PT, MSPT

DIRECTORSSusan A. Appling, PT, DPT, PhD

Cynthia Armstrong, PT, DPTAnthony DiFilippo, PT, PDT, MEd

Matthew R. Hyland, PT, PhD, MPASheila K. Nicholson, PT, DPT, JD, MBA, MA

Carolyn Oddo, PT, MSRobert H. Rowe, PT, DPT, DMT, MHS

Kip Schick, PT, DPT, MBASue Whitney, PT, DPT, PhD, ATC, FAPTA

Editorial Advisory GroupCharles D. Ciccone, PT, PhD, FAPTA

Gordon Eiland, PT, MA, ATCChris Hughes, PT, PhD

Benjamin Kivlan, PT, MPTPeter Kovacek, PT, DPT, MSA

Robert Latz, PT, DPTJeffrey E. Leatherman, PT

Allison M. Lieberman, PT, MSPTKathleen Lieu, PT, DPT

Alan Chong W. Lee, PT, DPT, PhDLuke Markert, PTA

Daniel McGovern, PT, DPT, ATCNancy V. Paddison, PTA, BA

Tannus Quatre, PT, MBAKeiba Lynn Shaw, PT, MPT, EdD

Nancy Shipe, PT, DPT, MSJerry A. Smith, PT, MBA, ATC/L

Mike Studer, PT, MHSSumesh Thomas, PT, DPT

Mary Ann Wharton, PT, MS

— QUOTED —

You have to have moral courage to stand up to the team, the management, the coach, and others, because ultimately you are responsible, first and foremost, for the patient’s welfare.

Bruce Greenfield, PT, PhD, MA, in “Practicing Ethically in Today’s Health Care Environment (page 26)



PT in Motion welcomes your opinions. We will consider letters, email, and posts that relate to specific articles in the magazine and those of general interest to the physical therapy profession.

Viewpoints

Online Comments

Education CostsGreat article. [“Financial Literacy and the New DPT Grad”1]

When analyzing the cost of higher education and expected income at graduation, the numbers simply do not add up. In conversation with new grad-uates, I frequently hear that early-career decisions are made solely on the need to pay off debt. One graduating PT and I determined that with his entry-level salary in outpatient physical therapy, he would have to use a quarter of his take-home pay for 15 years to pay off his debt (calculating his interest rate and cost-of-living pay increases).

Good financial education is imperative. But if students are educated, I fear they will choose a different profession. With that, I ask: Is physical therapist educa-tion outpricing itself? And, is the cost reasonable?

I am a huge fan of the proposed cur-riculum changes. How do universities continue to justify charging students for unpaid internships? If we are trying to get the price of education to a reason-able level, we need to take a close look at the fees associated with education. What would schools do if the clinical instructors who educate their stu-dents took a stand and stopped taking students until the schools reevaluated their fee structure for clinicals? Is it fair to charge students thousands of dollars for each rotation when they are not even on campus? Would universities simply price-shift?

I applaud alternative curricula. Mean-while, I will continue to pay on my own student debt into my 50s. Thank good-ness I got a low interest rate.Josh Zilm

I appreciate the information and com-mentary contained in this article. I have to agree with the ideas presented that

argue for increased financial literacy and decreased overall cost of tuition to become a physical therapist. It can be disheartening, though, to have followed much of the advice given in this article yet still face a mountain of debt upon graduating.

I was able to complete my undergradu-ate degree free of debt and even took a year off before PT school in order to increase my savings. My wife and I also had a daughter during this time, and thought it would be wise to try to live off of our savings for as long as possi-ble. Taking out loans solely for tuition purposes until this final semester of my education still will leave our final student loan amount just short of $120,000. As I noted, this can be quite disheartening. Having lived frugally, budgeted, and saved vigorously, I can only imagine how deeply indebted I would be had I not made the forward-thinking financial choices that I did.

It seems that as a profession we have jumped into the “doctoring” end of the pool without providing new graduates with the means (be they increased financial literacy education, decreased tuition, or increased compensation) to reasonably stay afloat.Jordan Tait Editor’s Note: Watch for an upcoming article on educational institutions’ vari-ous approaches to clinical education.

Defining Moment: Getting a Rise Out of HimThis article provides a great deal of insight and fundamentals to physical therapist practice [“Defining Moment: Getting a Rise Out of Him”2] First, the essential requirement is always to “try.” This is a notion that has been reiterated to me by multiple mentors in the acute hospital setting. In addition, the value of empathy and communication cannot be overstated. PTs have a unique role in

medical care. Physical therapy requires direct patient contact over a given period of time. In that sense, we have to establish rapport with patients in order to provide treatment, as do other health care professionals.

One factor that can be difficult to man-age is the will of the patient. I cannot imagine what many patients are going through, especially during this story. The patient is so young, and to have such a tragic turn of events must be a major challenge. I think the dialogue here is to consider what we can do as a profes-sional team to instill the will of patients to participate in physical therapy. In addition, the reciprocation we receive, whether from patients, family members, or colleagues, is open and rewarding, regardless of the form it takes.Andrew Hodgdon

Career Advice for Aging PTsExcellent article. [“Career Transitioning Advice for Aging PTs”3] I have been a PT since 1975. I “retired” from full-time practice in a hospital system but con-tinue part-time in outpatient rehabilita-tion and in private consulting. I still feel I can make a difference. I agree with the importance of maintaining “PT shape.” I stepped up my fitness program last year and feel good!Judith Horn

I am 71 and still working part-time with patients with developmental disabilities and intellectual disabilities in 5 group homes. Exercise helps remind me of how young I think I am.Thomas Hudson

Still practicing, working full-time home care in NYC at age 66. Climb 5 flights of stairs for some visits, carry a heavy bag, and walk several blocks from car to patient’s home several times a day. Besides being a clinician, I have had


7PTinMOTIONmag.org / April 2018

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In all correspondence, please include your full name, city, and state.Letters and posts may be edited for clarity, style, and space. Published letters and com-ments do not necessarily reflect the positions or opinions of PT in Motion or the American Physical Therapy Association.

the honor of publishing 2 studies in our Journal of Geriatric Physical Therapy and speaking at CSM in 2013. Not too bad for a 60+-year-old! It’s never too late to be what you could have been!Louis Depasquale

I am a “transitioning” pediatric thera-pist who spends a great deal of my day getting up and down from the floor with babies and kids in my arms, squatting, jumping, etc. I have rheumatoid arthritis, as well, and am changing how I practice to preserve my joints and am keeping fit within my restrictions. I try to remember that I can use my brains—clinical exper-tise and decision making skills—over my “brawn” by mentoring the next gener-ation of pediatric therapists. Love my profession!Karen Bensley

Chronic Fatigue SyndromeA great article. [“The Real Story About Chronic Fatigue Syndrome.”4] But it does lack information on how powerful patients are finding heart rate pacing and how effective standard heart rate measures are for monitoring the health of this patient group (ie, resting heart rate, staying within 110% of resting heart rate most of the day, and staying under the anaerobic threshold). While it is great to listen to patients, it is even more powerful to give them tools that help them to listen to their bodies.

The comments about food miss the fact that food, chemical, and environmental intolerances are prevalent. “Healthful eating” can help, as many food preser-vatives and flavorings exacerbate the symptoms—but so do many “healthy

foods.” The article could have empha-sized rest more, as it is rest that reduces the symptom load. The trick is inordi-nate amounts of rest combined with as much physical activity as is safe. It was a great starter article.Mary

REFERENCES1. Loria K. Financial Literacy and the New DPT

Grad. PT in Motion. 2017;9(1):34-40.2. Keil A. Defining Moment: Getting a Rise out of

Him.PT in Motion. 2015;7(3):62-63.3. Hayhurst C. Career Transitioning Advice for

Aging PTs. PT in Motion. 2018;10(2):26-30.4. Ries E. The Real Story About Chronic Fatigue

Syndrome. PT in Motion. 2017;9(8):16-25.



By Heather Smith, PT, MPH

Compliance Matters

MIPS and APMs: Where We Are NowIt’s time to prepare.

Heather Smith, PT, MPH, is the director of quality at APTA.

On January 1, 2017, the Centers of Medicare and Medicaid Services (CMS) launched the Quality Payment Program (QPP)—integrating several Medicare legacy quality reporting programs, including the Physician Quality Reporting System (PQRS), and affecting providers who bill Medicare Part B.Under QPP, eligible clinicians can opt to participate in 1 of 2 tracks: the Merit-based Incen-tive Payment System (MIPS) or advanced Alternative Payment Models (APMs). As discussed in this space last spring,1,2 physical therapists (PTs) are not yet included in mandated reporting under MIPS, but they likely will be added in 2019. It is imper-ative, therefore, that PTs immediately begin preparing for the 2019 reporting year.

Coming UpEarly this summer, CMS is expected to publish the

proposed QPP rule for 2019. These changes will not be finalized until late fall, however, when the final rule for 2019 is due. Given the late-year timing and the likelihood that CMS will propose the addition of PTs, therapists must start getting ready now.

PTs must invest in technol-ogy to support reporting and compliance. Those who are not yet using electronic health records (EHRs) should start preparing to make that move. MIPS is tied to considerably more significant incentives and

penalties—plus or minus 7% in 2021 based on 2019 per-formance—than was PQRS, so it is critically import-ant for PTs to continually monitor and document their performance throughout the 2019 reporting year.

What Do We Currently Know?There are several things we already know about QPP. Unfortunately, there also are a number of outstand-ing questions—about which APTA will continue seeking clarity. Following are the key issues.

MIPS participation requirements. Even if PTs are added to MIPS in 2019, we don’t know if this will include PTs in facility-based settings—such as hospi-tal outpatient and skilled nursing facilities—that bill Medicare Part B. We do know that if PTs are added, MIPS will include some, but far from all, PTs in private



practice. That’s because to par-ticipate in MIPS, private practi-tioners must meet a low-volume threshold.

For 2018, that threshold is Medi-care billing charges totaling at least $90,000 and provision of care to 200 or more Part B- enrolled Medicare beneficiaries. Providers who fail to meet that threshold cannot participate in MIPS. CMS has indicated that it may revisit the low-volume threshold definition for 2019.

MIPS participation as an individual or group. Because of the low-volume threshold, most individual PTs will not be eligible to participate in MIPS in 2019 even if PTs are added as an eligi-ble provider category. However, the low-volume threshold also applies at the group level, using the tax identification number of the practice. If the practice col-lectively exceeds the low-volume threshold, it must participate as a group, even if PTs within the practice are excluded as individuals.

If a PT is determined to be eligible either as an individual or prac-tice and does not partic-ipate in MIPS, that PT would be subject to the full penalty rate for that performance year. (Provid-ers can check their MIPS eligibil-ity status on the Quality Payment Program website at https://qpp.cms.gov/.)

MIPS quality-reporting changes. The quality-reporting category in MIPS and the former PQRS are similar, but 1 differ-ence is the percentage of eligible patients on whom providers must report for each quality mea-sure selected. Under MIPS, the reporting rate for 2018 is 60%—up from a 50% reporting rate under PQRS. Additionally, if providers are reporting via claims, they are expected to report on 60% of all Medicare fee-for-service patients. Those reporting via EHRs or reg-istries will need to report on 60% of all patients, regardless of payer.

Another change: Under PQRS, meeting or exceeding the reporting rate was the only




Compliance Matters

requirement for avoiding the penalty. Under MIPS, not only must providers meet or exceed the 60% reporting rate for each quality measure, but they also will earn a score for that measure that will impact the likelihood of receiving a penalty.

MIPS technology requirements. Although providers could use claims data submission for PQRS, they must use electronic data reporting for 2 of the 4 categories in the MIPS program. Additionally, those who participate in MIPS as a group must report using electronic data submission mechanisms.

Given the complexity of the MIPS program and the potential for high penalties, APTA recommends that PTs use technology vendors for data submission, including EHRs and regis-tries. Using electronic data-reporting mechanisms such as EHRs and reg-istries also will allow PTs to monitor data collection throughout the year,

better ensuring that data requirements are met in each of the MIPS categories.

Real-time feedback reports will alert PTs to issues with data collection or quality measure performance, facili-tating needed performance changes. Another benefit: Using EHRs and registries can decrease the reporting burden. EHRs often collect directly from documentation the data required for quality measures. The data then is used to calculate and report the mea-sure, allowing the PT to focus on per-formance rather than data collection.

PTs looking to incorporate new tech-nology should weigh several factors before contracting with a vendor. An EHR must fit their practice. Although there are no hard-and-fast rules on how to pick such a product, APTA has a resource page at www.apta.org/ehr to help PTs think through important considerations.

Also, although PTs have not had to use certified EHR technology, they will be

required to do so for MIPS. Ask the vendor, therefore, if it is certified, or planning to become so.

In addition to EHRs, registries are a valuable electronic reporting tool. The Physical Therapy Outcomes Registry (Registry) has a fully func-tional MIPS dashboard that provides real-time feedback and calculates a MIPS score throughout the year for the provider or group. The Registry interfaces with the facility’s EHR, seamlessly incorporating data for quality-measure reports.

Also, the Registry is developing new quality measures that PTs will be able to use in the MIPS program. For more information, visit the Registry website at www.ptoutcomes.com.

Opting for the APM track in QPP. In the shift to value-based payment, the ultimate goal is to get all providers into APMs. PTs currently can par-ticipate in APMs such as the com-prehensive joint replacement model.

Early Summer 2018Proposed 2019 QPP rule to be published

Late Fall 2018Final 2019 CPP rule to be published

Early 2020Deadline for 2019 MIPS data submission

Early 2019Finalize vendor selection, begin MIPS data collection

2021Incentive/penalties (+/– 7%) based on 2019 MIPS data



Unfortunately, however, to meet the requirements under the advanced APM track for QPP, providers must receive at least 25% of their payment, or see at least 20% of their patients, through an advanced APM. Given the diversity of patients typically seen in the private practice setting, achiev-ing these percentages will be chal-lenging. Also, while APMs continue to evolve, few models currently are available to providers.

APTA continues to explore opportuni-ties to work with members on par-ticipation in, and/or development of, APMs and advanced APMs.

What Should I Do Next?PTs in private practice should increase their knowledge about QPP, and pro-viders in facility-based settings who bill Medicare Part B should continue to monitor updates to the program. For specific information on these topics, visit these APTA webpages:

k QPP: www.apta.org/QPP

k MIPS: www.apta.org/MIPS

k Advanced APMs: www.apta.org/Payment/Medicare/AlternativeModels/

k Value-based care: www.apta. org/VBC/

REFERENCES1. Smith HL. Quality payment program part 1:

all about MIPs. PT in Motion. 2017;9(3):8-10. http://www.apta.org/PTinMotion/2017/4/ComplianceMatters/. Accessed January 16, 2018.

2. Jennings S. Quality payment program part 2: all about advanced APMs. PT in Motion. 2017; 9(4):8-11. http://www.apta.org/PTinMotion/2017/5/ComplianceMatters/. Accessed January 16, 2018.




Ethics in Practice

Jekyll and HydeA student’s uneven performance reflects his practice preferences.

When it comes to our jobs, we all have our own areas of particular interest and expertise. What is our responsibility to ourselves and others, however, when we are assigned responsibilities that lie outside our preferences and comfort zone? Consider the following scenario.

Ins and Outs After 6 years as a physical therapist (PT), Tim still tends to think of himself as a “new professional.” True, he has gained considerable experience and insight while rotating through his assign-ments at Metro Memorial Hospital, but there’s always so much more to learn! Indeed, 1 thing he likes about his job is the oppor-tunity to work in different settings and situations, with a variety of patient populations.

But not all of his early- career colleagues seem to share that enthusiasm, Tim

has noted. Shelly is a case in point. She graduated with her doctor of physical therapy (DPT) degree 2 years ago and is working in an outpatient sports rota-tion at the hospital. To date, Tim has noticed, Shelly has ended up in some form of outpatient care every time new assignments are posted. She has not yet worked on the inpatient side. What’s more, she has repeatedly announced how happy she is with this state of affairs.

Tim and others have over-heard Shelly saying things like, “I didn’t rack up all that student debt to use my skills

as a PT playing nursemaid to broken-down seniors!” and “I’m all about helping younger, healthier people return to active lifestyles.” Once, on a day when inclem-ent weather forced Shelly to help out on the inpatient side, she reportedly asked an occupational therapist, “How do you motivate yourself to work with people who aren’t ever going to be able to do much of anything for themselves?”

After a supervisor admon-ishes Shelly about the inappropriateness of such comments, she stops making them. Still, Tim knows from his brief chats with her that Shelly sees her future as lying in outpatient care, and that she considers any time spent on the inpatient side to be basically a waste of her time and talents.

Tim is forced to work more closely with Shelly, how-ever, when they are jointly assigned a student from a

By Nancy R. Kirsch, PT, DPT, PhD, FAPTA

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

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

physical therapy at Rutgers University. She also practices in

northern New Jersey.



downstate university. Tim will serve as Lance’s clinical instructor (CI) in the mornings in acute care, while Shelly will be the student’s CI in the after-noons on the outpatient side. Lance seems like a very bright young man, and he arrives at Metro Memorial referencing the glowing reports he’s received from 2 previous placements—1 in a general outpatient setting and the other at a sports physical therapy clinic. Tim knows that Lance is very inter-ested in musculoskeletal conditions in athletes and that he has begun apply-ing for residencies in that area. Still, Tim looks forward to showing Lance the ropes in a setting with which the student is unfamiliar.

By the time Tim meets with Shelly over lunch to discuss their respective 2-week

reports on Lance’s progress, however, Tim is feeling quite disheartened by the student’s performance. Lance is mostly disengaged when he’s with Tim. He’s reluctant to initiate anything without being pushed. He seems overwhelmed by the exigencies of acute care when he isn’t acting bored by its routines. Tim relates these observations to Shelly, who responds, “That’s definitely not the Lance I know. To me, he’s a rock star! I just wind him up and watch him go! He obviously loves the outpatient setting. I can see him having a great career as a sports PT.”

Given the wide gap in their assess-ments of Lance’s progress, Tim sug-gests to Shelly that he take Lance aside for a private chat before the 2 CIs schedule a conference call with the

director of clinical education (DCE) at Lance’s school. That chat takes place the following morning. Tim is stunned by Lance’s attitude and frankness.

“Of course my performance is better in the afternoons,” Lance says. “I’m much more comfortable in outpatient settings, helping people who can really benefit from my skills. The stuff that I’m doing with those patients, and that Shelly is teaching me, is totally in my wheelhouse. I’m learning things that I’ll actually be using in my career, and that’s very exciting to me.

“Look,” Lance adds. “I think it’s cool that you’re so dedicated to doing all you that can for these acute care patients. I appreciate your guidance. But it’s just not for me. Dr Miller [Shelly] gets that. We’ve talked about it. I frankly have a hard time seeing why any PT thinks that seeing an individual in the inten-sive care unit is beneficial to anybody. Also, forcing me to spend time in a set-ting in which I’ll never practice as a PT strikes me as useless and antiquated. Come on—this the 21st century!”

Yes, it is the 21st century, Tim rumi-nates when Lance exits. It’s a time when, to Tim’s mind, too many individ-uals within the profession—students and PTs alike—underappreciate the value of PTs having a broad base of knowledge and skills. It’s a time when not enough students and clinicians seem to understand and appreciate the



Two ColumnEthics in Practice

Considerations and Ethical Decision-Making

When a student or clinician appears to lack the basics of professional behavior—making that person vulnerable to lapses in ethical conduct—we cannot help but reflect on the content and effectiveness of his or her professional training. PTs must adhere to extremely high standards of behavior due to their fiduciary and ethical responsibilities to patients and clients. While students and clinicians may find that responsibility onerous at times, they should remember that they sought out a career in physical therapy—not the other way around. It is their responsibility, therefore, to adhere to profession’s accepted norms of professional behavior.

Realm. The realm is individual—between Tim, Lance, and Shelly. It ultimately will move into the institutional realm, as Lance’s school must make a decision about him.

Individual process. Shelly lacks moral sensitivity—she neither exhibits key professional values nor counsels Lance to do so. Tim, on the other hand, will show moral courage should he opt to tell Dora—as he seems likely to do—that he believes Lance is unfit to become a PT.

Ethical situation. Shelly has succumbed to moral temptation—choosing wrong actions over right ones in order to benefit herself. She avoids inpatient settings simply because she’d rather treat outpatients. Tim, for his part, will face an ethical distress should Dora decline to take action on Lance’s unprofessional behaviors.

Ethical principles. Item 2 of the preamble to the Code of Ethics for the Physical Therapist states that the Code’s purpose, in part, is to “Provide standards of behavior and performance that form the basis of professional accountability to the public.” The preamble further states that physical therapist practice is “guided by a set of seven core values: accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility.”

It would be difficult to argue that any of those provisions or core values are left untouched by this scenario.

Also applicable to this situation is Principle 1 of the Code. It states, “Physical therapists shall respect the inherent dignity and rights of all individuals.”

profound impact that PTs can have, and are having, across the spectrum of care and throughout the lifespan. Tim finds both Lance’s and Sherry’s attitudes and behaviors to be parochial, unprofes-sional, and unethical.

His troubled thoughts are interrupted by a phone call from Dora, the DCE at Lance’s school.

“My colleague and I were planning to set up a conference with you very soon to discuss Lance’s situation,” Tim says.

“I’ll bet you were!” Dora responds. “I’ve never seen such a Jekyll-Hyde report from 2 CIs about the same student in my 8 years in this position!” she exclaims. “But on the other hand,” she adds, “I suppose there have been some warning signs about Lance along the way.”

Warning signs? So, this perhaps isn’t the first time Lance’s lapses in profes-sionalism have been brought to Dora’s attention? Is that what Tim is hear-ing? Exactly how much has changed, he wonders, in the 6 years since he graduated from school? Back then, if a student was found to have clinical deficiencies, he or she wasn’t sent back into a clinical setting until those

deficiencies had been remediated. And what if a student, “way” back in 2012, had been deemed guilty of egregiously unprofessional behavior?

Tim well recalls that a classmate of his was ejected from the DPT program for making statements less shocking than those that Lance has uttered. And that, Tim believes, was exactly how things should be. Weed out the bad apples. Maintain the profession’s integrity by ensuring that all PTs stand ready to serve all patient popu-lations, all of the time.

Tim concedes that Lance’s clinical abil-ities may be at entry level, as required for graduation, in some settings. But what about the young man’s lack of pro-fessionalism? Is that a “fixable” prob-lem? How, exactly, does Dora propose to address that?



It seems to Tim that Lance is an unsuit-able candidate for graduation—just as it strikes him that Shelly, with her distaste for serving patients and clients outside of her preferred populations, shouldn’t work in settings in which her distaste for those she’s charged with serving is plainly obvious.

For Reflection What are the odds that a DPT student whose unprofessional behaviors are tolerated by his DPT program will go on to become a highly professional and ethical PT?

On the other hand, is that “old-school” thinking? If a student shows all the necessary clinical abilities to become an effective PT, and if he or she seems likely to respond in an optimal manner to the needs of patients and clients within the area in which he or she intends to practice as a PT, is that enough to welcome that individual into the profession?

Is Tim, in other words, a noble protector of the profession’s values? Or is he per-haps a bit of a dinosaur in his thinking?

For FollowupI encourage you to share your thoughts about the issues raised in this scenario by emailing me at [email protected].

If you are reading the print version of this column, go online to www.apta.org/PTinMotion/2018/4/EthicsinPractice/ for a selection of reader responses to the scenario, as well as my views on how the situation might be handled. If you are reading this column online, simply scroll down to the heading “Author Afternote.”

Be aware, however, that it generally takes a few weeks after initial publica-tion for feedback to achieve sufficient volume to generate this online-only feature.

resourcesIn this issue of PT in Motion (www.apta.org/PTinMotion):

k Article, “Practicing Ethically in Today's Health Care Environment” (page 26)

At www.apta.org/EthicsProfessionalism/:

k Core ethics documents (including the Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant)

k Ethical decision-making tools (past Ethics in Practice columns, cate-gorized by ethical principle or standard; the Realm-Individual Pro-cess-Situation [RIPS] Model of Ethical Decision-Making; and opinions of APTA’s Ethics and Judicial Committee)

At www.apta.org/PTinMotion/2006/2/EthicsinAction/:

k “Ethical Decision Making: Terminology and Context”




Sports that involve fighting are among the most challenging and stressful—not to mention dangerous—competitions. PTs who work with these athletes need to be on top of their own games.Combat athletes compete in many different sports. While some—such as wrestling, boxing, and karate—have been practiced for hundreds or even thousands of years, others, such as mixed martial arts (MMA) and Brazilian jiu jitsu (BJJ), are new to the scene. (The term “combat sports” describes a competition whose essence consists of direct combat between 2 competing athletes.1 See “Combat Sports and Terminology in Brief” on page 19 for descriptions of different combat sports and definitions of terms.)

Similar to athletes in other pro sports—as well as to tac-tical athletes, including military personnel, police, and

firefighters2—combat sports athletes’ continued employment relies on their physical performance and, ideally, avoiding injury. However, the physical demands of combat sports mean that injuries occur more frequently than in other sports. In MMA, for example, a number of studies have found an injury rate of 24-29 per 100 fight participations.3,4

Both women and men compete in combat athletics. Women compete in judo in the Olympics as well as at other levels; MMA fighter Ronda Rousey was an Olympic judo bronze medalist before transitioning to MMA, where she won the UFC (Ultimate Fighting Championship) women’s



bantamweight championship. Holly Holm was a profes-sional boxer and kickboxer before defeating Rousey to win the UFC bantamweight championship. Amanda Nunes, the current MMA bantamweight champion, started training in karate at age 7 and pursued training in boxing at the age of 16. She holds a black belt in BJJ and a brown belt in judo. In fact, many women combat athletes have practiced multiple martial arts.

Physical therapists (PTs) who specialize in working with these athletes focus on minimizing injuries, addressing those that do occur, and extending the careers of the athletes.

COMBINING MARTIAL ARTS AND PHYSICAL THERAPYJessica Probst, PT, DPT, founder of ThriveAgain Physical Therapy & Wellness in Washington, DC, fell in love with martial arts as she began her PT education in 1996. She studied jiu jitsu as she was learning about the human body.

“The joint locks [moves designed to make an opponent submit, involving the application of pressure to joints] complemented the details from my physical therapy ortho-pedics classes,” she says. “My detailed knowledge of the sternocleidomastoid muscles and carotid arteries augmented my chokes [submissions in which pressure is applied to the neck, depriving the brain of blood] to an impressive degree.”

Having experienced rib and thoracic injuries, a second-de-gree acromioclavicular joint sprain, and multiple finger and toe fractures while performing jiu jitsu, Probst switched to a martial art that would result in less wear and tear on her body. She transitioned to aikido (a defensive art using strikes, throws, and joint locks) in 2005. In 2008, she started Krav Maga (an Israeli military self-defense and fighting system). She now practices Muay Thai—also known as Thai boxing—that involves strikes by both the hands and feet.

Probst began her private practice in 2009 to meet the needs of martial artists and fighters. “I combine my extensive advanced manual therapy training with my martial arts training to provide tailored care,” she says. “I analyze tech-nique and identify the sources of the movement problem from a regional interdependence model. Then I complete manual therapy, stretches, strengthening, and neuromus-cular reeducation, and build back up into reintegrating appropriate movement into the specific problem area to maximize performance.”

Over the last decade, Probst has treated hundreds of martial artists and fighters in the Washington, DC, region, some of whom have gone on to win World Kickboxing Association championships, amateur and professional MMA competi-tions, Muay Thai competitions, and Taekwondo competitions.

While conditions and injuries for combat sports athletes can vary, the most common injuries Probst sees are rib injuries, thoracic restrictions, lower back pain, knee pain (frequently meniscal or at the iliotibial band or medial region), hip impingement and pain, ankle sprains, elbow hyperextension (often among “newbies” to their sport, she says), postconcus-sion headaches, and chronic whiplash.

She also sees a lot of shoulder impingement syndrome (SIS), which frequently occurs because the athletes have been taught to protect their chin while throwing jabs by “putting on a hoodie”—bringing their shoulders up and forward, as if shrugging into a jacket.

“Many of these patients stay in ‘fight stance,’ continuing to cover their chin as they go to their [daytime or salaried] jobs, and the anterior tipping of the scapula will frequently, over time, cause partial supraspinatus tears if not addressed,” Probst says. “For these patients, my first goal is to fully

“I analyze technique and identify the sources of the movement problem. Then I complete manual therapy, stretches, strengthening, and neuromuscular reeducation, and build back up into reintegrating appropriate movement into the specific problem area to maximize performance.”— JESSICA PROBST

MMA fighter Kirstin Murphy Schmidt (left) and Jessica

Probst, PT, DPT.



COMBAT SPORTS & TERMINOLOGY IN BRIEFHere are brief summaries of some of the sports and terms mentioned in this article.BOXING, both amateur and professional, involves attack and defense with the fists. Boxers wear padded gloves and generally observe the code set forth in the Marquess of Queensberry rules. Matched in weight and ability, boxing contestants try to land blows while attempting to avoid the blows of the opponent. A boxer wins a match either by outscoring the opponent—points can be tallied in several ways—or by rendering the opponent incapable of continuing the match. Bouts range from 3 to 12 rounds, with each round normally lasting 3 minutes.1

BRAZILIAN JIU-JITSU (BJJ) is a martial art and combat sport that teaches a smaller person how to defend himself or herself against a larger adversary by using leverage and proper technique. The Gracie family, founders of BJJ, modified judo and traditional Japanese jujutsu to create the art. It contains stand-up maneuvers but is most known for its ground-fighting techniques. Gaining superior positioning—so one can apply the style’s numerous chokes, holds, locks, and joint manipulations to an opponent—is the key in BJJ.2 Fights may be won by submission or by points awarded by the referee.

CHOKES are submission moves that apply pressure to the neck, cutting off blood to the brain. A player who does not “tap,” or submit, will lose consciousness.3

JOINT LOCKS are moves that apply pressure to a joint and push it in an “unnatural” direction (ie, locking an arm and forcing an elbow backward). This restricts an opponent’s movement and/or causes him or her to submit due to pain and/or potential for a hyperextension injury or broken bone.

JUJUTSU is a Japanese martial art and method of close combat for defeating an armed and armored opponent while using no weapon or only a short weapon. Because striking an armored opponent proved ineffective, practitioners learned that the most efficient methods for neutralizing an enemy took the forms of pins, joint locks, and throws. These techniques were developed around the principle of using an attacker’s energy against him or her, rather than directly opposing it.4

KARATE developed out of martial arts forms practiced on Okinawa, an island now part of Japan. The word karate is Japanese for “open hand” (kara means open and te means hand). Te signifies that the main weapon is the body. Instead

of an arsenal of swords or guns, the “karateka” cultivates a personal arsenal of punches, kicks, and deflection tech-niques. Kara relates to the psychology of karate. Karatekas are open to the world around them, making them better equipped to handle any attack.5 Historically, and in some modern styles, grappling, throws, joint locks, restraints, and vital-point strikes also are taught.

KRAV MAGA is a tactical mixed-martial art/combative and self-defense system that combines boxing, judo, jujitsu, and aikido. It was developed for the Israel Defense Forces and Israeli security forces. The primary goal, to neutralize a threat as quickly as possible, governs all the other principles of Krav Maga. It consists of strikes, holds, and blocks. The fighter looks to combine an offensive movement with every defensive movement.6

MMA (MIXED MARTIAL ARTS) is a full-contact sport that allows a variety of fighting styles to be used (including mar-tial and non-martial arts techniques). Striking and grappling techniques, either standing or on the ground, are permitted. The early years of the sport saw a wide variety of traditional styles, but it is now common for fighters to train in multiple styles, creating a more balanced skill set.7 A competitor may win by submitting his or her opponent (forcing the opponent to concede the match), knocking out the opponent, prompt-ing a referee stoppage (technical knockout), accumulating the most points from the judges, or causing an injury that results in a doctor’s stoppage.

MUAY THAI or THAI BOXING is the Thai national sport. In Muay Thai, competitors fight standing as in Western boxing, but elbows, knees, and kicks strikes are allowed, with the only protection being the gloves. An important part of this fighting style is the clinch (standing wrestle).8

REFERENCE1. Wallenfeldt EC, Poliakoff M, Hauser T, et al. Boxing. Encyclopaedia Britannica.

https://www.britannica.com/sports/boxing. Accessed February 11, 2018.2. Brazilian jiu jitsu. Black Belt Magazine. http://blackbeltmag.com/category/

brazilian-jiu-jitsu/. Accessed February 3, 2018.3. Worthington V. What’s that move called? https://breakingmuscle.com/learn/

what-s-that-move-called-a-glossary-of-mma-terms. Accessed February 2, 2018.4. Jujutsu https://en.wikipedia.org/wiki/Jujutsu.. Accessed January 29, 2018.5. Harris T. How Karate Works. https://entertainment.howstuffworks.com/karate1.

htm. Accessed February 11, 2018.6. McKay B. The Art of Manliness: A Primer on Krav Maga: The Combative System

of the Israeli Defense Forces. https://www.artofmanliness.com/2013/07/10/a-primer-on-krav-maga-the-combative-system-of-the-israeli-defense-forces/. Accessed February 11, 2018.

7. Types of Martial Arts. Master Chong’s World Class Tae Kwon Do. https://buffalotkd.com/types-of-martial-arts/. Accessed February 2, 2018.

8. Muay Thai—Thailand. http://thailand-muaythai.com/en/. Accessed February 3, 2018.



normalize thoracic mobility, costal mobility, and cervical mobility through manual interventions. Ribs 1-4 are very frequently restricted in these patients. Soft tissue work and stretching instruction usually is needed.”

“I try to retrain by having patients first protract and then upwardly rotate their scapula,” Probst says. “In multiple conversations I’ve had with competitive MMA athletes and Krav Maga black belts, many feel this still provides adequate protection while decreasing the incidence or likelihood of SIS.”

She notes that it’s also important to assess lumbar and hip mobility and lumbopelvic stability, as many of these patients are using their upper body to power their punches instead of rotating through their hips and pelvic girdle, and incorporating their whole body in delivering the strike. For them, Probst says, addressing fighting stance and striking form is crucial.

Lauren (Laurey) Lou, PT, DPT, a physical therapist at the Hospital for Special Surgery in White Plains, New York, started training in Muay Thai and later jiu jitsu, which heightened her passion for working with this population. She also was the lead PT for the Chinese National Wrestling and Judo teams at the Olympic Training Center in Beijing for the athletes prepping for the 2016 Olympic Games in Rio de Janeiro, Brazil. Lou is a board-certified clinical specialist in sports physical therapy.

“The thing I love most about treating combat sports athletes is that there isn’t the same narrow pattern of injuries that you see in other sports—in part because each combat sport is so different,” she says. “Basically, I see 2 types of injuries—acute, from taps and blows, and chronic, from repetitive movements and positions.”

For acute injuries, such as those to the ulnar collateral and medial collateral ligaments, Lou says most combat athletes continue to train during the healing process. “For these

During a boxing or MMA training camp, competitors typically spend the 10 to 12 weeks leading up to a fight getting into condition. The goal is to “peak” at the time of the fight. Training camp involves not just regular practice, but also honing skills specifically designed to defeat that particular opponent. It frequently involves some degree of weight cutting (the loss of a substantial amount of weight to qualify for a lower weight division), and special nutrition, as well as attention to any injuries the fighter has.

John Knarr, PT, MS, ATC, has worked with many individual athletes and sports teams. He runs Elite Physical Therapy in Rehoboth Beach, Delaware.

Serving as a PT during an athlete’s training camp, he says, can be an experience unlike any other. And he should know. He was the PT during the training camp of Wladimir Klitchko, a 2-time world heavyweight champion who competed from 1996 to 2017 and compiled a record of 64-5.

Knarr worked with Klitchko before his 2008 fight with Sultan Ibragimov—which Klitchko would win, regaining his World Boxing Organization heavyweight title.

Knarr recalls, “My first contact [with Klitchko] wasn’t an initial PT evalu-ation. It was on the phone. We talked to find out if we were compatible, because I’ll be living with the guy for 6 weeks. We do 5 weeks of preparation, a 5-week camp, and then a week of pretty intense media before the fight. Physicians are there ringside, making sure the fighter is coherent. After the fight, I make sure he’s healthy. I check him out for any impact from new or previous injuries. I’m in contact that night and again about a week later. After that, everyone goes their own way. It’s like a band separating after a performance.”

How do you know if everything’s going OK? “When you’re sitting around not doing anything,” Knarr says. “If there’s nothing other than prevention to do, you’re successful.”

IN A TRAINING

CAMP



folks,” she says, “I’ll use taping to help decrease stress to the area during training, then corrective exercises and strength-ening for the structures around the area.”

Regarding chronic injuries, Lou sees a lot of low back and shoulder pain. “Each fighter is different,” she says, “but a large contributing factor I’ve seen is from the fighter’s posture—rounded shoulders, pitched forward—compounded by the dominant patterns in specific types of combat sports such as wrestling, judo, and jiu jitsu.” Lou typically works with those athletes on inner core activation in reciprocal and rotational patterns. This may start with basic functional movement rolling patterns and then progress to more sport-specific positions; for example, standing exercises for a boxer or ground exercises for grapplers.

In addition, Lou observes, “most of these combat sports athletes need a lot of gluteal work. Some of them have super strong glutes, but they can’t access this strength due to the length tension in hip flexion, which is found in the typical fighters’ posture, versus extension. Although being in extension may not be ‘sport specific,’ this is an integral part of the corrective exercises that combat sports athletes must be doing outside of their skills training.”

George J. Davies, PT, DPT, MEd, FAPTA, brings another perspective to the subject. Davies teaches in the PT pro-gram at Armstrong Atlantic State University in Savannah, Georgia. He first experienced combat sports while serving in the United States Marine Corps almost 50 years ago. He later earned a black belt in karate and served as a sports medicine consultant to his dojo (the school or facility in which martial arts are practiced), where he developed prevention programs, revised the stretching and warm-up programs, and provided recommendations to any of the martial artists who became injured.

“When the instructors were competing, I would assist them with their conditioning programs and often would work the full-contact events, along with a ring physician, as a corner-man [a coach or trainer who assists a fighter during a bout],” he says. “When more serious injuries occurred, I would provide the appropriate physical therapist services.”

Davies notes that musculotendinous unit (MTU) strains or ruptures can occur in grappling sports because of some of the extreme positions into which the body is forced.

“It’s critical to work on a combination of static, dynamic, and ballistic flexibility of the MTU, with emphasis on end ranges of motion,” he says. “Moreover, performing strengthening and power exercises through the full ROM, particularly with end-ROM strengthening exercises, is critical to try to prevent MTU strains.”

IN THE MILITARYPTs also may work with military personnel who are taught and who practice combatives. The Army defines combatives as: “Hand-to-hand combat…an engagement between two or more persons in an emp-ty-handed struggle or with hand-held weapons such as knives, sticks, or projectile weapons that cannot be fired. Proficiency in hand-to-hand combat is one of the fundamental building blocks for training the modern soldier.”1

The military has had various forms of combat-ives-type training for decades, which in the past 10-15 years have been developed into formal programs in each of the services.

With support from the APTA Sports Physical Therapy Section (SPTS), Richard B. Westrick, PT, DPT, DSc, 3 years ago founded the section’s Tactical Athlete Special Interest Group for PTs working with military, law enforcement, and firefighter tactical professionals. (For more information, see “Protecting the Protectors” in the May 2017 issue of PT in Motion.2) Westrick is an associate professor in the Department of Physical Therapy at the MGH Institute of Health Professions in Boston.

“The various combatives programs comprised martial arts techniques from various disciplines and include grappling, striking, and weapons training,” Westrick says. “For nearly a decade, every military trainee has been required to go through these formal combative training programs, and they may continue to advance through various levels of proficiency during their military career.”

The most significant difference between training and competition for civilian combat sports and training for military warfighters is the potential consequences when hand-to-hand skills may be required, especially in a deployed setting.

Nevertheless, the similarities are great enough that more than a dozen military personnel trained in combatives or specific combat sports have gone on to carve out successful MMA careers. These include Randy Couture (former UFC heavyweight and light-heavyweight champion), Brian Stann, Brandon Vera, Tim Kennedy, and Liz Carmouche.

REFERENCE1. US Army Combatives—FM 3-25.150, 1-01, Definition of

Combatives. http://www.usarmycombatives.com/1-01-definition-of-combatives/. Accessed November 26, 2017.


THE ATHLETES SPEAKAs a teen, Kirstin Murphey Schmidt was in a serious car accident and needed multiple knee surgeries to walk cor-rectly. As she got older, she began training in Krav Maga and competing in jiu jitsu tournaments, then progressed to amateur MMA fights. She credits Jessica Probst, PT, DPT, with helping her earn the title of Virginia’s Pro Female Fighter of the Year in 2014.

“I’ve had many injuries that required me to see a PT. I have had a ruptured ligament in a finger, a torn labrum in my shoulder, numerous strained muscles and tendons, pinched nerves, elbow injuries, broken toes, jammed fingers, ‘stuck’ ankles, and many more,” she says. “Combat sports are tough on the body. Seeing a PT can reduce a lot of the injuries or shorten the downtime away from the sport.”

“I was able to easily develop my larger muscles, but often my small muscles were ignored, causing imbalances,” Schmidt says. “Jess had me do so many targeted stretches and exercises while I competed, allowing me to build up those small muscles to be more even and reduce the risk of a repeat injury.”

Kru Vivek Nakarmi has been training and competing in Muay Thai (also known as Thai boxing) since 2004 and is president and founder of Pentagon Mixed Martial Arts in Arlington, Virginia.

He’s fought competitively in various martial arts since the age of 8, and over the years has undergone surgeries to repair torn labrum on both shoulders. He’s also experienced knee injuries, a broken wrist, and injured knuckles from repeated punching; sprained fingers; and a herniated disc.

“As an athlete, extending the life of my body is key to my success as a professional fighter, so it is important to make sure everything is working properly and efficiently,” he says. “A good PT is a key partner in injury treatment and preven-tion for athletes. Also, it’s important to avoid unnecessary

surgery, and physical therapy often provides an effective alternative to surgery.”

Working with Ujjwal Shakya, PT, DPT, has been a critical part of his ability to continue fighting professionally.

“I wouldn’t be where I am today without him,” he says.

Ian McCall is a professional MMA fighter with a 13-6 record. Formerly under contract with the UFC (Ultimate Fighting Championship), he’s now fighting in the Japanese organi-zation Rizin. McCall’s had more than his share of injuries: “I’ve had broken hands twice, dislocated my elbow, and had 4 surgeries on my shoulder. I pulled my hip, pulled my groin, popped my knee, and had rib injuries.”

McCall speaks highly of physical therapy, not only for recovery from injuries but also to extend an athlete’s career. “My advice to other athletes: You definitely need it, including maintenance, preventive maintenance, and rehab. You have to constantly take care of yourself. Have the little things—a pinch in the knee or numbness in your hand—looked at before they become a real problem.”

Mike Suski, meanwhile, started off as a high school wrestler and amateur boxer in Michigan. He soon focused on boxing, compiling a winning record and national recognition that included being named to the US Boxing Team. Along the way, then-business mogul Donald Trump heard about Suski and hired him to be his “boxing bodyguard” at Mar-a-Lago for several years in the 1990s. Suski turned pro, compiled a 12-2 record, and once was ranked Number 10 in the world by the International Boxing Council, 1 of a number of boxing promotions. Suski describes his experiences in his book Small Town Boxer.

During a 12-year career, though, he’d experienced a number of injuries and, unknowingly, also was aggravating them. “Boxing had torn my body up. And after my pro career, I lifted weights and did a lot of running. I had a lot of insta-bility in my joints, and the weights started ripping up my shoulders and lower lumbar. So, my injuries from boxing were made a lot worse.”

He credits physical therapy—especially aquatic physical therapy—with helping him recover.

Kristin Murphy Schmidt, named Virginia’s Pro Female

Fighter of the Year in 2014, practices a kick. She says

she’s benefited greatly from physical therapy.



Ujjwal Shakya, PT, DPT, works with Kru Vivek Nakarmi, a Muay Thai fighter.


In his practice, Davies sees numerous shoulder anterior subluxations—a problem that, if not treated properly, can become a chronic condition.

“After a short period of immobilization, the patient needs to work on neuromuscular dynamic stability exercises to help the muscles compensate for the instability of the ligaments and the capsule,” he says. “Total body rehabilitation is used, even during the immobilization period. The patient performs cardio exercises, lower extremity strengthening and stretch-ing exercises, core exercises, scapulothoracic exercises, total arm strength exercises, and appropriate glenohumeral and rotator cuff exercises when the timing is appropriate.”

Plyometric exercises for the shoulder complex are performed for power training.

MIXED MARTIAL ARTSAs a former professional MMA competitor, Charles E. Rainey, PT, DPT, DSc, MS, a lieutenant commander with the Naval Health Clinic Hawaii, can relate to combat athletes because he experienced many of the same injuries during his competitive years.

MMA is a full-contact combat sport that allows both striking and grappling, while standing and on the ground. It uses techniques from other combat sports and martial arts, including kickboxing, wrestling, and BJJ.

“I have a common line of communication with the athletes because we speak the same language,” Rainey says. “So, when an athlete says he was put into a Kimura [an armlock] and adds, ‘I didn’t tap out quick enough,’ I know which shoul-der anatomical structures might have experienced trauma. I also know what physical demands these athletes face day in

and day out, and I understand the dynamics of training, rest, and recovery.”

In the realm of MMA, Rainey says the most common injury location is the head and face—predominately the nose, eyes, and jaw regions. This is followed by the lower extremities and then upper extremities.

“The upper and lower extremities tend to follow distal to proximal locations with regard to higher injury rate,” he says. “The hand typically suffers a higher injury rate, followed by the elbow and then the shoulder. The lower extremity follows the same pattern, with the toes having the highest injury rate, followed by the ankle and then the knee. The research shows this across multiple studies.”

Following physical therapy school, Rainey entered the military and was assigned to a special operations SEAL team (a special unit trained for unconventional warfare; “SEAL” is an acronym for SEa Air and Land) command whose physical and mental training regimens were similar to those for MMA athletes. That made it an easy transition.

“SEAL team operators also frequently train in combat sports and MMA, so having an MMA background was valuable in not only serving this population related to military training injuries, but also in addressing their specific combat arts training injuries,” he says.

Ujjwal Shakya, PT, DPT, founder of MMA & Sports Rehab in Arlington, Virginia, brings yet another set of experiences to his patients and clients. Shakya originally is from Nepal and long has been interested in martial arts.

“I have been working with combat sports athletes since I became a PT, partly because my brother-in-law is a pro-fessional Muay Thai fighter and I have been studying and treating his injuries for the past 8 years,” he says. “He owns Pentagon Mixed Martial Arts and this terrific opportunity has allowed me to be able to work with many other fighters and combat sports athletes. I myself have been training for the past 5 or 6 years and mainly practice Muay Thai.”

At MMA & Sports Rehab, Shakya says, while injuries vary from sport to sport and person to person, he mainly sees shoulder/neck and hip/knee injuries in the combat athlete population.

“Cross training is one of the best ways to engage muscles and joints that combat sports athletes don’t use as part of their regular training regimen. It’s important to pick another sport or movement that uses different muscle groups to improve muscle balance and overall stability.”— UJJWAL SHAKYA



“We see a great deal of hip flexor tendinitis as a result of repetitive kicking,” Shakya says. “We have successfully treated this condition with dynamic hip flexor stretching, manual therapy, dry needling, exercises focused on hip abductors, and eccentric hip flexor strengthening exercises.”

He also sees a lot of shoulder impingement/rotator cuff ten-dinitis because of repetitive punching—particularly “hooks.” For these injuries, he says it’s important to work on rotator cuff and scapular strengthening.

“Cross training is one of the best ways to engage muscles and joints that combat sports athletes don’t use as part of their regular training regimen,” Shakya says. “It’s important to pick another sport or movement that uses different muscle groups to improve muscle balance and overall stability.”

INJURIES IN ACTIONCombat sports athletes attempting roundhouse kicks for Muay Thai, MMA, or karate are more prone to meniscal tears, as many martial artists will rotate in weight-bearing through their knee and lower leg instead of pivoting on the ball of their foot. Repeated weight-bearing rotation through the knee can cause significant wear and tear through that joint, say PTs who treat these athletes.

“To avoid this, it is important that the patient has excellent hip external rotation ROM and lumbar mobility,” Probst says. “He or she must also have excellent lumbo-pelvic stability and hip external rotator strength. For these folks, I recom-mend piriformis, adductor, and hip flexor stretches; clamshell exercises with excellent pelvic stability; and planks and side planks. I frequently do retraining on Pilates rotation discs to retrain deep hip rotators and teach patients how to use their hips and pelvic girdle to rotate instead of rotating through the knee or tibia.”

Lou describes a challenge she encountered while working with a jiu jitsu athlete who has a long history of shoulder impingement, with bilateral labral tears, caused by years in the ring.

“We did rotator cuff and peri-scapular muscle work, deep neck flexor endurance, and pec active releases,” she says. “He got back to 80%, but every time he fought, he’d experience a flare up. Then we started incorporating single-leg strength and balance, lumbo-pelvic stability, and glute strength into his shoulder program. That was the key for him.”

Shakya once treated a fighter who’d had pain at the lower neck/upper thoracic spine with numbness and tingling for 2 months after receiving an improperly executed rear naked

Mixed martial arts involve not only striking but also submission moves, such as chokes. David Tepper, left (son of this magazine’s editor), won the regional Elite Fighting Championship with a choke. He’s been helped by physical therapy after several injuries.



choke (a choke applied from an opponent’s back), as his neck was awkwardly twisted.

“He was in a great deal of pain when looking up and was unable to perform push-ups. He saw me 2 months after his original injury. I was able to assess him thoroughly and perform thoracic spine manipulations, dry needling, and myofascial release to improve his symptoms,” Shakya says. “After the first session, he was able to look up without any symptoms and perform 5 push-ups. He was back in full training mode 2 weeks later, following further strengthening and manual therapy treatment.”

APROPOS FOR ALLA great deal of what PTs do with combat sports athletes can be applied to other patients as well, these PTs say.

“I spend a lot of time thinking about rotational patterns for my combat athletes—but reciprocal and rotational patterns are very functional for all patients,” Lou says. “A patient who is older and has chronic low back pain needs inner core stability in the presence of rotation as much as your Thai boxing fighter does.”

Everyday activities—using proper movement patterns to bend down to pick something up, putting something on the top shelf, opening a door, carrying a suitcase, walking, stair negotiation—all include a component of rotation or antirota-tion and a reciprocal pattern.

The clinic at which Davies has practiced for almost 30 years covers approximately 1,700 sporting events a year and works with many college, high school, middle school, youth, and recreational athletes.

“Many of the fundamental treatments are similar,” he says. “Where the divergence occurs is more in the terminal phases of rehabilitation, where it is focused more on specificity of activity. Obviously, someone returning back to activities of daily living does not require the levels of specific training that combat athletes need to return to their activity.”

The PTs interviewed for this article describe combat sports athletes as a highly resilient population who are dedicated and tough-minded in their approach to training and rehab.

“As with any patients, the key to successful treatment is proper education about their body, understanding their symptoms, and effectively treating them,” Shakya says.

Keith Loria is a freelance writer. Additional interviews were conducted by Don Tepper, editor of PT in Motion.

REFERENCES 1. Noh JW, Park BS, Kim MY, et al. Analysis of combat sports players’ injuries

according to playing style for sports physiotherapy research. J Phys Ther Sci. 2015;27:2425-2430.

2. Ries E. Protecting the protectors. PT in Motion. 2017;9(4):16-25.3. Bledsoe GH, Hsu EB, Grabowski JG, et al. Incidence of injury in professional

mixed martial arts competitions. J Sports Sci Med. 2006;1(5):136-142.4. Ngai KM, Levy F, Hsu EB. Injury trends in sanctioned mixed martial

arts competition: a 5-year review from 2002-2007. Br J Sports Med. 2008;42(8):686-689.

“I spend a lot of time thinking about rotational patterns for my combat athletes—but reciprocal and rotational patterns are very functional for all patients. A patient who is older and has chronic low back pain needs inner core stability in the presence of rotation as much as your Thai boxing fighter does.”— LAUREY LOU

Lauren (Laurey) Lou, PT, DPT,

has worked with athletes

from many combat sports.



PRAC

TICING ETHICALLY

In Today’s Health Care Environm

ent

BY MICHELE WOJCIECHOWSKI



Ethical challenges always have been present in the practice of physical therapy. But the evolution of health care and society in general has put increasing pressure on PTs, PTAs, and students. It’s not always simple to “do the right thing”—nor is the right path always clear.

Back in 1935, the American Physiotherapy Association—the forerunner of the American Physical Therapy Association (APTA)—issued a code of ethics.1 It stated, in part:

Diagnosing, stating the prog-nosis of a case and prescribing treatment shall be entirely the responsibility of the physician. Any assumption of this respon-sibility by one of our members shall be considered unethical.

Yes, the profession has come a long way in the intervening 83 years. And physical therapists (PTs) with expertise in ethics say that with health care rapidly changing, the profession must stay ahead of the curve when it comes to ethics.

To keep up with trends, “we look for eth-ics evidence and literature in medicine, nursing, and psychology… That’s where our evolution will be,” says Nancy R. Kirsch, PT, DPT, PhD, FAPTA. There is a growing body of ethical evidence in physical therapy literature, PTs interviewed for this article say. Kirsch directs the doctor of physical therapy program at Rutgers University’s School of Health Professions in New Jersey.

In 2000, Ruth Purtilo, PT, PhD, FAPTA, delivered the 31st Mary McMillan Lecture. In it, she identified 2 major periods in the evolution of ethics in physical therapy— the “Period of Self-Identity,” beginning around 1935, and the “Period of Patient-Focused Identity,” beginning around 1957. She also foresaw development of a third period: Societal Identity. (See “Ethics in 3 Acts” on page 29, which also includes Purtilo’s views on the evolution of ethics since 2000.)

This is the period that physical therapists are now facing. In fact, Principle 8 of the Code of Ethics for the Physical Therapist and Standard 8 of the Standards of Ethical Conduct for the Physical Therapist Assistant go beyond the individual, self-focused, and

patient-focused identity.2,3 They address therapists’ responsibility to participate in efforts to meet the health needs of people locally, nationally, and globally.

In addition to the decades-long evo-lution of ethics described by Purtilo, Kirsch cites major changes in the profession in the past few years. “PTs weren’t really seeing themselves as the major decision makers. They felt they could defer,” Kirsch says. “But the evo-lution over the past decade has been incredible. Ethics is much more at the forefront—primarily at the institutional level and regarding relationships with other health care providers. There’s more of an awareness now that ethics are clinically relevant—that you can’t be in professional practice without dealing ethically with issues involving payment, productivity, and patient care decision making.”

Mary Ann Wharton, PT, MS, adds that in the more than 30 years that she has focused on ethics issues, the questions facing PTs have changed drastically. In the past, she explains, issues tended to be related to a patient having unreal-istic expectations, or a colleague who wasn’t providing adequate care or a good plan of care for patients.

Today, she says, questions often arise that focus on reimbursement restric-tions that limit patient access to an adequate plan of care—often requiring therapists to make hard ethical deci-sions about whether to continue care or end services to patients who may not have achieved their full rehab potential. PTs also face pressures to increase productivity, and to up-code charges to enhance reimbursement.

Finally, Wharton states, “Ethical issues also are much more intertwined with law—specifically with fraud and abuse laws. They’re related to bigger health care system issues.” She is an indepen-dent consultant and longtime chair of the Pennsylvania Physical Therapy Association’s Ethics Committee.

GAIL JENSEN

TAMMY FREY

BRUCE GREENFIELD



This expansion from health care to business and system issues, in turn, can result in conflict between physical therapy as a practice and physical therapy as a business, say the PTs interviewed for this article.

“We as PTs are bound by APTA’s Code of Ethics for the Physical Therapist and by the idea that the patients’ needs come first,” says Dolly Swisher, PT, PhD, MDiv, FAPTA. “So, although health care is a business, we recognize the need for the company to be financially viable.” Swisher is interim director of the School of Physical Therapy and Rehabilitation Sciences within the Morsani College of Medicine, USF Health at the University of South Florida.

Still, the tension between practice and business can cause difficulties. “One of the biggest problems is that the health care system—and all the reimburse-ment and the regulations behind that system—ignores the science behind what we do,” Wharton asserts.

Ethics TodayHow do these ethical challenges present themselves? Kirsch writes a monthly column, Ethics in Practice, for PT in Motion. Each column presents a scenario in which a PT or physical therapist assistant (PTA) faces an ethical challenge. Sometimes the course of action seems clear, although the PT or PTA may be uncomfortable selecting it. At other times, conflicting issues make the preferred direction far less certain. (See this month’s column on page 12; past scenarios are posted online at www.apta.org/PTinMotion.) Readers are invited to provide their views on each scenario. The result often is lively online and/or email debate and discussion.

The column, too, reflects the evolution in ethics. “It initially was a trial,”

Kirsch explains. “Where people didn’t used to be able to identify issues, now there’s not a day when I don’t have 4 or 5 people contacting me regarding an ethical issue.”

Kirsch offers this caution, however, about recognizing ethical issues: “It’s not about the crazy things that you know you shouldn’t do. More often,” she notes, “it’s the daily risk factors—professional isolation, not engaging with other colleagues or becoming too far removed from them, and your own physical and mental health. You need to get in touch with some of the risk factors that can make you vulnerable to an ethical breach.”

So, what are some of today’s ethical issues? They can arise even before one becomes a PT or PTA.

Laurie Kontney, PT, DPT, MS, a clinical professor and director of clinical edu-cation in the Department of Physical Therapy at Marquette University, sends more than 65 students around the country for clinicals. While she empha-sizes that such experiences usually are positive for all concerned, she concedes that some students experience prob-lems. She describes one.

In this instance, the student was concerned about the clinic’s business practices. “Every patient seemed to be getting the same exercises. The staff sat in the back room while the techs and aides were providing care,” recounts Kontney. “This had never happened before when we sent a student to this clinic.” This scenario not only illus-trates a clinical problem, it also has a clear ethical component. Principle 3 of the Code of Ethics obligates therapists to make independent professional judgment informed by sound evidence to meet the needs of each patient.2

For a week, Kontney and the student talked nearly every night about how

the student might best raise her concern. The dilemma was heightened because the student was quiet and reserved. “She ended up saying things like, ‘I have some questions about this. I don’t want to be delegating my patients after the eval because I need to learn how to treat them. I think they need more exercises.’”

What was the outcome?

“People there actually listened to her,” Kontney says. “They said they didn’t know this was the student’s perception, and they ended up changing their ways. That student made a big difference.”

“Generally, physical therapists don’t like conflict,” says Swisher. “That’s why we have to teach students, and have them practice what they would do in particular situations. There may come a time when they need to speak up, so they need to know how to do it.”

Consider, Kirsch adds, the case of new grads. “They’re out there, having to take responsibility for ethical issues. They tell me, ‘My gosh, that actually happened!’ They are the most vulnera-ble, because they don’t have the experi-ence in dealing with those issues.”

Productivity, not unexpectedly, is a big ethical sticking point—and not just for PTs.

PTAs also are feeling pressure to increase productivity. Tammy Frey, PTA, with Geisinger HealthSouth at Woodbine in Danville, Pennsylvania, served with Wharton on the Pennsylvania Chapter’s Ethics Committee and has been appointed by 2 Pennsylvania governors to fill the PTA seat on the Pennsylvania State Board of Physical Therapy. Frey reports she’s heard that some PTAs, who are supposed to be treating a patient every 45 minutes, are being asked to do so every 30 minutes.

“Some PTAs are getting pressured to produce, and it’s all about the finan-cials,” says Frey. “That isn’t conducive

“We as PTs are bound by APTA’s Code of Ethics for the Physical Therapist and by the idea that patients’ needs come first.”DOLLY SWISHER



ETHICS IN 3 ACTSOne of the trailblazers in the field of ethics in physical therapy is Ruth Purtilo, PT, PhD, FAPTA. At APTA’s Annual Conference (as the gathering then was known) in 2000, she delivered the 31st Mary McMillan Lecture on “A Time to Harvest, a Time to Sow: Ethics for a Shifting Landscape.”

In that address, she identified 2 major periods in the evolu-tion of ethics in physical therapy, and described what she saw as the outlines of a third. She called the 2 eras up to that time the “Period of Self-Identity,” beginning around 1935, and the “Period of Patient-Focused Identity,” beginning around 1957.

“In the Period of Self-Identity, we established the moral foundations for a true professional relationship with physi-cians and other health care professions,” she said. “These therapists had read, correctly, a shifting social landscape that was enduring a worldwide depression and would, a few short years later, feel the corrosive effects of a world war and the challenges of social reconstruction following it, as well as face the global ravages of the polio epidemic. Indeed, the entire social terrain of the western world would force physicians down from the mountaintops to labor shoul-der-to-shoulder with nurses and whoever else would share the crushing burden of health care in these extreme circum-stances. They found physical therapists ready.”

This was followed by the second period, which expanded to encompass patient inclusion. “In the Period of Patient-Focused Identity, we established the moral foundations for a true professional relationship with our patients and clients,” Purtilo said.

The post-World War II landscape included new thinking about the scope of individual rights. “New rights were articulated through the United Nations Declaration of Human Rights, the US civil rights movement, Medicare and Medicaid legislation, the American Hospital Association Patient Bill of Rights, and the constitutional right to privacy, to name some.”

Purtilo continued, “In this rights-intensive territory, the individual’s interests became the ideological, political, and economic standard of policy so that health care professionals had only to follow what was happening in the rest of society to give patients a stronger voice in decisions affecting them.”

At the time of that lecture 18 years ago, Purtilo foresaw the development of a third period: Societal Identity. She explained, “Our present task is to become full partners with society. Why try to make such a partnership? Because the larger community of citizens and its institutions no longer will accept any other alternative. Either we fully partner or be rooted out like the last millennium’s dead stalks.”

She saw the health care system being affected by the Human Genome project, genetically implanted medica-tions, robots in the surgical suite, and computerized patient records. These, Purtilo said, required that the profession strive for 2 goals:

First, “We can use our strong self-identity to remind society what a health care profession—and the profession of physical therapy specifically—is designed to do…physical therapists must demand appropriate care for all patients who can benefit more from physical therapy interventions than from those of any other group or by any other means.”

The second goal, she said, was to learn what’s been accom-plished with a patient-focused identity “to make a compelling case for how we can work with society to ensure that a well-defined area of basic patient needs can be met in the new season.”

That was nearly 2 decades ago. What, if anything, would Purtilo change? “The major difference I would propose today,” she says, “is that the development may have been sequential as we moved into the current state of ‘PT in society,’ but the challenge is to understand that the full flourishing of physical therapy into the future depends on understanding all of the phases as progressing simultane-ously. Or, maybe more accurately, those phases are circular and integrative, much like a spiral, carrying along the key remnants of the past.”

“We can use our strong self-identity to remind society what a health care profession—and the profession of

physical therapy specifically— is designed to do.”RUTH PURTILO



to them feeling as though they’re giving good quality and compassionate care. It’s about getting patients in and getting them out.”

At most facilities, Frey says, PTAs should be able to go to their supervi-sors to report ethical concerns without fear of repercussions. Yet some fear that their job will be in jeopardy if they refuse to follow a supervisor’s direc-tive to meet unrealistic productivity standards or provide an inappropriate level of care based on both evidence and ethics.

Sandy Davis, PT, chair of APTA’s Ethics and Judicial Committee (EJC), notes that another ethical issue faced by PTs, PTAs, and students is bullying—by patients, colleagues, or superiors, or in their roles as clinical instructors (CIs). “When this happens, we need to advo-cate to stop it, she says. “Often, those who are harassed stay silent because they’re afraid or feel intimidated.” Davis is a contributing faculty member at the University of St Augustine for Health Sciences, and a volunteer instructor at the University of Florida in Gainesville.

If the person can’t speak up to the bully, Davis says, then he or she should talk with a supervisor—and, if necessary, contact an attorney. “These are serious

issues that people sometimes dismiss by saying the bully was just kidding. This issue often isn’t talked about because it’s so sensitive,” she observes.

But it’s not just the health care provider who may be bullied. Gail Jensen, PT, PhD, FAPTA, says she’s seen an increase in PTs showing disrespect

to patients. For example, a PT or PTA may make fun of a patient who has a language barrier, or is morbidly obese. “That’s distressing,” Jensen says. “We should respect all human beings and demonstrate it both verbally and nonverbally.” Jensen is dean of the graduate school, vice provost for Learning and Assessment, and a faculty associate in the Center for Health Policy and Ethics at Creighton University in Nebraska.

Bruce Greenfield, PT, PhD, MA, presents another bullying scenario. “Students can be bullied by other health care professionals at a larger institution, such as a hospital, or even by their clinical instructors,” he notes. “Students need to report incidents to their faculty member who works with clinicals. Nobody should put up with being disrespected.” Greenfield, a member of the EJC, is a professor in the Division of Physical Therapy at Emory University in Atlanta, and a senior fellow at the school’s Center for Ethics.

Another area in which ethical conun-drums often arise is when PTs contract with sports teams—professional, college, even high school. Greenfield points out that when a PT works for a sports team, he or she has a loyalty to the team and to each athlete. At times, this may cause a conflict.

For example, if an athlete is injured, the PT who is working with him or her may be coerced by the team, manage-ment, parents, or even the athlete to permit return to play before rehabilita-tion is complete. “It’s hard to navigate through this issue,” says Greenfield. “You have to have moral courage to

APTA RESOURCESIntegrity in Practice Home Page

k http://integrity.apta.org/Ethics/

Code of Ethics for the Physical Therapist

k www.apta.org/uploaded Files/APTAorg/About_Us /Policies/Ethics/CodeofEthics.pdf

Standards of Ethical Conduct for the Physical Therapist Assistant

k www.apta.org/uploaded Files/APTAorg/About_Us /Policies/Ethics/Standards EthicalConductPTA.pdf

Ethical Decision- Making Tools

k www.apta.org/Ethics/Tools/

The Realm-Individual Process-Situation (RIPS) Model of Ethical Decision Making

k www.apta.org/uploaded Files/APTAorg/Practice_and_Patient_Care/Ethics/Tools/RIPS_DecisionMaking.pdf

Ethics Interpretations and Opinions

k www.apta.org/EJC Opinions/

Ethics in Practice Articles from PT in Motion

k www.apta.org/Ethics/Tools/Articles/

“When bullying happens, we need to advocate to stop it. Often, those who are harassed stay silent because they’re afraid or feel intimidated.”SANDY DAVIS



stand up to the team, the manage-ment, the coach, and others, because ultimately you are responsible, first and foremost, for the patient’s welfare. You need to use sound professional judgment regardless of the needs of the team. You can try to come up with a compromise, but not at the expense of the athlete’s safety.”

Ethical issues can arise from question-able legal activities, as well. Kontney cites the use of unlicensed or other staff—such as aides, techs, and even ath-letic trainers—to perform functions that they aren’t permitted to do. “Sometimes, they’re being used in a physical therapy clinic, and their services are being represented as physical therapy,” says Kontney. “Some PTs use extenders more than they should because they want to keep their doors open, which can be difficult with increasing health care costs. They’re also trying to maintain access for patients.”

In nearly 25 years, she can count on 1 hand, she says, how many times she’s actually had to pull a student from a clinic due to illegal or unethical practices. Kontney adds, though, that she recently withdrew some students from a clinical affiliation after she found out that they were being required to do things that weren’t permitted by the state’s practice act. “Some of these behaviors that we see are very concern-ing,” she says.

Greenfield cites a similar issue involv-ing aides, but adds a glimmer of hope. “Improper use of personnel used to be more widespread,” he says. “Each state’s practice act now prescribes the role of the aide. In the old days, aides used to perform treatments and engage in all kinds of activities that they really shouldn’t have been doing. Today in the state of Georgia, aides may only provide supportive activities to patient care that does not include direct provision of any patient intervention but, rather, includes only assisting a patient after cessation of treatment, or

assisting during treatment provided by a physical therapist.”

What PTs and PTAs Can DoWhile APTA has established the Code of Ethics for the Physical Therapist and the Standards of Ethical Conduct for the Physical Therapist Assistant, the documents note, respectively, that “No code of ethics is exhaustive, nor can it address every situation” and that “No document that delineates ethical standards can address every situation.”

Although PTs and PTAs are encouraged to familiarize themselves with the principles and standards that each doc-ument outlines, there undoubtedly will be situations in which they may need to seek outside help. “Ethics is more than a code,” says Wharton. “The code offers guidance, but it can’t offer specific solutions. It is not a book of rules.”

Bud Langham, PT, MBA, chief clinical officer for Dallas-based Encompass Home Health & Hospice, says he believes that the authors of the APTA Code of Ethics for the Physical Therapist, and those who have updated it over the years, “did a really great job,” but he acknowledges that it’s sometimes tough to make decisions in isolation.

So, Langham has a process when he is asked for advice. “I always start with having the PT or PTA define the problem, because I don’t want to give any guidance without fully understand-ing the situation. I ask what the person is being asked to do—or what he or she thinks is being asked,” he says. “First we do a legal test. Are you being asked to do something that’s illegal?

“If the concern is that it’s something unethical but not illegal, then we do the

‘Mom’ test,” Langham continues. “And that is, ‘If you were to fully lay out this problem, would you be ashamed if the direction you chose to take were to be shared with your mother?’”

Langham has a final test he uses with PTs who are struggling with ethical issues—the newspaper test. “Would you be ashamed if your decision were shared on the front page of your community’s newspaper?” Langham asks. “If any of these things bother you, then you need to think about what you need to do.”

“That’s how I help people,” he says. “Most of the time, when ethical ques-tions come up, the solution comes out in 1 of those steps.”

Those seeking help also might talk with trusted mentors and friends, suggests Langham. Kirsch offers a similar sug-gestion, accompanied by an admission: “I’m not Ann Landers. But when people reach out, we tell them to bounce a situ-ation off a person they trust. Bounce the idea off a colleague and see what that person thinks. But I always put it back to the questioner: ‘Here are some tools to use.’ I’ll give them tools, or refer them to APTA.” (See “APTA Resources” on page 30.)

Wharton mentions that most APTA chapters have an ethics panel or an ethics committee that offers educa-tional sessions or publications that, like Kirsch’s Ethics in Practice column, discuss contemporary ethical situations and provide tools and steps to facilitate making a good ethical decision.

PTs also need to understand the concept of complicity, advises Jensen. “If you’re complicit, it means you saw something that wasn’t okay but you didn’t say anything. That non-action becomes an action. This can happen at both an individual level and an

“I always start with having the PT or PTA define the problem, because I don’t want to give any guidance without fully understanding the situation.”BUD LANGHAM



CHOOSING AND USING THE RIGHT ETHICAL MODELIs there an actual set of instructions on analyzing an ethical problem? Is there a clear way to get from the problem at Point A to the answer at Point B?

No, there isn’t.

In fact, in the realm of philosophy, multiple Point Bs exist—a choice of “best outcomes.”1 For example:

k The Utilitarian Approach: An ethical decision that produces the greatest good for the greatest number.

k The Rights Approach: An ethical decision that best maintains and protects the fundamental rights and privileges of the people affected by it. Actions are wrong to the extent that they violate the rights of the individuals.

k The Fairness or Justice Approach: An ethical decision that distrib-utes benefits and harms among individuals in a fair, equitable, or impartial way.

k The Common Good Approach: An ethical decision that assumes a society comprises individuals whose own good is inextricably linked to the good of the community. The focus is on ensuring that the social policies, systems, institutions, and environment are beneficial to all.

k The Virtue Approach: An ethical decision that best meets certain ideals to which people should strive. The test is: “What kind of person should I be?”

In all of society’s arenas—including education, business, and health care—there are multiple models to get from Point A to Point B (whatever it’s decided that Point B should be).

One of the more widely used models in physical therapy is the Realm-Individual Process-Situation Model of Ethical Decision Making, or RIPS

for short. This model was initially presented at APTA’s 2004 Combined Sections Meeting.2

The RIPS model assumes that approaching an ethical situation should include consideration of the:

k Environmental context (realm—indi-vidual, organizational, or societal)

k Individual process involved (ethical sensitivity, judgment, motivation, or courage)

k Situation (ethical issue, problem, dilemma, or moral temptation)

In analyzing the situation, the authors suggested that the ethical deci-sion-making process has 4 steps:

1. Recognize and define the ethical issues,

2. Reflect,3. Decide the right thing to do, and4. Implement, evaluate, and reassess.

However, the authors conceded, “One limitation of the RIPS model is that it offers a rational, linear approach to resolving an ethical problem, although many elements of ethical situations are not solely rational. For example, there are emotional and rational elements of ethical situations that are not easily factored into decision-making frame-works. Caring, commitment, personal or organizational values, fear, obliga-tion, peer pressure, and courage are all relevant to ethical situations, and these do not always come to life in a rational,

linear model.”

Nancy R. Kirsch, PT, DPT, PhD, FAPTA, who writes the monthly Ethics in Practice column in PT in Motion, com-ments, “RIPS has evolved over time. It has a good foundation, but it’s not the only way to look at an ethical issue. We use parts of it in our monthly column. We add in moral potency, a concept developed in the military. We’ve focused on RIPS because it works nicely for physical therapy but, as the profes-sion has changed, so has society.”

Still, as noted, a variety of other ethical models exist. For example, the Six Step Process of Ethical Decision Making3 consists of:

1. Gather relevant information2. Identify the type of ethical problem3. Use ethics theories of approaches to

analyze the problem4. Explore the practical alternatives5. Complete the action6. Evaluate the process and outcome

REFERENCES1. Velasquez M, Andre C, Shanks T, et al. Thinking

Ethically. Markkula Center for Applied Ethics, Santa Clara University. https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/thinking-ethically/. Accessed February 3, 2018.

2. Arslanian LE, Davis CM, Swisher LL. Ethics from the Trenches: Everyday Ethics and the Real World. Section on Health Policy & Administration. 2004.

3. Doherty RF, Purtilo RB. Ethical Dimensions in the Health Professions, 6th ed. St. Louis, MO: Elsevier;2016:108-118.

THE RIPS MODEL

Realms Individual Process Situation k Individual

k Organizational

k Societal

k Moral Sensitivity

k Moral Judgment

k Moral Motivatoin

k Moral Courage

k Issue

k Problem

k Dilemma

k Temptation



organizational one,” she explains. “To be a moral agent, you’ve got to take an action that’s going to make a difference in the outcome.”

In addition to experiencing ethical problems, PTs also may experience ethical dilemmas. “A true ethical dilemma is often the decision between 2 right choices—not necessarily between a right and a wrong one,” says Jonathan Cooperman, PT, DPT, JD, MS. He gives an example: “Let’s say you’re a PT with your own practice, and you rent space in a building owned by a group of physicians. They say they want to own your practice, and, in effect, are exercising their option on your lease. So, in 90 days you have a choice—you can either walk away or become an employee of the physicians. Yet, you have argued for a long time that physician-owned PT practices are wrong.

“Therefore,” he continues, “it would seem that the right thing to do would be to walk away. However, you have 6 employees who rely on you for their income. You also have 2 kids in college, and your dedication and obligation is to your children. If you walk away, you don’t know that you can raise enough money to start a new practice, or continue to make a go of it in the town you’re in.

“These are the types of instances that people lose sleep over,” Cooperman says.

But sometimes, PTs don’t have to choose between 2 rights. They have to choose between right and wrong. “At the end of the day, when you’re in a really tough situation, you still need to do the right thing,” says Langham. “As professionals, that’s our responsibility—to do the right thing.”

Looking ForwardWhat does the future hold for ethics in physical therapist practice and among PTAs and students? And how can today’s and tomorrow’s PTs, PTAs, and students best prepare?

“We have to recognize our obligation to shape health care policy in ways we haven’t before,” Swisher says. “If we aren’t trying to help influence the societal prerogatives about who gets coverage and who doesn’t get coverage, we will miss out on a lot of opportuni-ties. Advocacy can mean lobbying, but it also means speaking out on behalf of people as a whole.”

To teach future PTs how easily they can make a difference, Kontney has her stu-dents write personal advocacy letters about ethical issues. “Part of the barrier to advocacy is that people think they can’t make a difference,” says Kontney. Her students have written advocacy let-ters about topics including repeal of the therapy cap and permitting PTs to be named to the National Health Service Corps so that physical therapy can be provided to underserved areas. This, she explains, not only would offer a way to ease the burden of student debt for new graduates, but also would help address another ethical issue—getting care to more people who need it.

“We can provide pro bono care, but that doesn’t solve the overall problem. Unless we look at how we can advo-cate—not just for the individual patient, but for the patient population—we’re always going to have these problems,” Kontney says.

She points out that APTA has made it easy for members to write advocacy letters. “We have flash campaigns in

which PTs and PTAs can go to APTA’s legislative website. They even can send a form letter if they don’t have time to write to their individual representa-tives,” she says.

Wharton recommends taking advocacy to another level. “To help with the payment problems specific to individ-ual patients, we need to engage in true collaboration with patient advocacy groups to fight for more just payment policies and procedures,” she says. She notes, for instance, that AARP joined with APTA in its effort to repeal the therapy cap. “We should encourage consumers to do the same, when possible,” she says.

“To meet these challenges, it is a mistake for PTs simply to rely only on personal character formation or go back into the professional autonomy mode that is designed to set us apart among the professions,” says Purtilo. “Members of the profession must be confident and malleable in what is required for professional ethical iden-tity formation today. The association must be integrated into the evolving societal landscape, arm-in-arm with other groups who are prepared to do the same.”

Michele Wojciechowski is a freelance writer.

REFERENCES1. The American Physiotherapy Association

Code of Ethics and Discipline. Presented at the Fourteenth Annual Convention of the American Physiotherapy Association, Atlantic City, NJ. June 1935.

2. Code of Ethics for the Physical Therapist. American Physical Therapy Association. www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Ethics/CodeofEthics.pdf. Accessed February 11, 2018.

3. Standards of Ethical Conduct for the Physical Therapist Assistant. American Physical Therapy Association. www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Ethics/StandardsEthicalConductPTA.pdf. Accessed February 11, 2018.

“We can provide pro bono care, but that doesn’t solve the overall problem. Unless we look at how we can advocate, we’re always going to have these problems.”LAURIE KONTNEY


Putting the

“FUN” Into Functional Recovery

By Michele Wojciechowski

Do some of your patients resist exercise? Try making it joyful.



Lively polka music surges from the treatment room as Dennis Klima, PT, DPT, PhD, MS, leads a patient in a dance. But he’s not having a party. He’s providing rehabilitation.“I incorporate dancing as part of neuromuscular reeducation, as well as aerobic training,” says Klima, an associate professor of physical therapy at the University of Maryland Eastern Shore. “Some of those dances can go on for 4 or 5 minutes without a break.”

Klima believes he was among the first physical therapists (PTs) to use dancing as a technique in treating patients who are older. For 30 years he was artistic director and choreographer of the Ojczyzna Polish Dance Group. While he loves dancing, however, it was his patients who gave him the idea to add it to treatment.

Early in his career, while working with patients of Polish and Italian descent at a skilled nursing facility in Dundalk, Maryland, Klima learned that many of the women had the same objective: to be able to dance at their daughter’s or granddaughter’s wedding. “That was a great goal to work toward,” he says. Dancing fueled their enthusiasm and made the facility a draw for others.

Today, Klima also uses ballroom dancing—such as the foxtrot, the waltz, the cha-cha, and even swing—with patients of all ages. “I augment the music. I pick a tempo that’s appropriate to the patient’s level of function,” he says. “To challenge them, I speed it up or use more difficult music, because I want them to progress. If the patient has greater impairments, I may start by holding onto them to help their balance and begin with basic weight shift to slower music with more assistance, then progress toward faster music with turns.” The turns are important, he explains, because they challenge the vestibular system.

Klima also advises patients’ family members and friends on how to dance with that person at home. “Not only is it really great for the patient, but it’s also phenomenal for the family member or friend,” Klima says. He even has his PT students take a mini-practical on incorporating dance with patients.

Klima and the other PTs profiled in this article have found that by making

activities fun, patients are more willing to do their exercises and, therefore, can achieve their goals more quickly.

In the Patient’s CornerAt Rock Steady Boxing (RSB) in Indianapolis, a group of people don boxing gloves and for 90 minutes participate in noncontact boxing—hit-ting punching bags, shadow boxing, and building up a sweat. Besides being “ring mates,” they have something else in common—they all have Parkinson disease (PD).

“Our patients like the novel aspect of boxing. Many had never boxed before,” says Stephanie Combs-Miller, PT, PhD, an RSB medical advisory committee member. For a decade, she has been involved with RSB, a nonprofit, commu-nity-based boxing program specifically for people with PD.

“Rock Steady puts people in classes with others who have similar physical abilities and are at similar stages of the disease,” says Combs-Miller. “They build cohesive groups, keep each other accountable for coming in, and form strong relationships with one another.” She is an associate professor at the Krannert School of Physical Therapy and director of research for the College of Health Sciences at the University of Indianapolis.

Putting the

“FUN” Into Functional Recovery



With programs in nearly every state and many countries, RSB provides boxing classes to help people maintain better function, balance, gait, gross motor movement, range of motion, posture, and activities of daily living. “RSB even has classes for people with lower levels of ability. They may do chair-based exercises, but it’s the same concept. They still are doing boxing-type activities and exercising as intensely as they can tolerate,” she says.

Over the years, Combs-Miller has conducted studies of the program’s outcomes. “Most of the time we’re using common outcome measures regularly used by PTs. We’re interested in our patients’ walking function, balance, strengths, quality of life, and other psychosocial measures,” she explains. “We’re also focused

on cardiorespiratory outcomes and endurance in a high-intensity interval training program.”

Working with community programs holds added benefits for PTs, Combs-Miller says. “In traditional physical therapy, we see people on a short-term basis. But with a community program such as RSB, we have an opportunity to collaborate and see how people do long-term with fun exercise,” she says. “We also can partner with these programs help the members as well as our own businesses.”

Every other month or so, RSB conducts a free health screening. “We triage patients based on their reports and either refer them to the appropriate PT—such as orthopedic or neurologic—or to another appro-priate health care provider, such as a

physician, occupational therapist, or speech pathologist,” Combs-Miller explains. “These programs give people opportunities to exercise and build community. They also give PTs ways to expand their own practices and develop community partnerships.”

All the Right MovesInstead of reaching out to established community programs, Jamie Haines, PT, DScPT, created PT-CONECT (Physical Therapy-Chippewa Outreach in Neurorehabilitation and Education with Community Teams) at Central Michigan University (CMU), where she is an assistant professor in the doctor of physical therapy program.

“I had taught a class on neurologic interventions at 2 other universi-ties that had programs similar to PT-CONECT. When I came to CMU, I was teaching it again, and I knew that bringing in participants with neurologic conditions would help them and my students,” says Haines. “I pair 2 students with a community partner—the term for the volunteers, who technically aren’t patients.” Most participants have chronic neurologic conditions such as multiple sclerosis, traumatic brain injury, spinal cord injury, stroke, and PD.

Haines’ second-year students see the volunteers for 6 visits. After conducting initial evaluations, “They get to practice their intervention, communication, and handling skills, and they send the partners home with

As part of Central Michigan University's PT-CONNECT program, PT student Tonya Bickley (right), under the supervision of Jamie Haines, PT, DScPT, uses boxing to help Tammy, who has cerebral palsy and wanted to work on her dynamic standing balance.



sustainable home exercise programs that have been put together specifi-cally to help them address the issues they themselves identified.”

Students assign fun-focused exercises to increase the likelihood that the volunteers will do them at home. “Research tells us that an engaged brain has better potential for recovery,”1 Haines notes.

PTs know that exercise repetition can lessen recovery time, but it’s difficult to get someone to keep doing the same thing over and over. “So,” Haines says, “you make it fun. We have partners put on boxing gloves and make boxing moves. You couldn’t normally get them to reach across their bodies 10 times in a row, but with boxing you can get them to do 300 reaches in 10 minutes.” Besides boxing, her students use dance, music, walking to the beat of a metronome, and even competition to get partners to exercise. “We ask, ‘How many sit-to-stands can you do with me?’ For some, competition builds camaraderie and gets them to do what they otherwise wouldn’t.”

Haines describes 1 patient in a wheel-chair poststroke who was working on balance. He had been a hunter, so stu-dents set up paper targets of deer on a wall and taught him how to stabilize with the hand affected by the stroke, lift a Nerf gun, and shoot sponge pellets. “He hadn’t hunted in a long time because he was in a wheelchair, but his eyes lit up doing this activity,” Haines says.

She adds that even with fun activities some partners are fearful to participate. “When partners are too scared to try something, we use safe patient han-dling and mobility equipment, includ-ing overhead ceiling harnesses and floor-based mechanical lifts,” Haines says. “It’s amazing to see what they will do when they know they can’t fall. They will box, dance, run, and even kick a ball. Fear is a huge limitation for people with neurologic conditions.”

Hippotherapy: Not Just Horsing AroundIf you see Lori Garone, PT, MS, walking next to a person on a horse, know that she’s not involved in a horseback-riding lesson. Rather, she’s providing physical therapy and incorporating hippotherapy into the patient’s plan of care, as a certified hippotherapy clinical specialist.

According to the American Hippotherapy Association (AHA), “Hippotherapy refers to how occupa-tional therapy, physical therapy, and speech-language pathology profes-sionals use evidence-based practice and clinical reasoning in the purpose-ful manipulation of equine movement to engage sensory, neuromotor, and cognitive systems to achieve func-tional outcomes. In conjunction with the affordances of the equine environ-ment and other treatment strategies, hippotherapy is part of a patient’s integrated plan of care.”2

“Hippotherapy uses principles of motor learning, dynamic systems theory, and

sensory integration. It is intricately related to 3-dimensional pelvic motion transferred from the highly organized neurological system of the horse to the patient. The horse is the only animal that can provide the same pelvic motion that we use when we move,” says Garone, who is AHA’s second vice president.

Although hippotherapy most com-monly is used with children, it can be used with adults, too.

Hippotherapy affects the neurological, vestibular, visual, auditory, motor, sensory, and gastrointestinal systems, says Garone. It’s also fun. “We take the children out of the clinic and get them into nature. They’re relaxed. They’re happy. They enjoy being on a horse. They forget that it’s therapy, so they’re more motivated to participate in treatment.”

Playing GamesDanielle Levac, PT, PhD, MSci, doesn’t always host children in the Rehabilitation Games and Virtual Reality Lab that she directs at Northeastern University (NU) in Boston. But when she does, they tend to be in awe of the floor-to-ceiling screens displaying virtual worlds.

And, like most kids, they also like to play the video games—which are, however, for research purposes.

“I collaborate with engineers, game designers, and programmers to evaluate existing off-the-shelf com-mercially available games such as the Nintendo Wii or the Microsoft Kinect,”

“Research tells us that an engaged brain has better potential for recovery.” — Jamie Haines



says Levac, an assistant professor in the Department of Physical Therapy, Movement, and Rehabilitation Sciences at NU. “I also work with developers of rehabilitation-specific games that are being developed.”

She says her research focus is on under-standing existing games—which ones might be most relevant for particular patients, and which elements of a particular game will engage patients while getting them to perform desired movements. “I want to learn what it is about one game versus another, or one platform versus another, that might be most effective for learning, while also engaging and sustaining motivation,” Levac explains.

When mainstream platforms such as the Wii and Xbox were introduced, clinicians were excited, she recalls, because they were the first gam-ing-based systems that incorporated full-body movements. “The games on those platforms were thought to be fun, motivating, and engaging,” Levac says. They were a way to solve the problems of getting pediatric patients to perform certain movements at the appropriate times. And if the children had the game systems at home, they could continue their exercise programs there.

“Playing video games that have good design principles—giving rewards for behavior—can be fun and motivating, while helping patients regain function,”

says Levac. “We’re all motivated by the visceral pleasure of getting rewarded for our performance. But we only are motivated if it’s properly challeng-ing,” she notes. “If it’s too easy or too difficult, we don’t want to keep playing. Another important motor-learning prin-ciple is autonomy—patients’ ability to choose what they want to do and when they want to do it.”

“Patients’ improved motor skills while gaming are only beneficial if they can transfer those skills to real-life activ-ities,” Levac explains. “If they learn a skill by playing a Wii game, they need to be able to mimic the movement to reach up to get a cup, for example.” (See “Using Motor Learning to Help Patients” in the February 2018 issue of PT in Motion.)

One caveat is that mainstream off-the-shelf games won’t work for every patient, says Levac. Modifications may be necessary. “It can be as simple as turning off the volume for patients who are too stimulated by the auditory aspect,” she notes. “But because Wii and Kinect don’t allow you to adjust the difficulty levels of the games—other than choosing beginning, middle, or advanced—PTs can choose to add or take away an element to make the game easier or more difficult. For example, a PT might reduce a cognitive challenge by instructing the patient to focus only on the red balls in a game. Likewise, a PT could increase the challenge by having a patient play the game while counting backward from 20 by 3s.”

“I want to learn what it is about one game versus another, or one platform versus another, that might be most effective for learning, while also engaging and sustaining motivation.”— Danielle Levac

A patient plays a video game in the Rehabilitation Games and Virtual Reality Lab at Northeastern University, which features floor-to-ceiling screens.



Another issue may occur when a patient has the gaming system at home, Levac says. A PT may not know if the patient is playing the game as instructed or is simply playing it to get a good score, without regard to the PT’s directions. This is where specially designed games come in.

Tracking DataWhen she was a college professor, Sheryl Flynn, PT, PhD, studied off-the-shelf video games and their use in rehabilitation. People were engaged and motivated to play, but she felt that something was missing.

“There was no data other than game scores—the player received so many points or earned stars. But what does that really mean in terms of a therapeutic outcome? That wasn’t clear,” says Flynn, founder and chief executive officer of Blue Marble Health. In addition, she continues, “People were motivated to a point, until they hit a level they couldn’t pass. The games couldn’t adjust to fit their skillset.”

Flynn created her company to address these issues. “Off-the-shelf video games don’t provide important information such as data about the human performance metrics. Nor is there an adjustment for skill level. I started Blue Marble Health to focus on evidence-based science that’s enter-taining; we value both things equally,” she explains.

Another challenge, Flynn notes, is that PTs give patients home exercise

programs but have no idea if they’re doing them—or, if they are, how much and how often. Blue Marble, therefore, has created programs that look and feel like regular video games but also track human performance metrics involving attention, memory, executive function, visual perception, and more. Clinicians can access this data to see how well their patients are doing with the exercise program at home.

After an episode of care ends, clinicians still can access the patient’s data as long as they remain connected with the patient. “So, if a PT sees that 3 patients have started to slip in terms of how they are doing, that PT can contact them to see if they want to be evaluated to deter-mine why their scores are decreasing,” says Flynn. The company’s performance analytics tools enable clinicians to assess patients, assign routines, and track progress. The tools also allow clin-ical administrators to collect population data through the reporting function.

The games run on Windows-based tablets and computers. They have 2 aspects—cognitive and physical. “The physical platform is focused on bal-ance, fall prevention, vestibular impair-ments, arthritis, and COPD [chronic obstructive pulmonary disease]. The cognitive platform measures attention, memory, executive function, and visual perception,” Flynn says. “And playing them is fun!”

Blue Marble Health was founded in 2011 with a contract from the Department of Defense. The military had been searching for a video game for concussion rehabilitation of troops returning from wars in Iraq and Afghanistan. While the company’s focus on veterans primarily addressed the cognitive side, the balance and fall prevention in the physical program also can be used for veterans.

To develop the apps, Flynn interviewed clinicians, read workbooks on cognitive

A screen shot from Treasure of Bell Island, a therapeutic game that challenges attention, memory, and executive function. It was developed by Blue Marble Health.



function, and researched scientific evidence and clinical guidelines to identify best practices for brain impair-ment interventions. “We did a study with these war veterans comparing our use of video games with traditional workbook cognitive rehabilitation,” Flynn says. We found that—in a short period of time—the veterans had improved cognitive function more so using our game than they did with the traditional workbook.”3

In an effort to address the potentially costly and catastrophic consequences of a fall, the apps also empower patients to track their fall risk. If fall risk increases, PTs are alerted and can encourage patients to visit the clinic to determine the reason. In this way, PTs possibly can catch the decline in function before a fall actually occurs, Flynn says.

Get Out of Your HeadWhen a young male patient from Brazil first came to PhysioFitness in Rockville, Maryland, he had been using crutches for half of his life. Clinic co-owner Jan Dommerholt, PT, DPT, examined the boy’s knee. The patient flinched, although he’d received no diagnoses for this pain, which had lasted more than 3 years.

“What would happen if you walked without your crutches?” asked Dommerholt, who also owns Bethesda Physiocare Inc and Myopain Seminars.

“I can’t do that,” the boy replied. No matter what Dommerholt said, the boy refused to walk without the crutches. So he tried another strategy.

Handing him a ball the size of a basketball, Dommerholt took the boy to a sports wall at PhysioFitness and said, “Just throw the ball at these lights.” Because he couldn’t throw the ball while using both crutches, the boy dropped 1. After hitting 1 of the lights, the ball went past the boy, who couldn’t catch it. He went crawling after it. He kept doing the activity. He wasn’t quite tall enough to reach the highest light, so he jumped—sans crutches—to complete the task. He reported no pain. After 10 sessions, he stopped using the crutches completely, even outside the clinic.

By making the boy focus externally—on the game and the ball—rather than internally—on his body and chronic pain—Dommerholt says that he was able to get the patient to work on his functional recovery while having a lot of fun. “Almost all chronic pain patients have kinesiophobia—they’re terrified to move,” explains Dommerholt. “That’s why we use a strong external focus. The key is to make exercise enticing and to bring the fun back into functional rehab. An internal focus will limit people. If you emphasize what they can-not do, you emphasize their fears and anxiety—even if you don’t want to.”

For example, Dommerholt says he doesn’t tell a patient, “Make sure you don’t hyperextend your elbow, because you could pop your joint.” Instead, he puts the patient in the proper environ-ment, absorbed in an activity in which the patient naturally will do what the PT wants.

Patients at PhysioFitness jump on tram-polines while catching Frisbees that are thrown to them, use a climbing wall in a black-lighted room with glow-in-the-dark holds, and evade laser lights in a room that resembles one in the movie Mission Impossible.

“Everyone loves it,” says Dommerholt. “When they love what they’re doing, they move again.”

Michele Wojciechowski is a freelance writer.

REFERENCES1. Kleim JA, Jones TA. Principles of experience-

dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. February 2008(51):S225-S239.

2. An Introduction to Occupational Therapy, Physical Therapy, and Speech-Language Pathology Incorporating Hippotherapy in Clinical Practice. Fort Collins, CO: American Hippotherapy Association, 2016. http://www.americanhippotherapyassociation.org/wp-content/uploads/2015/02/AHA-Intro-PPT-for-MedProfessionals_9_28_2016_final-ver.pdf. Accessed January 10, 2018.

3. Kennedy BL, Wirthrington N, Dupree PJ, Black J, Flynn S. Treasure in therapeutic neurogaming for cognitive rehabilitation. Arch Phys Med Rehabil. 2010(96):e30-31.

"We found that—in a short period of time—the veterans had improved cognitive function more so using our game than they did with the traditional workbook.”— Sheryl Flynn




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Professional Pulse

Health Care Employment Rose 20,600 in January; Growth Strongest in Medium And Large Firms

DATAPOINTS

Economy At A

Glance

CHANGE IN HEALTH CARE

EMPLOYMENT

UNEMPLOYMENT RATE32,800

20,600 4.1%4.1%

CON

SUM

ER P

RICE

INDE

X

0.2%

0.5%

(All items)

0.4%

0.0%

PRODUCER PRICE IN

DEX

(Finished Goods)

EMPLOYMENT COST INDEX

0.6%(Civilian workers)

All figures are from December 2017-January 2018 except Employment Cost Index, which reflects third-to-fourth-quarter change.Source: Bureau of Labor Statistics, Department of Labor http://www.bls.gov/eag/eag.us.htm

0.7%

Health care added 20,600 jobs in January, following an increase of 32,800 in December, according to the US Bureau of Labor Statistics (BLS), for a total of 15,888,000 people nationwide employed in that field. Outpatient care centers added 5,100 jobs. Ambula-tory services added 7,700 jobs. Home health services added 700 new jobs after no change in December. Its employment now stands at 1,433,300. Health subgroups that lost employment included dentists (5,100), physicians (1,100), and nursing care facilities (2,100). For the year, health care added 294,900 jobs.

Total nonfarm payroll employment increased by 200,000 in January. Rising sectors, in addition to health care, included construction, food services, and manufacturing.

Meanwhile, payroll company ADP has issued its monthly National Employment Report, finding that private sector employment increased by 234,000 in January. ADP, which uses a different methodology than does BLS, calculated that employment in health care and social assistance increased by 41,000. Other large gainers included leisure/hospitality (46,000), administrative/support services (32,000), and trade/transportation/utilities (51,000).

Companies of all sizes reported solid gains. Small businesses—defined as 1-49 employees—added 58,000 jobs. Medium businesses—50-499 employ-ees—added 91,000 jobs. And large businesses—500+ employees—added 85,000 jobs.

According to Ahu Yildirmaz, vice president and co-head of the ADP Research Institute, “We’ve kicked off the year with another month of unyielding job gains. Service providers were firing on all cylinders, posting their strongest gain in more than a year. We also saw robust hiring from midsize and large companies, while job growth in smaller firms slowed slightly.” According to ADP, 2018 appears to be on track to be the eighth consecutive year in which the economy creates over 2 million jobs.

www.bls.gov/emp/ep_table_102.htm

www.adpemploymentreport.com/2018/January/NER/NER-January-2018.aspx

Income/ Employee

Revenue/ Employee

Asset Turnover

Receivables Turnover

Current Ratio

EHC 7,306 107,660 0.80x 8.79x 1.38

THC -4,202 144,830 0.79x 5.92x 1.29

USPH 5,304 104,130 1.01x 8.16x 2.29KND -1,659 62,910 1.04x 5.15x 1.56

AVERAGE 1,687 104,883 0.91x 7.01x 1.63

Note: In 2017 HealthSouth changed its name to Encompass Health Corporation and its stock symbol from HLS to EHC.

EHC: Encompass Health Corporation | THC: Tenet Healthcare USPH: US Physical Therapy Inc | KND: Kindred Healthcare

All data are TTM (trailing twelve months). Information updated: 2/14/18 * Last 4 quarters + Rounded to nearest dollar Source: Fidelity Investments: www.Fidelity.com

Operating Metrics of Selected Health Care Companies

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http://www.apta.org/apta/hotjobs/default.aspx


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Professional Pulse

Home Health Faces Challenges in Wake of Budget DealA major advocacy issue for the physical therapy profession was resolved with the elimination of the hard cap on therapy services under Medicare (see facing page), but other provisions in the budget bill passed in February have created different challenges. Case in point: In the home health arena, patients and providers are facing budget cuts and a reduction in payment units, with the possibility of even more dramatic—and potentially damaging—changes to come.

The final budget package includes provisions reducing the home health care unit of payment to 30 days from its current 60-day unit. In addition, the home health market basket percentage—the amount of money CMS plans devote to goods and services in a particular area—will be 1.5%. Both changes are slated to start in 2020, and other potential harmful moves could be on the horizon. The changes, opposed by APTA, were included late in lawmakers’ negotia-tions around the budget deal, with no

opportunity for input from stakehold-ers. The new provisions also elimi-nate therapy thresholds that affect episode payment calculations.

The payment unit changes echo provisions included in CMS’ failed attempt to adopt what it called the Home Health Grouping Model (HHGM), a sweeping overhaul of the home health payment system pro-posed the summer of 2017. APTA and other groups opposed nearly all of the proposals associated with HHGM, including the switch to the 30-day payment unit. In a letter to CMS, APTA described the 30-day unit as a change that would produce a “per-verse financial incentive for providers to inappropriately decrease lengths of stay and/or avoid admitting patients who will require care beyond the 30-day episode.” CMS dropped its efforts to adopt HHGM in the fall. (See PT in Motion’s feature story in the February issue, “The Payment Squeeze in Postacute Care,” for more background on HHGM.)

Although the 30-day unit adopted in the budget deal is similar to what was proposed in HHGM, there’s 1 major difference: the provision now in place is budget-neutral. The 30-day unit proposed by CMS through the HHGM would have resulted in signifi-cant reductions in reimbursement.

But that doesn’t mean the ideas behind HHGM are dead. In fact, says Kara Gainer, APTA’s director of regulatory affairs, the budget deal also includes a provision direct-ing the Department of Health and Human Services (HHS) to develop a new case-mix system that can be implemented by 2020. The concern of APTA and other home health supporters is that HHS will resurrect many of the changes proposed in the HHGM.

With the therapy cap issue settled, APTA will focus its advocacy efforts in different ways, Gainer says. The threats to home health will be 1 of the association’s targets.

www.apta.org/uploadedFiles/APTAorg/Payment/Medicare/Coding_and_Billing/Home_Health/Comments/APTACommentsCY2018HomeHealthPPSProposedRule.pdf

www.apta.org/PTinMotion/2018/2/Feature/PaymentSqueeze/



HEALTH CARE HEADLINES

Therapy Cap Fix and Improved Access for Medicare Patients Comes With PTA Payment CutThe looming threat of a hard cap on physical therapy services under Medi-care has been eliminated.

As part of a sprawling bipartisan budget deal passed in February, Congress enacted a permanent solu-tion to the problematic hard cap on outpatient physical therapy services under Medicare Part B. The action ends a 20-year cycle of patient uncer-tainty and wasteful short-term fixes.

Ending the hard cap had been a high priority for APTA since its introduc-tion in 1997 as part of the Balanced Budget Act. Legislators’ backing for repeal reached a tipping point in 2017, when lawmakers developed a bipartisan, bicameral agreement to end the cap. Congress failed to enact that deal in 2017, but elements of the plan are included in the recently-ap-proved 2-year budget.

That’s the good news. The bad news is that Congress chose to offset the cost of the permanent fix (estimated at $6.47 billion) with a last-minute addition of a payment differential for services provided by physical therapist assistants (PTAs) and certi-fied occupational therapy assistants (COTAs) compared with payment for the same services provided by physical therapists (PTs) and occupa-tional therapists (OTs), respectively. The payment differential, which was strongly opposed by APTA and other stakeholders, provides that PTAs and OTAs will be paid at 85% of the Medicare physician fee schedule beginning in 2022.

That pending payment differential under Medicare is somewhat com-parable to that between physician assistants and physicians, but it was added to the budget bill late and without warning. It wasn’t part of the 2017 bipartisan agreement legislators reached, nor was it part of any discus-sions or negotiations on Capitol Hill after that.

When the proposed differential was added to the budget deal, APTA quickly reached out to congressional offices with proposed amendments. None were accepted. The next morn-ing, Congress passed the massive budget legislation that includes increases for military and domestic spending, adding an estimated $320 billion to the federal budget deficit.

“Stopping the hard cap is a victory for our patients, and for our dedicated advocates,” said APTA President Sharon L. Dunn, PT, PhD, a board- certified orthopaedic clinical spe-cialist. “For 2 decades we have held back the hard cap through repeated short-term fixes—17 in total—that were achieved each time only through sig-nificant lobbying efforts by APTA and other members of the Therapy Cap Coalition. In that time, the hard cap was a genuine and persistent threat to our most vulnerable patients—a threat we saw realized earlier this year, when Congress failed to extend the therapy cap exceptions process. Today that threat has been eliminated.”

Dunn said the January 1, 2022, imple-mentation date for the PTA payment cut that APTA opposes provides time to explore solutions with the Centers for Medicare and Medicaid Services (CMS) as it develops proposed rules.

“APTA will leverage its congressional champions, the APTA Public Policy and Advocacy Committee, and the PTA Caucus on strategies to address the CMS activities,” Dunn said. “Our collective efforts will drive the associ-ation’s work to ensure that guidance to implement the new policy is favor-able to PTAs and the profession, while ensuring that access is not limited for those in need of our services.”

The legislation provides a fix for the therapy cap by permanently extend-ing the current exceptions process, eliminating the need to address the issue from year to year. Among the provisions included in the new policy:

k Claims that go above $2,010 (adjusted annually) still will require the use of the KX modifier for attestation that services are medi-cally necessary.

k The threshold for targeted medical review will be lowered from the current $3,700 to $3,000 through 2027. However, CMS will not receive any increased fund-ing to pursue expanded medical review, and the overall number of targeted medical reviews is not expected to increase.

k Claims that exceed $3,000 will not automatically be subject to targeted medical review. Instead, only a percentage of providers who meet certain criteria will be targeted, such as those who have had a high claims-denial percent-age or have aberrant billing pat-terns compared with their peers.

For home health, the deal includes positives related to rural add-ons, a market basket update increase of 1.5% in 2020, and use of home health medical records for determining eligibility. However, it also requires a switch from a 60-day to a 30-day episode in 2020 and eliminates the use of therapy thresholds in case-mix adjustment factors. (See related story on page 44 for more details.)

“While this package does not afford APTA with everything we would have liked, we should take a moment to celebrate closing the door on a 20-year advocacy effort that has challenged our ability to ensure timely and appropriate services to patients,” Dunn said. “Reaching this milestone affords APTA the opportu-nity to expand our advocacy agenda to implement more fully our vision to transform society by optimizing movement to improve the human experience.”



Professional Pulse

CMS Issues Coding, Other Details On Supervised Exercise Therapy for Peripheral Artery DiseaseThe US Centers for Medicare and Medicaid Services (CMS) has released details on how it will process claims made as a result of its decision to cover supervised exercise therapy (SET) in the treatment of peripheral artery disease (PAD).

The expansion covers physician-referred SET for up to 36 30- to 60-min-ute sessions over a 12-week period. The sessions must be conducted in a physician’s office or outpatient facility, and must be delivered by “qualified auxiliary personnel”—a designation that includes physical therapists, nurses, and exercise physiologists. Supervision is to be conducted by a physician or “non–physician practitioner”—a physician assistant or nurse practitioner/clinical nurse specialist.

Although CMS announced the change in May 2017, it only recently released details of provider coding and claims processing for Medicare Administra-tive Contractors (MACs). This information is available from 3 resources:

k A Medicare Learning Network “Medicare Matters“ posting on the changes

k A CMS update to the Medicare Claims Processing Manual

k A CMS update to the Medicare National Coverage Determinations publication

To receive coverage for SET, Medicare beneficiaries with PAD must have a face-to-face visit with a physician and be referred for the program. The physician visit also must include education on cardiovascular disease and PAD risk reduction. Medicare Administrative Contractors can allow for more sessions or a second set of 36 sessions, but these additional sessions require another referral.

www.cms.gov/Outreach-and-Education/Medicare-Learning-Net-work-MLN/MLNMattersArticles/Downloads/MM10295.pdf

www.cms.gov/Regulations-and-Guidance/Guidance/Transmit-tals/2018Downloads/R3969CP.pdf

www.cms.gov/Regulations-and-Guidance/Guidance/Transmit-tals/2018Downloads/R204NCD.pdf

BuzzFeed Features Physical Therapy ‘Success Stories’How about a little good news? Specifically, how about a little good news from patients who credit physical therapy and their physical therapists (PTs) with transforming their lives?

Recently, BuzzFeed published “9 Physical Therapy Success Stories That’ll Make You Choke Up A Bit,” a collection of first-person accounts from patients who faced a range of issues includ-ing spine facture, labrum tears, recovery from a coma, and interstitial cystitis. The reason for the project, according to Buzz-Feed, was to “inspire others who are currently recovering from pain, injuries, surgery, or other problems.”

A few quotes from contributors:

“Thanks to physical therapy, I am now able to postpone [knee] surgery for at least 5 years with-out risking harm. Even though it may be hard, physical therapy is worth it in the end.”

“It was difficult and scary, but I can honestly say physical ther-apy saved my life.”

“My advice to all of you is to lis-ten to your PT and trust them.”

“One specific thing: PTs and [occupational therapists] need more recognition and props. They have to work really hard to get some of us back to some sort of norm.”

“I owe [my physical therapist] my mobility and my life without pain.”

www.buzzfeed.com/anthonyrivas/physical-ther-apy-stories-restore-faith-medi-cine?utm_term=.wtVbO0boV



HEALTH CARE HEADLINES

Musculoskeletal Disease: A Major Contributor to Health Care CostsMusculoskeletal diseases aren’t just widespread— they’ve also become a significant factor in the economy, with associated costs estimated at an amount equal to 5.76% of the US gross domestic product. That’s just 1 of the insights offered in the latest edition of a detailed report on the impact of musculoskeletal conditions across the country.

Advance-published sections of the US Bone and Joint Initiative’s (USBJI) 4th edition of “The Burden of Mus-culoskeletal Diseases in the US” are being rolled out at the USBJI web-site. The report compiles extensive data on a wide range of conditions, including low back pain, neck pain, arthritis, osteoporosis, and injuries both in aggregate and among special populations, and includes insight on

economic impact. The latest edition also features a new section on neuro-muscular diseases.

According to USBJI, more than half of all adults in the US now report a chronic musculoskeletal condition—a rate that outpaces the prevalence of reported respiratory conditions (24%) and circulatory conditions including high blood pressure (42%). Chronic low back pain, joint pain, and disabil-ity make up 3 of the top 5 most com-monly reported medical conditions, the report states.

In turn, musculoskeletal conditions have become a major factor in health care costs—an estimated $332 billion between 2012 and 2014, according to USBJI, with costs likely to increase with an aging US population.

Three chapters of the latest edition now are available, with more to be released in the coming weeks. USBJI said it hopes the resources will help highlight the need for more materials devoted to addressing prevention and treatment of musculoskeletal disorders.

“In spite of [the overall prevalence and significant costs], research funding for musculoskeletal-related conditions remains substantially below that of other major health conditions, such as cancer and respiratory and circulatory diseases,” the report says. “If health care costs in the future are to be con-tained, musculoskeletal diseases must come to the forefront of research.”

APTA is a founding member of USBJI.

www.boneandjointburden.org/

APTA’s popular Business Skills in Physical Therapy: Strategic Marketing home-study course is in its second edition, with new ideas from author Peter R. Kovacek, PT, DPT, MSA, founder of PTManager.com, added to the tried-and-true guidance that made the fi rst edition an APTA bestseller.

Want to attract today’s health care customers?

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Business Skills in Physical Therapy: Strategic MarketingAPTA’s popular Business Skills in Physical Therapy: Strategic Marketing home-study course is now in its second edition, offering you the latest strategies—along with the tried-and-true guidance from the first edition—that will help every practice, large or small, capture the opportunities to build and maintain a strong customer base in today’s vibrant, yet challeng-ing, health care marketplace.

See what’s new from author Peter R. Kovacek, PT, DPT, MSA, founder of PTManager.com:

• The Physical Therapist Marketing Readiness Assessment Tool for you, your team, and your entire organization

• Discussions on branding your practice and the physical therapy profession

• Updates on regulation and legislation that affect payment for services

• Guidance for using “new marketing” tools such as the Internet and social networking

• Expanded analysis of evaluating success

• Contemporary covered-coil binding that lays flat for easier reading

Strategic Marketing includes case studies, a marketing readiness assessment tool, and an outline for developing a full marketing plan. Pass the final exam and receive continuing credits through the APTA Learning Center (learningcenter.apta.org).

Other courses in the Business Skills in Physical Therapy series:Legal IssuesDefining Your Business

www.APTA.org

Earn .6 CEU!(6 contact hours)



Professional Pulse RESEARCH

ROUNDUP

To Avoid LBP, Runners Should Think DeepEven though they are keeping fit, up to 14% of American runners experi-ence low back pain (LBP) each year. But runners can reduce their risk by developing their deep-core muscles, said the authors of a recent study in the Journal of Biomechanics.

While many fitness enthusiasts focus on their abs, they may neglect the trunk muscles they can’t see. “Improper function of this muscu-lature may lead to abnormal spinal loading, muscle strain, or injury to spi-nal structures, all of which have been associated with increased low back pain risk,” said the researchers.

To test this hypothesis, the authors used motion-capture technology to collect kinematic data from 8

participants with no history of back pain and no recent injuries. The data, gathered while the participants ran, was used to create simulated full-body models in OpenSim, a software tool for modeling movement.

In the simulations, researchers gradually weakened the models’ deep-core muscles, both individu-ally and together. They found that when deep-core muscles are weak, superficial-core muscles—particularly the superficial longissimus thoracis (LT)—tend to overcompensate, which may result in muscle injury or fatigue. And since the superficial LT was most often the muscle overcompensating for weak deep-core muscles, it may be “most at risk for fatigue or injury” if

deep core muscles are not function-ing properly.

The authors said that certain deep-core muscles appear to be more important than others in runners. “The deep erector spinae required the larg-est compensations when weakened individually,” the authors wrote, con-cluding that “it may contribute most to controlling running kinematics.”

When all deep-core muscles were weak, or when only the deep-erector spinae was weakened, there was a sig-nificant increase in both compressive and shear spinal loading in the upper back, with a decrease in the lower back. Over time, this could result in damage to the spine and increase the risk of injury, the authors warn.

www.ncbi.nlm.nih.gov/pubmed/29249454

http://opensim.stanford.edu



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Professional Pulse

PTJ: Research on Computer Gaming’s Effectiveness in Physical Therapy Needs to Level UpPlaying active computer games (ACGs) may increase older adults’ physical activity, but authors of a recent article pub-lished in Physical Therapy (PTJ) say that current data provide “lit-tle confidence” that such activity improves physical health or cognition. And it’s not yet clear whether it is safe for older adults to play ACGs unsupervised.

Active computer gaming such as Nintendo Wii or Microsoft’s Xbox is being used in rehabilitation based in part on an assumption that sounds reasonable enough: Because the games are fun and motivating, adherence to phys-ical therapist interventions will improve, which will in turn have an impact on health outcomes such as falls. Authors of the PTJ review sought to determine if that assumption is supported by data.

They analyzed 35 randomized controlled trials with 1,838 total participants to deter-mine whether ACGs improved balance, functional exercise capacity, functional mobility, fear of falling, and cognition. The authors also examined partic-ipant adherence to interven-tions and factors such as dose, frequency, setting, and whether interventions were supervised.

They found that playing ACGs had a “significant moderate effect” on cognition and bal-ance, and on functional exercise capacity when participants played for more than 120 min-utes per week. But ACGs had no effect on functional mobility or fear of falling. Researchers inter-pret the findings with caution, as all of the studies were rated as low or very low quality.

The fact that ACGs had a mod-erate effect “on one outcome associated with falls risk yet no effect on another…highlights the importance of tailoring ACG interventions to older adults’ specific needs for daily func-tion,” the authors wrote. The ACG interventions employed a variety of mechanisms to improve function, they explain, and facing forward while stand-ing in 1 spot may have helped participants improve balance but not functional mobility.

The authors also raised safety as an issue for ACGs, which they said hold “promise for self-led exercise interventions for even the most frail.” But determining which ACGs are safe to use unsupervised was impossible to determine, as only 3 studies used unsupervised interven-tions. Further, only 9 studies included individuals with balance impairments—making them less likely to be unable to engage in traditional exercise. This makes it difficult to evaluate the effects of ACG for this popu-lation, the authors wrote.

“Findings of this review sug-gest that ACGs may provide positive physical and cognitive health benefits greater than those observed following no treatment, traditional exercise, or rehabilitation interventions for balance, functional exercise capacity, and cognitive function,” the authors concluded, but high-er-quality, “robust” randomized controlled trials are needed “in order to state with confidence” that playing ACGs is effective.

https://academic.oup.com/ptj/article/97/12/1122/4097725

RESEARCH ROUNDUP



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Professional Pulse

Making Transformation Possible: Panelists at APTA Event Explore Paths Toward Rethinking Pain ManagementEnding the opioid crisis—or even just making a dent in it—is going to require transforming an entire culture’s attitudes about pain and its man-agement. But panelists at a recent APTA event believe there are models and concepts that provide hope for a future in which multidisciplinary nondrug approaches to pain replace an opioid prescription as the norm in health care.

At its February 5 live event, “Beyond Opioids: Transforming Pain Man-agement to Improve Health,” APTA brought together 7 panelists with a range of perspectives. The entire conversation was broadcast live on Facebook, and a recorded version is available for viewing.

Though each speaker brought something different to the table, a few common threads emerged when it came to what it will take to address the opioid epidemic, particularly as it relates to pain management. Pan-elists tended to emphasize the need for increased and more open com-munication, better identification of risk factors for opioid abuse, greater use of multidisciplinary approaches to pain management, and the need for more education delivered to patients, providers, employers, and entire communities.

Panelist Joan Maxwell’s story served as a touchpoint, highlighting the patient experience and bringing current weaknesses in pain man-agement into sharp relief. Maxwell’s journey as a patient began with a double mastectomy, which led to a staph infection and 9 surgeries in less than 3 years. Along the way, Maxwell experienced a stroke. And at every juncture, she was prescribed opioids, with few conversations about what to expect in terms of pain and what other ways her pain might be managed.

Luckily for Maxwell, who now is a patient and family advisor for John Muir Health and patient-member of Patient & Family Centered Care Part-ners Inc, she was able to avoid addic-tion. Her brother-in-law, however, was not as fortunate. Over the course of what Maxwell described as “2 failed back surgeries,” he became addicted to opioids. His wife administers his drugs and hides the medications from him.

“He was just a regular person like all of us,” Maxwell said, “but just 1 sur-gery, and he was addicted.”

Both Grant Baldwin, director of the division of unintentional injury pre-vention for the Centers for Disease Control and Prevention, and Rep Donald Norcross (D-NJ) echoed Max-well’s call for better communication, albeit in different settings. Baldwin told the audience that more outreach is needed to spread the word about the CDC’s guidelines for chronic pain management and its recommenda-tions for nondrug approaches as a first-line treatment. Norcross spoke about the need for better commu-nication to lift the stigma around addiction and help communities and the federal government focus on a disease model.

Norcross even offered advice about getting the message out. “Make an appointment when your congressman or congresswoman is in your district, and give the real story,” Norcross said. “This is not some urban issue that happens in the dark of night. This can happen anywhere.”

As medical director of Swedish Pain Services in Seattle, Washington, and president of the American Academy of Pain Medicine, Steven Stanos, DO, brought firsthand knowledge of the latest approaches to pain man-agement. He outlined an intensive multidisciplinary process at Swedish

Pain Services that involves PTs, occupational therapists, pain medi-cine specialists, pain psychologists, and nurses in group and individual treatment settings. Stanos conceded that such systems are not available to everyone, and that cost can be challenging for some patients. Still, he said, patients everywhere should be wary of treatment that relies on pain medications only.

“I always think that [the presence of an opioid prescription] is a marker that [patients] didn’t have comprehensive care,” Stanos said. “A lot of [what needs to change] is about education and unlearning maladaptive ideas.”

Sarah Wenger, PT, DPT, is doing that through a “Power Over Pain” pro-gram that emphasizes individualized approaches to management, with a focus on education and honest con-versations with patients. Wenger is a board-certified clinical specialist in orthopaedic physical therapy and an associate clinical professor at Drexel University’s College of Nursing and Health Professions.

In many instances, Wenger explained, patients need to understand that they may always experience some degree of pain—”I don’t think zero pain is particularly realistic for any of us,” she added—but that they can be empow-ered when they understand how to manage pain in healthy ways. “The truth is, most people don’t feel really great on opioids,” Wenger said.

Echoing previous panelists’ empha-sis on communication were the final 2 speakers, Tiffany McCaslin and Bill Hanlon, PT, DPT, who also is a board-certified clinical specialist in orthopaedic physical therapy. McCaslin, a senior policy analyst for the National Business Group on Health, said employers need to come to grips with the impact opioids and opioid-based pain treatment is having



UPDATE ON OPIOIDS

on employees and, in turn, on the overall operation of the business itself. The concept is at the heart of a new summit program being rolled out by her organization. “We’re pressing on our members to take a look at this issue with eyes wide open” and to reduce the stigma around addiction, McCaslin said.

As a PT working in addiction recovery at the St Joseph Insti-tute in Port Matilda, Pennsylva-nia, Hanlon often finds himself helping patients who have been adversly affected from a pain treatment system that relies too heavily on opioids. But that’s not the entire patient popula-tion, he explained—many of the individuals he helps don’t have underlying pain but experience it for the first time in the form of withdrawal symptoms.

In either case, he said, commu-nication and a multidisciplinary approach are key.

“The way we approach addiction needs to be multidisciplinary, just as the approach to manag-ing pain needs to be multidisci-plinary,” Hanlon said. “And as we get all the disciplines involved and understand the psychology of the person…we can help them more and more.”

But according to Hanlon, that multidisciplinary help must begin with helping a patient to under-stand what’s possible—without an overreliance on opioids.

“It’s about communicating with people,” Hanlon said. “It’s talking with people and letting them experience the wellness.”

www.facebook.com/American PhysicalTherapyAssociation/videos/10157059779298294/

Drug and Alcohol Abuse Spikes As Perceived Health Care ProblemA recent Gallup poll has found that Americans’ mention of drug and alcohol abuse as the most urgent national health problem has shot up. In November 2017, 14% of US adults named it the most urgent health problem in the country, up from 3% a year earlier.

Mention of drug and alcohol abuse is more than double the previous high of 6%—recorded in 1997, when use of methamphetamine, as well as “club drugs” such as ecstasy, were on the rise. From 1999 to 2015, no more than 2% of Amer-icans cited substance abuse as the nation’s most urgent health problem.

In the overall ranking of most urgent health problems, drug and alcohol abuse, at 14%, follows access to health care, at 24%, and cost, at 16%.

http://news.gallup.com/poll/222293/substance-abuse-spikes-perceived-health-problem.aspx

APTA Releases New #ChoosePT VideoAnyone can experience pain—but nobody should feel trapped by opioids as the only way to manage it. That’s the message at the heart of APTA’s newest video public service announcement (PSA)—“Choose More Movement and Better Health”—in the #ChoosePT opioid-awareness campaign.

The PSA, which debuted during a live APTA panel discussion on pain man-agement (see facing page), features a teenaged boy, an adult woman, and an older man each experiencing pain, attempting to manage it through opioids alone, and ultimately making progress with physical therapy.

“Pain is personal, but treating pain takes teamwork,” the voiceover says. “When it comes to your health, you have a choice—choose more movement and better health. Choose physical therapy.”

The PSA is part of the associa-tion’s national public awareness campaign, #ChoosePT, which has won multiple national awards, including best video for the initial public service announcement.

APTA’s first #ChoosePT PSA reached more than 377 million Americans via television and radio in its first year of release, and APTA’s official consumer information website, MoveFor-wardPT.com, was visited by more than 3.2 million users in 2017.

www.youtube.com/watch?v=zAaf_wqeDck

www.moveforwardpt.com/ChoosePT/

APTA's latest PSA for the #ChoosePT campaign focuses on teamwork to manage pain.



Professional Pulse

IN MEMORIAMRobert Hickok, PT, MHARobert Hickok, PT, MHA, died on January 10 at the age of 91. He had served as a member of APTA’s Board of Directors and as president of the Missouri Physical Therapy Association. He also was on the Organizing Board of Trust-ees of the Foundation for Physical Therapy.

Hickok earned his bachelor’s degree from Washington University’s School of Physical Therapy in 1953 and began a 20-year career as a PT and director of rehabilitation at Jewish Hospital. After receiving a master’s degree in health administration he began working as the assistant vice chancellor for medical affairs at Washington University School of Medicine.

Now’s Your Chance to Step up To APTA Committee ServiceHave you ever wondered how the McMillan lecturer is selected? Are you a strategic business thinker able to help move your association’s finances forward? Are you ready to serve your profession?

The call for volunteers to serve on APTA committees is open. Members interested in serving on the Ethics and Judicial, Finance and Audit, Leadership Development, and Public Policy and Advocacy committees, an Awards subcommittee, or the Reference Committee are encouraged to let APTA know of their willingness to participate.

APTA heavily relies on its volunteers and needs the best skills, passion, and var-ied perspectives to build an energetic, inclusive, and innovative corps of volunteer leaders.

www.apta.org/VolunteerGroups/

Ready to take a lead in shaping the future of APTA? Apply through the Volunteer Interest Pool by updating your profile, then click “Apply for Current Vacancies” to answer questions specific to the committee. Don’t forget to click “Save Changes” to complete your application. Your profile and thoughtful responses to the application question will be read carefully and will help us select the most appropriate, diverse, and inclusive teams possible.

www.apta.org/apta/volunteers/default.aspx?NavID=10737421976

Foundation Awards Kendall Scholarships, Research GrantsThe Foundation for Physical Therapy (Foundation) recently awarded Florence P. Kendall Doctoral Scholarships for 2017 to Rachel Bican, PT, DPT, The Ohio State University; Kristina M. Kelly, PT, DPT, EdM, Ohio State; Jesse L. Kowalski, PT, DPT, University of Minnesota; Dana R. Mathews, PT, DPT, MS, University of Delaware; and Lauren M. Pacho, PT, DPT, board-certified neurologic clinical specialist, Ohio State.

The $5,000 Kendall Doctoral Scholarship is awarded annually to out-standing physical therapists as they begin their first year of graduate studies toward a postprofessional doctoral degree.

Four researchers also were awarded a total of $230,000 in research grants from the Foundation in support of their projects to evaluate the effectiveness of physical therapist interventions. Those awardees and grants are:

Stephanie Di Stasi, PT, MSPT, PhD, board-certified orthopaedic clinical specialist—Mercer-Marquette Challenge Research Grant. Di Stasi was awarded a $40,000 grant for a study on load modification vs standard exercise for individuals with greater trochanteric pain.

Kenneth J. Harwood, PT, PhD—Health Services Pipeline Grant. Harwood was awarded a $50,000 grant to pursue a 1-year research project titled “The Effects of Timing of Physical Therapy on Health Care Costs, Utiliza-tion, and Opioid Use.” The grant was made possible through a donation from APTA.

Victoria G. Marchese, PT, PhD—Snyder Research Grant. Marchese was awarded the $40,000 Snyder grant for a 1-year research project focused on a strengthening intervention for childhood cancer survivors of low-er-extremity sarcoma.

Charles A. Thigpen, PT, PhD, MS—Magistro Family Foundation Research Grant. Thigpen was awarded $100,000 for a 2-year project titled “Effectiveness of a Physical Therapy First Musculoskeletal Pathway.”

https://foundation4pt.org/2017- kendall-scholarships-research-grants/



Actress Kathy Bates Helps to Publicize Lymphedema Management In APTA Oncology Section’s JournalHealth care providers are increas-ing their knowledge of lymph-edema management, but there’s still much work to be done. Just ask film and television star Kathy Bates, author of a guest editorial in a special issue of Rehabilitation Oncology (RO) entirely devoted to the disease. RO is the science jour-nal of the APTA Oncology Section.

Bates’ editorial, available for free, not only gives an account of her experience with lymphedema after a bilateral mastectomy, but also provides insight into how much the patient experience has changed over the decades. Bates explains that her mother experi-enced lymphedema after cancer surgery in the 1970s, and that, “with no treatment in those days, I watched her spirit defeated as she realized she would have to live with the pain and heartache for the rest of her life.”

Given the experience with her mother and another individual she knew who lived with lymph-edema after surviving stage 4 melanoma, Bates was well aware of the effects of lymphedema and pleaded with her surgeon to leave as many lymph nodes intact as possible. Bates writes that when her surgeon later told her that he felt it necessary to remove 19 lymph nodes from her left armpit and 3 from her right, she was “dev-astated” and experienced what she describes as an “emotionally draining” recovery.

Eventually Bates came to terms with the necessity of the node removal, but she now lives with the reality of lymphedema. In the

editorial, she writes of her treat-ment and management of ongo-ing symptoms, and of her more recent work with the Lymphatic Education and Research Network (LEARN), which she now serves as spokesperson.

Bates wrote that with an estimated 140 million individuals with lymph-edema—some undiagnosed—it’s imperative that efforts to edu-cate both patients and providers continue.

“Lymphedema needs to be recog-nized as a disease that deserves money for research,” Bates writes. “We need awareness.…Please help me spread the word.”

In an accompanying open-access editorial, guest editor Nicole Stout, PT, DPT, FAPTA, certified as a lymphedema therapist by the Lymphology Association of North America, describes the advance-ments that have been made in both lymphedema management and clinical knowledge among health care providers. She adds, however, that more needs to be done.

“The true measure of our advance-ment is in how our patients are impacted by the evolution in the field,” Stout writes. “Decreased wait times to access therapy, more knowledgeable therapists, and better and higher-quality materials and treatment devices have emerged in the last decade. However, there are still significant barriers to care and clinical ques-tions that we must set our sights on solving in the next decade,” including payment, access to spe-cialty care, and the slow growth of telehealth services.

http://journals.lww.com/rehabonc/pages/currenttoc.aspx

ASSOCIATION RESOURCES

From PT Pintcast: Embrace Outcomes RegistriesMedical specialty societies and asso-ciations have a responsibility to help members define, measure, and report value—or someone else will do it for them. And registries such as APTA’s Physical Therapy Outcomes Registry are important vehicles for staying ahead of the curve.

This was 1 takeaway from a recent PT Pintcast podcast featuring Heather Smith, PT, MPH, APTA director of quality, and Nathan Glusenkamp, a registry expert who is director of registries at the American Academy of Orthopaedic Surgeons (AAOS).

For Glusenkamp, associations are ideal for developing clinical registries because they bring “specialized expe-rience” that can’t be matched. He is “a firm believer that if [medical specialty societies] are not engaged in defining value, reporting value, measuring value—that’s still going to happen, but it’s probably going to happen in a way [members] don’t like.”

Smith said that association-run regis-tries serve another important func-tion: helping providers get a handle on the seemingly inevitable move toward value-based health care.

“I can’t stress enough, being prepared ahead of time and really getting involved as early as possible to start to think about the value that you bring,” Smith said in the podcast. “Not just in the care that you deliver today, but think more broadly about the new and different ways we may be able to bring value to the health care system. Being able to support payment for these services in new and emerging models is really exciting. So you’ve got to be involved to reap the benefits of the new frontier we’re moving into.”

www.ptoutcomes.com

www.ptpintcast.com


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Parker Laboratories Expands Space to Meet Increasing DemandParker Laboratories Inc is relocating its corporate offices and finished goods warehouse to new space in Fairfield, New Jersey, while manufacturing facilities are expanding at the current Fairfield location.

The move and expansion increase Parker’s footprint to 100,000 square feet in the United States; the company also has international operations in the Netherlands. The moves, Parker says, respond to increased demand and anticipation of higher future demand.

The company is celebrating its 60th year in the ultrasound and electro- medical industries.

OPTP Introduces New Fascia Massage BallsOPTP has introduced 2 new Franklin Method fascia massage ball sets. The blue set is medium density and the purple set has a firmer density. Both can be used for Franklin Method exercises and for general massage therapy to relieve tension in tight areas. Their small size, OPTP says, makes them suitable for foot massage, helping to lessen and prevent pain associated with plantar fasciitis. They’re also portable—facilitating gym and travel use.

What Do Vinyl Gait Belts Offer?Quality • Reliability • Safety • Durability • CleanabilityAPTA offers 2 great gait belts, both with “wipe clean” ability, nickel-plated, rust-resistant rivets and hardware, and an imprint of the APTA logo to show your commitment as an APTA member.

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By Neal B. Finkelstein, PT, MPT, LMT, MSDefining Moment

They were 3 very different individuals who cumulatively have had a major impact on my life and those of others.I’ve worked in a variety of practice settings over the course of my 14-year career as a physical therapist (PT)—in acute care, at a physician’s office, at skilled nursing facility, and now in home health.

One challenge in home health, as in other settings, is working with commercial insurers. We’re allotted a certain number of visits with patients, but we must justify and lobby for care provision beyond that limit. This can be quite frustrating, as we often see ways in which patients would benefit from our continued services.

Another challenge involves previous level of func-tion (PLOF). Commercial insurers want PTs to return patients to their PLOF. But

the parameters for PLOF often are a gray area. If, for example, an individual was walking 3 years ago, had a stroke, and has been in a wheelchair ever since, it clearly cannot be the responsibility of the PT to return that person to walk-ing in the manner in which he or she did before the stroke occurred.

With those issues noted, here’s the story I’d like to tell.

I had a patient who lived in a hotel room with her husband. She was 56 years old, had morbid obesity, and had been limited to her bed for more than 9 months. Her husband was using a lift device to transfer her from bed to a chair. Her insur-ance company had allotted me just 6 visits.

My immediate reaction was, “Six visits! I could simply limit my focus to prevent-ing bed sores and leading her through leg-strength-ening exercises, but, holy cow, she’s just a year and a half older than I am! If I were her, I wouldn’t want to spend the rest of my life lying in bed or only sitting up in a chair.”

So, at the end of my first visit, I explained to her husband the challenges that her insurance situation pre-sented. I wanted to prepare him for what I was going to say next. “We’ll get her into the chair on my next visit, and then I’ll quickly be able to determine if walking is a reasonable goal for her,” I said. “I’ll keep her safe—don’t worry about that. But I need to determine what her physical capabilities are, so that I can help her maximize them. Provided we make progress, I’ll doc-ument that to the insurance

Beyond LimitationsExtending coverage and horizons.

Jacksonville, Florida-based Neal B. Finkelstein, PT,

MPT, LMT, MS, is a home health PT for Advance

Rehabilitation Management Group. He has a website at

www.smilellc.com.

Defining Moment spotlights a particular moment,

incident, or case that either led the writer to a career in

physical therapy or confirmed why he or she became a

physical therapist or physical therapist assistant. To submit

an essay or find out more, contact Associate Editor Eric

Ries at [email protected].



company. Then they’ll authorize more visits. That will give us an opportunity to really enhance your wife’s quality of life.”

On the second visit, I leveraged proper body mechanics and asked the patient to try to use her legs to stand. With only minimal assistance from me she stood for about 15 seconds. That told me what I needed to know. After I sat her down, I announced, “You’re going to walk again. I’ll make sure your insurance company gives me the visits we’ll need for us to get that done.”

Over our next few sessions, we worked on both standing and sitting exer-cises, and I gave her a home exercise program. As I’d forecast, we made enough progress that insurance autho-rization was extended beyond the 6 initial visits. Before long, she could perform standing balance activities, placing one foot in front of the other to strengthen her hip muscles in more of a static walking stance.

She soon progressed to being able to take a few steps with a walker and only contact guard assistance from me. One of her legs was notably weaker than the other, however, and she was dragging

it. To help correct that problem, on my next visit I had her stay in bed, and I used my own body as resistance during leg presses. I progressively used more of my body weight to help strengthen her weight-bearing tolerance.

Lo and behold, when we tried walk-ing again during the next visit, she no longer dragged the leg! She was extremely excited that she now could walk with the walker for about 20 feet before getting too tired to continue.

The next challenge was the height of her bed. As it happened, I was friendly with the owner of the hotel. I explained the situation, and the bed was replaced with one that sits closer to the floor. That allowed my patient’s husband to help lift her in and out of bed without needing the lifting device.

The insurance payments stopped eventually, but by that time my patient’s life had been transformed in ways that neither she nor her husband had foreseen when I first met them. The bottom line was, I’d seen in her not a person with a hopelessly disabling condition, but a contemporary who was in danger of being unnecessarily forced to spend the rest of her life in

bed. I’d seen an opportunity to do for that woman what I would want some-one to do for me, were I in that situa-tion. I’d want to walk again. I’d want to stop being so dependent on someone else. In short, I’d want my life back.

As I watched her guide her walker those 20 feet the first time, I felt almost as excited as she was. “If you 2 ever decide to renew your vows,” I told the happy couple, “I’d be more than hon-ored to walk you down the aisle.” They thanked me and laughed.

Talk about renewal! My patient’s success made me feel renewed and revitalized in my own profession.



By the NumbersBy the NumbersBy the NumbersBy the Numbers

Female college athletes annually injured in both practice and competition playing women’s basketball, as reported by the National Collegiate Athletic Association. The injury rate is 6.5 per 1,000 athlete exposures.

SOURCE College Sports–Related Injuries —United States, 2009–10 Through 2013–14 Academic Years. Morbidity and Mortality Weekly Report. Centers for Disease Control and

Prevention. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a2.htm.

Americans who say that pre-scription drugs have made lives better. That’s a drop from 62% in August 2015 and 73% in March 2008.

SOURCEKaiser Health Tracking Poll:

September 2016. Kaiser Family Foundation. http://kff.org/tag/tracking-poll/.

American adults who say their most desired health benefit from food or nutrients is weight loss or weight management. Cardiovascular health is the next most desired ben-efit, followed by energy and digestive health. Farther down the list—all below 5%—are muscle, bone, and mental health.

SOURCE2017 Food & Health Survey.

International Food Information Council Foundation. 2017. www.foodinsight.org/sites/default/files/2017_Food_and_Health_Survey_-_Final_Report-rev.pdf.

20.3%Physical therapist educa-tion program graduates in 2016 who were minorities.

SOURCEAggregate Program Data: 2016-

2017 Physical Therapist Education Programs Fact Sheets. Commission on Accreditation in Physical Therapy Education.

393Accredited and developing physical therapist assistant education programs. That’s a slight dip from 394 in 2015 and 408 in 2014.

SOURCEAggregate Program Data: 2016-2017 Physical Therapist Assistant Education

Programs Fact Sheets. Commission on Accreditation in Physical Therapy Education.

4.1 millionVisits to hospital emergency depart-ments (ED) in 2014 due to “back symptoms.” That was the sixth-most-frequent reason for an ED visit, accounting for 2.9% of all such visits. (First was “stomach and abdominal pain, cramps and spasms,” at 7.9%.)

SOURCENational Hospital Ambulatory Medical Care

Survey: 2014 Emergency Department Summary Tables. www.cdc.gov/nchs/data/nhamcs/web_tables/2014_ed_web_tables.pdf.

50%Health care data breaches attributable to criminal attacks. Other causes: third-party snafu (41%), stolen computing device (39%), and unintentional employee action (36%).

SOURCESixth Annual Benchmark Study on Privacy & Security of Healthcare Data.

Ponemon Institute.

10,858

31%

56%


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