This document discusses issues related to utilization management (UM) programs used by health insurers to manage physical therapy benefits and costs. It notes that outsourcing UM functions to third parties has increased due to provisions in the Affordable Care Act. Common problems with these UM programs include restrictive definitions of medical necessity, administrative burdens on providers from documentation requirements, delays in reviews and appeals, and tiering systems that penalize providers. The article advises physical therapists to engage with payers on these issues.
1. For Members of the American Physical Therapy Association February 2015
Healing
Lacrosse Players
The Future of
Physical Therapist
Education
Health Care
Technology
Today
2.
3.
4. 2 PTinMOTIONmag.org / February 2015
Vol 7 No 1 February 2015
6 Compliance
Matters
What you need to know about
utilization management.
10 Ethics in
Practice
Weighing the pros and cons
of a Facebook friend request.
82 PTAs
Today
APTA membership is
important in advancing
the profession’s future, the
author says.
84 Defining
Moment
Cleaning house—literally—
confirmed her career choice.
THE FUTURE OF
PHYSICAL THERAPIST EDUCATION
As health care evolves, so must the education of physical therapist
students. What will physical therapist education look like in 20 years?
Columns
Departments
48 Professional
Pulse
+ Data Points
+ Health Care Headlines
+ Business Sense
+ Association Resources
+ Research Roundup
72 Marketplace
+ Career Opportunities &
Continuing Education
+ Products
78 Advertiser Index
88 By the Numbers
28 STICKS AND STONES:
TREATING LACROSSE PLAYERS
Lacrosse is classified as a collision sport, the same as football. And its
name comes from the stick wielded by the players. These PTs help prevent
lacrosse injuries and are involved in rehabilitation when the inevitable
injuries occur.
38 HEALTH CARE TECHNOLOGY TODAY
Technological advances highlighted in this issue include nasal cells used
in a spinal cord transplant, telehealth kiosks, tips to control technology
vendor demos, the risk of medical device hacking, a robotic exoskeleton
whose developer is seeking approval for home use, and more.
15
8. Compliance
Matters
6 PTinMOTIONmag.org / February 2015
by Lindsey Still, JD
Compliance
Matters
Utilization Management
Review Essentials
Engagement with payers is key.
As payers explore ways to cut health
care costs and reduce utilization,
APTA has seen a surge in the use of
programs known as third-party physical
medicine and rehabilitation (PM&R)
benefit management, or utilization
management (UM).
Their increased popularity
is due in part to a provision
of the Patient Protection and
Affordable Care Act (ACA)
called the medical loss ratio
(MLR), which is intended
to limit insurer profit by
requiring that a minimum
percentage of premium
dollars be spent on medical
care (as opposed to admin-
istrative costs). Under this
provision, midsized insurers
are required to maintain an
80/20 ratio—meaning that
at least 80% of premium
dollars must be spent on
medical care, and no more
than 20% may be spent on
administrative costs. Large-
group plans must maintain
an 85/15 ratio. If an insurer
does not achieve the medi-
cal-care ratio target, it must
pay a penalty in the form of
customer rebates.
(Note: The term “midsized”
includes individual insurers
and businesses with 1 to 100
employees. “Large-group”
applies to employers with
more than 100 employees.)
While rebates to consumers
may be viewed as beneficial,
the MLR also has produced
unforeseen consequences,
such as the outsourcing of
UM. Traditional UM per-
formed by payers—including
concurrent and retrospec-
tive review—is considered
an administrative expense
under the MLR. If, however,
the payer outsources the
UM function to an external
vendor that offers quality-
improvement services, UM
is considered to be a med-
ical expense, and thus is
included in the medical care
portion of the MLR.
Creating and implementing
an in-house rehabilitation
quality-improvement pro-
gram can be costly for the
payer. To control costs, there-
fore, some payers are con-
tracting with UM companies
that purport to have exper-
tise in rehabilitation and
offer quality improvement
services. Given the financial
benefit to insurers, the trend
toward outsourcing manage-
ment of the rehabilitation
benefit can be expected to
continue, and accelerate.
Issues With UM
Programs
APTA has been working
with state chapters affected
Lindsay Still, JD, is a payment
specialist in APTA’s Payment
and Practice Management
Department. Senior Practice
Management Specialist Elise
Latawiec, PT, MPH, contributed
to this column.
9. 7PTinMOTIONmag.org / February 2015
by this trend. Several
common problem areas
have been identified. They
include the definition of
medical necessity, admin-
istrative burdens, delays in
the review or appeals pro-
cess, and provider tiering.
Defining medical necessity.
One of the most critical
issues is the definition of
medical necessity. Each
payer has its own defini-
tion of medical necessity
and established criteria
for meeting this standard.
Often, however, UM compa-
nies do not follow the defi-
nition of medical necessity
established by the payer—
employing, rather, a more
restrictive definition. When
definitions are not aligned,
requests for treatment of
conditions and injuries that
normally would have been
covered under the payer’s
definition of medical neces-
sity may be denied.
This also is confusing for
patients with regard to their
policy benefits. Patients
enroll in a health care plan
expecting to receive its
specified physical therapy
benefit. If, however, the
benefit management com-
pany does not adhere to the
payer’s rehabilitation policy
and definitions, delays or
denials may occur of med-
ically necessary physical
therapist services that are
covered under the enroll-
ee’s plan. This exacerbates
patient uncertainty and
confusion.
Administrative burdens.
Administrative burdens
imposed by UM companies
can be daunting. Most of
these companies require
physical therapy clinics,
for example, to complete
an online medical neces-
sity review (MNR) form to
request approval of ongoing
visits. Completing this form
necessitates input from both
clerical and physical ther-
apy staff, and takes physical
therapist (PT) time away
from direct patient care.
Additional patient visits
often are approved only in
small increments that have
little or no correlation to
clinical presentation. Thus,
PTs may have to submit
multiple MNR requests for
a single patient. Not only
does this require additional
paperwork and substantial
data entry, but it may delay
patient care when MNR
requests are not authorized
in a timely manner. These
delays cause interruptions
in necessary services,
interfering with patients’
progress and adherence
to the plan of care. Such
delays may increase patient
apprehension, and concerns
about payment may lead
them to cancel scheduled
appointments or discon-
tinue therapy altogether.
Interruptions in treatment
frequency, in turn, increase
the likelihood of poor
more information
For additional guidance, visit the Office of the
National Coordinator for Health Information Technol-
ogy’s mobile device privacy and security webpage at
http://healthit.gov. (Go to “For Providers & Pro-
fessionals,” then “Privacy & Security,” then “Mobile
Devices Privacy and Security.”) The site offers tips,
videos, answers to frequently asked questions (FAQs),
downloadable materials, and more.
For additional guidance on HIPAA privacy and
security rules, go to APTA’s HIPAA resource page at
www.apta.org/HIPAA/. The site offers FAQs, APTA
summaries of legislation, links to pertinent videos
from a variety of sources, and more.
10. Compliance
Matters
8 PTinMOTIONmag.org / February 2015
patient outcomes and higher down-
stream costs.
Review or appeals. In addition to the
administrative burden imposed by UM
programs, the review or appeals pro-
cess offered by most companies can be
quite one-sided. One UM vendor, for
example, requires 3 levels of internal
review if a claim is denied, and a level
of external appeal, as well, with strict
limits on provider filing. Conversely,
many UM contracts do not specify
any timeframe for responding to the
provider’s appeal request.
Furthermore, authorization requests
and appeals may well be reviewed by
individuals who are not licensed PTs.
APTA’s policy is that peer review of
physical therapist services should be
provided only by an actively licensed
PT free of sanctions to practice physical
therapy. Given the potential impact on
a PT’s plan of care and interventions,
APTA considers the involvement of a
PT peer reviewer to be critical.
Tiering. Most UM programs place
providers or facilities into tiers based
on utilization patterns and other
poorly defined criteria. The tiering
system can be extremely complex and
may penalize even the most prudent
provider. In addition, once tiering
has been established, the provider’s
opportunity to improve or appeal its
tier placement can be limited. Most
UM programs, for example, review
provider tier assignments annually
and afford providers the opportunity
to advance only a single tier per year.
Moreover, depending on the tier to
which a provider is assigned, pre-
authorization requirements may be
more onerous than they would have
been in a different tier.
Not only does the tiering system place
additional burden on providers, but
it also may adversely affect patients’
access to timely and appropriate physi-
cal therapist services.
These are just a few of the common
problems APTA has identified as
large insurers across the country
begin to contract with UM compa-
nies. APTA also has observed issues
related to functional measurements,
patient access, documentation require-
ments, billing policies, and payment
methodologies.
What Providers and
Chapters Can Do
Should you learn that a payer in
your state is planning to implement
a UM program, there are several
steps you can take to address the
issues outlined in this column.
First, notify your chapter of the payer’s
intent to implement a benefits-manage-
ment program. The chapter then should
reach out to the insurance company and
request a meeting to discuss the UM
program. Do not reach out to the UM
vendor. It is best to start with the payer
and see where that discussion leads.
When discussing the benefits-man-
agement program with the insurance
company, the chapter should ask such
questions as:
What prompted the change? Might
the insurer consider other options,
such as starting with a pilot pro-
gram rather than going directly to
full implementation?
On what basis was this UM vendor
selected? Has the program been
beta tested?
What type of documentation does
the UM program require? How long
will it take to complete an authoriza-
tion request?
Will training be offered prior
to implementation of the UM
program?
Your chapter also should determine if
other states are affected by implementa-
tion of the UM program. If so, state chap-
ters can combine resources and work
together to discuss the benefits-manage-
ment program with the payer.
Next, review the UM vendor’s physical
therapy policy. Compare the payer and
UM definition of medical necessity.
Also, see how the UM vendor defines
function and functional change, and
which assessment tools it designates
to measure change.
Chapters and providers also should
closely review the UM vendor’s
process to request patient visits, and
determine the administrative burden
accompanying such requests.
Finally, keep an eye out for tiering
criteria, and review the UM company’s
appeals process.
After the chapter has analyzed the
physical therapy policy, it should iden-
tify the person or people at the insur-
ance company who handle inquiries
about the UM program. It is prudent to
develop a coordinated schedule to reg-
ularly update the insurance company
on how well the benefits-management
program is working. Chapters should
provide their members with program
updates, and may consider creating
a webpage for reporting issues and
collecting data.
11. 9PTinMOTIONmag.org / February 2015
Be proactive. Initiate dialogue with
payers now. Never assume that your
relationship with a payer is good
enough. Building and maintaining a
strong relationship takes continuous
effort. There is no guarantee, however,
that any payer will notify you before
signing a UM contract. If you do not
have a relationship with a payer in
your state, start by inviting payer
representatives to your facility to view
typical therapy visits and discuss
mutual concerns, such as operational
obstacles or restricted access to care.
Chapters also can hold payer/
employer forums to educate attending
parties on pertinent rehabilitation
issues and facilitate the develop-
ment of payer relationships. The key
challenge for APTA, state chapters,
and providers is to identify and offer
payers viable alternatives to UM
programs that are attractive to all
stakeholders.
Don’t Wait
Again, as a result of this provision of
the ACA, it is expected that more and
more insurance companies will seek
out the services of benefits-manage-
ment providers in an effort to reduce
rehabilitation costs, control utilization,
and ensure compliance with MLR
requirements. But remember, it is
never too late to develop a relationship
with a payer. Do not wait to take action
until after a UM program has been
implemented.
Please contact APTA if you have ques-
tions about PM&R benefits-manage-
ment programs. Call 800/999-2782,
ext 8511, or direct e-mails to advo-
cacy@apta.org.
12. 10 PTinMOTIONmag.org / February 2015
A Friendly Reminder
Social media can be great for public relations, but they
also present conundrums.
Ethics in Practice
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 in Newark. She also
practices in northern New Jersey.
F-r-i-e-n-d. Six letters that can mean
a lot—or not so much. Consider the
following scenario, in which a simple
request is weighted with potential
ramifications.
Facing a Choice
As the youngest and newest
physical therapist (PT) at
his clinic, Jeff is used to
being the “go-to guy” for
some of the older and less
tech-savvy PTs on staff
when it comes to issues
related to Internet technol-
ogy (IT) and social media.
He has helped several
PTs shape their personal
Facebook pages, led a staff
in-service on Twitter, and
contributes to the private
practice’s website, in-house
blog, Facebook page, and
Twitter feed.
Jeff tries to keep his per-
sonal presence on social
media separate from his
professional one. While he
is personal-page “Facebook
friends” with some of his
coworkers and even with a
few former patients (with
a caveat that will be dis-
cussed shortly), he makes
it a rule never to discuss
anything work-related in
those interactions. He keeps
up with the lives of selected
work friends just as he
would any other friend on
Facebook. Jeff’s personal
policy is to turn down friend
requests from former or
current patients—thanking
them for their interest but
politely explaining that that
he would prefer to keep the
relationship strictly profes-
sional. (He knows, too, that
former patients may well
become future ones.)
There are a few exceptions
that come with asterisks—
former patients with whom
Jeff has become both
Facebook and full-fledged
friends through shared
interests in skiing and/or
golf, Jeff’s biggest recre-
ational passions. A couple of
his former patients are, like
Jeff, members of the local
ski club. Two other former
patients are members of
the golf club to which Jeff
belongs. A fifth former
patient belongs to both
groups; Jeff now considers
him to be a close friend.
One day, Jeff receives via
Facebook a friend request
from a recent patient named
Michael, who had presented
with several comorbidities
and made great progress
while he was under Jeff’s
care. Michael sometimes
made Jeff uncomfortable,
however, by, in Jeff’s view,
oversharing about his per-
sonal life. During one visit
he told Jeff that he often
by Nancy R. Kirsch, PT, DPT, PhD
13. 11PTinMOTIONmag.org / February 2015
feels insecure and defen-
sive, that he has few friends,
and that he gets depressed
when he feels that his
overtures of friendship have
been rebuffed. On another
occasion he told Jeff that
he’s “been told” he can be
pushy and needy, but that
he finds it difficult to back
off.
Jeff doesn’t know whether
Michael ever has seen a
mental health professional,
but he suspects the possi-
bility from some allusions
Michael has made. Jeff
never encouraged or sought
to prolong these personal
lines of conversation when
Michael introduced them.
He typically tried, rather, to
refocus Jeff on his physical
therapy and the movement
issues on which Michael
and he were working.
On this final visit for physi-
cal therapy, Michael pointed
to a photo on Jeff’s desk of
the PT standing on a golf
course with his clubs and
remarked out of the blue, “I
really like you. You should
teach me to play sometime.”
Jeff had responded lightly,
“Golf will break your heart!
Get out before you even
start, my friend. That’s my
advice to you.”
Jeff replays that conver-
sation as he views the
Facebook friend request on
his computer screen. Could
Michael have imbued Jeff’s
innocuous word choice with
unintended meaning?
In this particular case, Jeff
is reluctant to proceed as he
typically does—explaining
his reasoning and declin-
ing Michael’s Facebook
request. He doesn’t really
know what to do. So, at first
he does nothing. He hopes
the request has no out-
sized meaning for Michael.
Maybe it’s just 1 of many
“friend” requests Michael
has made, and Michael
won’t pursue it further.
The next day, however, Jeff
returns to his office after
lunch to find a voicemail
message from Michael
asking if he’d received the
Resources
At www.apta.org/Policies/Ethics/:
Standards of Conduct in the Use of Social Media
At www.apta.org/EthicsProfessionalism/:
Core ethics documents (including the Code of Ethics for the Physical Therapist and
Standards of Ethical Conduct for the Physical Therapist Assistant)
Ethical Decision-Making Tools (past Ethics in Practice columns, categorized by
ethical principle or standard; the Realm-Individual Process-Situation (RIPS) Model of
Ethical Decision-Making; and opinions of APTA’s Ethics and Judicial Committee)
At www.apta.org/PTinMotion/2006/2/EthicsinAction/:
“Ethical Decision Making: Terminology and Context
14. Ethics in Practice
12 PTinMOTIONmag.org / February 2015
Considerations and
Ethical Decision-Making
Jeff must determine whether to respond to Michael’s Facebook friend
request in the same manner as he has addressed past requests from
other former patients, or whether to accept the request as, essentially,
a goodwill gesture to a patient who Jeff believes has emotional issues.
Realm. Individual, as the scenario focuses on rights, duties,
relationships, and behaviors between 2 people.
Individual process. Moral courage and moral potency. There are
risks to whichever course of action Jeff takes. “Friending” Michael on
Facebook holds untold potential ramifications. But declining to do so
could have an adverse effect on a former patient. Assessing his ethical
obligations and choosing a path requires of Jeff both moral qualities
cited above.
Situation. This is a problem or issue, in that important moral
values are being challenged.
Ethical Principles and
Complementary Materials
The following principles of the Code of Ethics for the Physical Therapist
offer Jeff guidance:
Principle 2A. Physical therapists shall adhere to the core values of
the profession and shall act in the best interests of patients/clients
over the interests of the physical therapist.
Principle 3A. Physical therapists shall demonstrate independent and
objective professional judgment in the patient’s/client’s best interest
in all practice settings.
Principle 3D. Physical therapists shall not engage in conflicts of
interest that interfere with professional judgment.
Principle 4B. Physical therapists shall not exploit persons over
whom they have supervisory, evaluative, or other authority
(eg, patients/clients, students, supervisees, research participants,
or employees).
The APTA position Standards of Conduct in the Use of Social Media
(HOD P06-12-17-16) is instructive, as well. While many of the issues with
which it deals are not germane to this scenario, it does instruct PTs,
physical therapist assistants (PTAs), and students to “consider when and
how to separate their personal and professional lives on social media.”
The document further urges PTs, PTAs, and students to “consider
whether to interact with patients” on their personal—as opposed to
work-related—social media outlets.
e-mail from Facebook. The PT real-
izes at that moment that he’s probably
going to have to engage Michael soon
on the subject. But he isn’t sure what
exactly to say or write to Michael—
recalling how deeply affected his for-
mer patient had seemed to be by the
perceived rejections he’d recounted
during his physical therapy visits. Jeff
doesn’t immediately respond to the
phone message, either, unrealistically
hoping—but hoping nonetheless—that
Michael’s inquiries will end there.
Unsurprisingly, however, when Jeff
checks his e-mail between patient
visits the following morning, he finds
that he’s received a message from Jeff
that reads, simply, “Left you a phone
message. Please check.” There’s also
an automated message from Facebook
reminding Jeff that Michael had sent
him a friend request the day before.
Jeff slumps down in his office chair.
He doesn’t want to further dent
Michael’s self-esteem, but neither
does he wish to engage in this way
with a former patient. He also worries
about leading Jeff on, in a sense, as he
has reason to believe that his former
patient may equate Facebook friend-
ship with a real, multidimensional
relationship. How to let him down
gently?
Or, should he let him down at all?
Could a Facebook friendship with
Michael “work”? Might his profes-
sional/personal rule of thumb toward
social media, Jeff wonders, be a little
too rigid?
His phone buzzes, alerting him that
his next patient has arrived. As he
exits his office, he eyes the copies of
Physical Therapy on his bookshelf,
15. 13PTinMOTIONmag.org / February 2015
which remind him that he can draw
on APTA resources in considering
his course of action. He resolves to
explore the association’s website at
lunchtime to see what guidance the
Code of Ethics for the Physical Thera-
pist might offer him, and whether any
other APTA documents shed addi-
tional light.
For Reflection
Jeff will find useful not only APTA’s
Code of Ethics for the Physical Thera-
pist, but also the document Standards
of Conduct in the Use of Social Media.
(See the “Considerations and Ethical
Decision-Making” box) Might Jeff also
consider using those documents as
blueprints for crafting a practice-wide
policy on the use of social media in all
its facets?
For Follow-up
I encourage you to share your
thoughts about the issues raised
in this scenario by e-mailing me at
kirschna@shrp.rutgers.edu.
If you are reading the print version of
this column, go online to www.apta.org/
PTinMotion/2015/1/EthicsinPractice/
for a selection of reader responses to the
scenario presented in this column, as
well as my views on how the situation
might best be handled. If you are read-
ing this column online, simply scroll
down for that material.
Be aware, however, that it generally
takes about 2 weeks after initial publi-
cation for feedback to achieve sufficient
volume to generate this online-only
feature.
17. 15PTinMOTIONmag.org / February 2015
The Future of
Physical
Therapist
EducationBy Michele Wojciechowski
As health care continues to evolve rapidly,
so will the physical therapy profession and
the ways students are educated. What will
physical therapist education look like in 10
or 20 years? Experts weigh in.
18. 16 PTinMOTIONmag.org / February 2015
If any of that anecdote seems
implausible—a physical therapist
working as the leader of a shared
leadership interdisciplinary health
care team, students being taught
how to be leaders in this environ-
ment, or both—consider: the future
is coming, and that scenario could
well come true. Just 20 years ago,
physical therapists couldn’t have
imagined being able to use the
Internet to teach classes. Ten years
ago, most didn’t envision using
their phones to watch a YouTube
video of a PT working with a
patient. And today it’s difficult to
know what the physical therapy
field and its education will be like
over the next several decades.
However, it is possible to make
some educated predictions.
Interprofessional
Teams
“The way we practice is going to
affect physical therapist educa-
tion,” says Jody Frost, PT, DPT,
PhD, FNAP, lead academic affairs
specialist at APTA. “In the future,
you’re going to see health care
moving from provider-centric to
patient-centric, in which patients
identify what their issues are. More
and more, our curricula must begin
to prepare learners for a whole
different health care system.”
Because health care is becoming
more patient-centered, it also is
moving to team-based, collabo-
rative care, explains Frost. “As a
result, over time you’re going to
see that independent practitioners,
no matter what profession—PT,
OT, etc—are going to practice in
team-based situations. They will
not be independent, freestanding,
or private without any partners.
They will be on a team because
the health care system is being
designed to make it easier for the
patient, not more difficult.
“Here’s the mantra—the right peo-
ple at the right place and the right
time for the patient.”
To understand what this will mean
for physical therapist education,
the PTs interviewed for this article
explain, you first have to under-
stand what the mantra will mean for
the physical therapists themselves.
With the focus on the patient, Frost
says, more interventions may occur
in community practices rather than
hospitals. If a patient comes into a
community practice, he or she will
be evaluated by the entire team
at once—the patient won’t need to
repeat the same information mul-
tiple times. The team may ask the
patient what he or she is having the
most problems accomplishing and
then identify the primary issues to
address. They will figure out which
team members can best address
those issues.
Furthermore, Frost says that there
may be a stronger emphasis on
prevention and wellness care.
Some people already schedule reg-
ular wellness visits with their PTs
today; more will do so in the future.
Clients will have annual movement
screenings just as they have annu-
al dental appointments.
Overall, Frost predicts that one of
the biggest changes in education
is that certain curriculum com-
ponents will become interprofes-
sional. And this won’t happen only
in physical therapy but across all
health care professions. Particular
parts of the curriculum will be
about integrating the 4 interpro-
fessional education (IPE) core
competencies: values/ethics for
interprofessional practice, roles/
responsibilities of different health
professions, interprofessional
communication, and teams and
teamwork.
The physical therapist fits into the
health care team as the movement
system expert. Depending on the
patient’s diagnosis, the PT may
immediately lead the team, may
share the leadership as described
in the opening anecdote, or may
serve as a member of the team. PTs
will need to be able to work within
T
he year is 2025. A surgeon has performed a total hip replacement
on a patient. As the patient is taken to recovery, the next steps in
his recovery are discussed by his health care team: a physician,
a nurse, a physical therapist (PT), an occupational therapist (OT), a
pharmacist, and a psychologist. The focus now will be on recovery and
movement. “My work with Mr Smith is done,” says the surgeon while
looking at the physical therapist. “You take it from here.” The physical
therapist looks at her team, steps into the leadership position, and says,
“Let’s gauge his recovery. Then I want to set up a schedule for physical
therapy and other interventions to get him up and discharged as soon
as appropriate.”
The professor turns to his webcam and speaks to his class about the
interaction they just observed through real-time cameras. “What steps
will the physical therapist take now that she’s the team leader? How
can she work with the team to best help the patient?” asks the instruc-
tor. “In other words, where do we go from here?”
Good question.
19. 17PTinMOTIONmag.org / February 2015
a team environment, but also be
able to step in as leader when
needed. Therefore, they need to be
educated in how to be leaders and
how to work with other health care
professionals.
Educational Needs
While health care systems are
beginning to deliver team-based
health care, physical therapist
education generally is not yet
structured to provide that range of
skills. But the movement is in the
right direction. “There are insti-
tutions doing interprofessional
education, and they’re doing it very
well,” says Janet Bezner, PT, DPT,
PhD, associate professor in the
Department of Physical Therapy
at Texas State University. She says
that while interprofessional edu-
cation is not now an accreditation
requirement in physical therapy, it
probably will be in the not-so-dis-
tant future.
Because they will work with other
health care providers, PTs will
need to know how to communicate
in ways that all team members
understand. Just like other health
care workers, PTs have a specific
terminology. To work together,
providers will need to standardize
or at least understand each other’s
terminology to effectively share
information. “We need to think
differently about content,” says
Bezner.
In the 44th Mary McMillan Lec-
ture in 2013, Roger Nelson, PT,
PhD, FAPTA, professor emeritus at
Lebanon Valley College in Penn-
sylvania, made a similar point
when he stated, “physical thera-
pist professional education must
increase its emphasis on … the
development of communication
skills, including communication
with the patient, communication
with the caregiver, communication
with other health care profession-
als, and communication with the
third-party payer.”1
Physical therapists will need to
learn how to communicate with
all these players in health care.
Further, Nelson adds, they’ll have
to be able to do it in a relaxed, easy
manner rather than the formal way
they do now.
“Leadership needs to be more front
and center in our curriculum,” says
Bezner. She’s uncertain, though,
about whether leadership will
be taught as a separate class or
threaded throughout the PTs’ en-
tire curriculum. The answer should
become more apparent in the fu-
20. 18 PTinMOTIONmag.org / February 2015
ture, as more of the PT curriculum
begins to evolve, she says.
Hybrid Learning
Today, the cost of PT education is
high and continues to grow. Frost
says, “PT schools are outpricing
themselves with their current
model. To survive, they may
move more to ‘hybrid learning’ or
‘universities without walls.’” There
will be changes to what is offered
face-to-face and to what is offered
via online classes, webinars, and
other communication forms, she
suggests. In fact, this transition
has already begun in some PT
education programs.
Bezner adds that another innova-
tion—flipped classroom models—
will become more common. “His-
torically, we have used classroom
time to teach the information. Then
students use their homework time
to think about how it applies. With
the flipped classroom, it’s the op-
posite,” she explains. “Students are
exposed to the information for the
first time on their own—today it’s
usually through a recorded lecture
or some other resource. Then, they
come into the classroom, and we
talk about how it applies. In the
future, we will use classroom time
to really solve problems and apply
the conclusions to patient care.”
Gina Maria Musolino, PT, MSEd,
EdD, agrees. “We need to be more
efficient so that we can use our
future face-to-face time to do the
higher-level learning,” she says.
Musolino is associate professor
and director of clinical education
in the Morsani College of Medi-
cine’s School of Physical Therapy
& Rehabilitation Sciences. She also
is the president of APTA’s Educa-
tion Section. “I don’t get together
with my students any more without
them having completed something
outside the classroom,” she says.
Making these changes—moving
more of the educational process
outside the classroom—may result
in another change. In the future,
Frost says, the curriculum struc-
ture could allow students to move
at their own pace. Not all students
necessarily will begin their edu-
cation at the same time or finish
at the same time, as is the practice
today. The educational process will
begin to account for the differences
in learners’ styles and capacities.
Students who move through the
curriculum more slowly might not
be penalized. If students can move
faster, though, it may reduce their
tuition and other costs.
21.
22. 20 PTinMOTIONmag.org / February 2015
Adam, PT, DPT, has been a practicing physical therapist for nearly 10 years in an
orthopedic private practice. His schedule is fully booked for the day when a patient
walks in requesting to be seen for neck strain following an auto accident.
Adam wants to help the patient, who is clearly in pain, and he doesn’t want to
disappoint the patient or the referring physician, one of his top referral sources. Since
he doesn’t have time to fit a full evaluation and treatment session into his schedule,
Adam directs Katie, his physical therapist assistant (PTA), to perform the evaluation
and document her findings within the patient’s chart. Adam knows he can find
a few minutes to review the evaluation between his other patients and provide
treatment to his new patient.
What Adam doesn’t realize is that, even though his goal to ensure the patient is seen
as soon as possible is a noble one, he is asking Katie to perform the physical therapist
evaluation, which is outside of the scope of a PTA’s licensure. This is considered
inappropriate use of supervised personnel and is a violation of state law.
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23. 21PTinMOTIONmag.org / February 2015
Allowing students more flexibility in
setting their own pace will be beneficial,
Bezner says, because the PT student is
changing. She already has a handful
of students with different needs—in-
cluding second-career students, single
parents, and those with families—and
those numbers are increasing. “It’s
difficult for these students to dedicate 8
am to 5 pm Monday through Friday to
school,” she says. While some programs
already offer weekend or online classes,
many more will.
Research and Evidence-
Based Practice
In addition, future PT education pro-
grams will include a strong emphasis
on research, says Jim Gordon, PT,
EdD, FAPTA. Gordon, who presented
the 2014 McMillan Lecture, is profes-
sor and associate dean in the Division
of Biokinesiology and Physical Ther-
apy at the Herman Ostrow School of
Dentistry at the University of South-
ern California.
“We understand when the training
of physicians requires them to go to
larger academic institutions, and I
think we need to take our profession
seriously in the same way. We need to
have programs at strong institutions
that are capable of excellent teaching,
cutting-edge research, and true inter-
professional education,” Gordon says.
Gordon says he wants to see the pro-
fession develop the physical therapy
equivalent of the medical profession’s
1910 Flexner Report which, one observ-
er said, “transformed the nature and
process of medical education in Amer-
Allowing students more flexibility in
setting their own pace will be beneficial
because the PT student is changing.
25. 23PTinMOTIONmag.org / February 2015
ica with a resulting elimination of
proprietary schools and the estab-
lishment of the biomedical model
as the gold standard of medical
training.”2
Gordon envisions the study lead-
ing to recommendations regarding
the structure of future physical
therapist education. Health care
professionals who aren’t PTs
would compare physical therapist
academic programs with those of
other health professions and pro-
vide advice on the structure of PT
academic institutions.
Having such a report would
provide a mechanism to eliminate
what Gordon sees as an evolving
2-tiered education system, because
the small, inadequately resourced
programs with too few faculty
members and not enough empha-
sis on research would be forced to
either change or close.
The Movement System
APTA’s vision statement sees the
physical therapy profession as
“Transforming society by opti-
mizing movement to improve the
human experience.” Frost says that
physical therapist education may
be affected by the vision’s focus
on movement. “The experts in the
movement system are physical ther-
apists, and the curriculum might
be organized differently around the
movement system,” says Frost.
For example, Frost says that if
PTs want to look at how and why
patients move, they won’t focus
on a specific joint. Instead, they
also will consider the patient’s
motivation, the patient’s function,
and how he or she is moving. All
those factors will be analyzed to
help determine which areas of
movement are problematic and
prevent patients from performing
their desired activities. “Education
is going to be oriented a little dif-
ferently,” says Frost. “Instead of an
Orthopedics 1 class, you might find
an integrated curriculum around
the movement system.”
Nelson, during his McMillan
Lecture, told about an experience
he had nearly half a century earlier.
He had been assigned to the care
of a seaman who worked in a ship’s
galley. The seaman’s thumb had to
be amputated. Nelson knew that
most of the seaman’s hand function
depended on a prehensile thumb,
so he had a dentist cast a prosthetic
thumb in the prehensile position.
26. 24 PTinMOTIONmag.org / February 2015
Nine months later, the seaman
visited Nelson—with no thumb.
Nelson asked what had happened.
The seaman responded that he had
thrown it overboard after receiving
complaints from his fellow sailors
who had repeatedly found his pros-
thetic thumb in the meals he served
them. The seaman had found a way
to do his job without an opposing
thumb on his dominant hand.
That experience, Nelson says,
“helped me to see the importance
of looking beyond the pathology
and obvious impairment—to inter-
act with all aspects of the patient,
and understand the patient’s envi-
ronment and his individual expec-
tations for the services received.”
Nelson hadn’t been taught that in
school. Tomorrow’s students may be.
Clinical Education
And Residencies
Clinical education may be different
as well. “You’re going to see some
shifting occurring regarding what
is still in the curriculum and what
is actually in clinical practice,”
says Frost. PT students who will
have learned via some IPE classes
may be prepared for collaborative
patient-centered teams for their
clinical education. They will work
with students from other health
care professions such as medicine,
nursing, pharmacy, psychology,
and occupational therapy.
In addition, physical therapist educa-
tion may offer more residencies. “In
the future, we may find the profes-
sion of physical therapy requiring
residencies for those who want to be-
come specialists,” says Frost. “I think
we’re going to see more residencies
and fellowships develop. We have
quite a few now, but those are going
to grow significantly to accommo-
date a need and a demand within the
profession from graduates.”
However, that may require a major
change in the profession’s ap-
proach to residencies. In the 18th
John H.P. Maley Lecture in 2013,
Kornelia Kulig, PT, PhD, FAPTA,
FAAOMPT (Hon) noted that “the
ratio of applicants to residency
acceptance is rapidly increasing.”3
She cautioned, “Although this is a
good problem to have, we need to
avoid the potential pitfall of creat-
ing new residencies solely for the
purpose of meeting the demand.”
Kulig proposed shifting the bulk
of residencies from “small clinical
communities” to universities. She
explained, “It is time to look for an
optimal, not just suitable, environ-
ment in which to house residen-
cies. This environment includes
clinicians, clinical scholars, and
laboratory researchers … I believe
that university-based education
programs provide for an optimal
residency environment.”
Technology and
The Faculty
As the health care field and edu-
cation change, so will the require-
ments of faculty. In the future, fac-
ulty members and faculty experts
are going to be blended differently,
“It is time to look for an optimal,
not just suitable, environment in
which to house residencies.”
28. 26 PTinMOTIONmag.org / February 2015
says Frost. Faculty will engage in
team teaching with professionals
in other fields and teach across spe-
cific areas, both theoretically and
practically. Besides interprofession-
al team teaching, they will engage
in case-based teaching. They also
will conduct online education and
whatever other new technological
teaching modes that exist.
Musolino says that as more gets
shared via telehealth, students
will need to learn how to perform
new procedures. As a result, so will
their professors before them.
For example, Musolino describes
research addressing people with
chronic diseases. Sensors can be
placed on the patients’ feet, mea-
suring the pressure. If patients are
staying in their homes longer—as
opposed to the hospital or skilled
care—these sensors may provide
data that can be transferred remotely
to let the physical therapists know
if these patients are moving around
enough throughout the day. PTs may
then become “real-time responsive”
to prevent movement from declining.
Suppose, Musolino continues, that
garments with sensors are worn not
only by patients, but also by phys-
ical therapists. Physical therapists
then might be capable of remotely
facilitating their patients’ move-
ments through the interconnected
3-D and 4-D sensing technologies. If
the technology enables PTs to feel
what their patients are feeling and
to guide movement, instructors will
have to learn these technologies to
teach them to students.
On the other hand, if a single PT
is able to teach this to hundreds
or even thousands of PT students
across the country online or using
another technology, then not all in-
structors will need to be proficient
in that specific new application.
Tomorrow’s instructors, howev-
er, will need to be able to teach
students who are comfortable
with technology. They will teach
students who are unlike earlier PT
students. Bezner points out that to-
morrow’s students will have known
and used technology all their lives.
That familiarity will have direct
implications in terms of the con-
tent that will be taught.
Musolino agrees. She says that
students today grew up with gam-
ing—using video game systems—in
their lives and often want to use the
same elements to motivate patients
and clients, often through the use
of gamification. This will continue,
and future students undoubtedly
will develop different kinds of
games to use with patients.
Addition and Subtraction
With all these different educational
components being added to the fu-
ture DPT curriculum, will some of
today’s content have to be reduced
or eliminated?
“Interventions that are demonstrat-
ed not to be evidence-based or that
are shown not to really make a dif-
ference, that’s what will come out
of the curriculum,” explains Frost.
Nelson, in his McMillan Lecture,
identified 2 areas “for less empha-
sis to balance those areas in which
the emphasis is increased”: (1)
teaching impairment ratings and
(2) the use of passive modalities.
Regarding the former, Nelson said,
“Range of motion and manual mus-
cle testing measures are not partic-
ularly reliable and are irrelevant to
the more important measure of the
patient’s ability to function in his or
her environment.” Regarding pas-
sive modalities, Nelson observed,
“Successful outcomes are related to
the therapist’s skilled intervention
to maximize the patient’s func-
tional outcome, not to the type and
amount of modalities used.”
No matter the specific developments
over the coming decades, the PTs
interviewed for this article said that
1 theme was particularly important
to include in physical therapist
education. “We have to continue to
teach our students how to clinically
reason and to critically think,” says
Musolino. “We will never be able to
totally predict the future. Because of
this, we have to teach students how
to think and absorb evidence and to
be critical in their analysis as well as
to clinically reason through problem
solving and cases.”
Nelson made a similar point
during his McMillan Lecture:
“Our DPT programs do an excel-
lent job of preparing students for
a position in physical therapy as
the position now exists, but not for
the position of the future. We need
to encourage broader and more
creative thinking and problem
solving, teaching our students to
think about the most efficient ways
to deliver patient care and how to
build on their competencies.”
Frost picks up on that theme: “Some
of the diseases we have today won’t
exist or will be modified in the
future. Some people who are para-
lyzed today may eventually not be.
With this in mind, we’ll need to fig-
ure out the role of physical therapy
and the professional education that
will be needed to graduate a compe-
tent and collaborative team-based
practitioner to provide patient-cen-
tered care. We’ll have some things
in the future that we can’t even
begin to imagine now.”
Michele Wojciechowski is a free-
lance writer based in Maryland
and a frequent contributor to PT
in Motion.
References
1. Nelson RM. The Next Evolution. Phys Ther.
Oct 2013;93(10):1415-1424.
2. Duffy TP. The Flexner Report—100 Years Later.
Yale J Biol Med. Sep 2011;84(3):269–276.
3. Kulig K. Residency Education in Every
Town: Is It Just So Simple? Phys Ther. Jan
2014;94(1):151-161.
30. 28 PTinMOTIONmag.org / February 2015
Lacrosse was named for the stick
its players wield. As the saying
goes, sticks and stones can break
bones. Lacrosse players experience
myriad other injuries as well. Physical
therapists help prevent injuries and
rehabilitate injured players.
By Keith Loria
31. 29PTinMOTIONmag.org / February 2015
L
acrosse is a comparatively old sport—
certainly older than baseball, basketball,
football, or rugby. Historians believe it
was played as early as the year 1100 among
indigenous peoples in North America.
More recently, lacrosse has become one of the
fastest-growing team sports in the United States,
with an annual growth rate of nearly 10% during
the past decade. In 2013, nearly 750,000 lacrosse
players participated on organized teams. More
than a third of the players—37%—were female.1
In competitive lacrosse, men’s lacrosse is consid-
ered a contact sport. Body contact is allowed and
is part of the game’s tactics. In fact, the National
Collegiate Athletic Association (NCAA) classi-
fies men’s lacrosse as a “collision sport,” placing
it in the same category as football and ice hock-
ey. Meanwhile women’s lacrosse—with different
rules—is considered a non-contact sport. Any
contact is usually incidental. But contact and
injuries still occur.
Injury rates are expressed as injuries per “athletic
exposure” (AE)—which refers to either a practice
session or game. Those rates vary widely based
on the player’s age, sex, and whether the injury
occurred during practice or a game. For example,
based on recent studies, the overall injury rate
for men’s lacrosse during games is 11.5 per 1,000
AEs.1
Among high school boys in competition,
the injury ratio is 3.61. Among high school girls
during practice, the injury rate drops to 1.54.3
According to the NCAA, the most frequently
injured body parts for male lacrosse players are
the ankle, upper leg, and knee, which when com-
bined account for 48% of all injuries. Meanwhile,
the most common injuries are ligament sprains
(incomplete) and muscle strains, which, together,
account for 50% of injuries in male lacrosse.2
The picture is somewhat different for high school
players. There, the most common injury among
both boys and girls is sprains/strains (boys:
35.6%; girls: 43.9%) and concussions (boys: 21.9%;
girls: 22.7%). The most commonly injured body
sites in high school competition are the head/
face (32.0%), lower leg/ankle/foot (17.8%), and
knee (12.2%).3
Part of the variation in injuries also is due to
the different types of lacrosse. “Outdoor and
indoor lacrosse are actually 2 different brands
of lacrosse that see 2 different styles of play and,
subsequently, a variety of pathologies,” accord-
ing to Adam Thomas, PT, DPT, ATC.
Thomas is an assistant clinical professor at
Northeastern University and serves as head ath-
letic trainer for the Boston Cannons professional
lacrosse team and assistant trainer for Team USA
Lacrosse. He’s also worked as a trainer for the Bos-
ton Blazers Professional Indoor Lacrosse team.
Thomas says, “With regards to outdoor lacrosse,
I tend to see more traditional orthopedic injuries,
and usually lower body injuries. Over the last
32. 30 PTinMOTIONmag.org / February 2015
Common InJuries
few years, we have seen lower back
injuries and hamstring injuries at the
beginning of the season.”
Timothy Tyler, PT, MS, ATC, a physical
therapist at the Nicholas Institute of
Sports Medicine and Athletic Trauma
at Lenox Hill Hospital, has worked with
a number of lacrosse players through
the years. In his experience, hamstring
injuries are the most common.
Other common injuries include frac-
tured thumbs (typically with goalies and
also from getting slashed) and inversion
ankle sprains. Still, Thomas says that
the most common injury he deals with is
hamstring strains, typically as a result of
an imbalance, or improper warm-up or
poor off-season training.
Yoni Rosenblatt, PT, DPT, OCS, of
Baltimore-based True Sports Physical
Therapy, was part of the Israel men’s
national lacrosse team’s training staff
last summer. Rosenblatt has worked
with nationally ranked boys and girls
high school lacrosse teams, current Di-
vision I, II, and III athletes, and World
Championship competitors.
“I see a lot of strains and sprains. A
lot of ACLs and strains of the lower
extremities. I have seen an inordinate
amount of hip pathology in the la-
crosse athlete,” he says. But Rosenblatt
suggests that a significant factor in
injuries may have little to do with the
game itself: “I think it has a lot to do
with the training regimen and then the
12-month season in which they com-
pete. It’s just overload. And when the
hips, particularly, become overloaded
and they’re put in those compromising
lower positions.”
Further, Rosenblatt says that a contrib-
utor to some injuries isn’t connected in
any way with athletics.
“When a patient comes to me with
groin pain, first it’s important to figure
out: Is this a muscle strain? Is this a
muscle tear or is this coming from
some type of inside-the-joint pathol-
ogy? Then there’s a matter of really
teasing out which muscles are weak.
Very commonly, especially in student
athletes because they’re spending
so much time sitting at a desk, the
front of their hips are very tight and
the back of their hips, their glutes,
are very weak,” he says. “And so my
first attempt is to try to figure out how
we can flip that. How do we open up
and loosen the front of the hip and
how do we tighten up and strengthen
[the back]? Sometimes it’s a matter of
Ankle
Knee
Face
48%
of all injuries:
Ankle, Upper
Leg, & Knee
32%
Head, Face
50%
Ligament
sprains
and Muscle
strains
17.8%
Lower leg,
Ankle, Foot
12.2%
Knee
In The NCAA In High
School
Upper
Leg
Lower
Leg
Head
Foot
33. 31PTinMOTIONmag.org / February 2015
waking the muscles up or activating
the posterior of the joint or the glute to
offload the hip.”
Once he’s determined that, he con-
siders which exercise and manual
interventions will help the joint.
Rosenblatt worked with player Lee
Coppersmith while coaching the Team
Israel squad this past summer. Copper-
smith is considered by followers of the
sport to be 1 of the fastest lacrosse play-
ers in the country. He currently plays
professionally for the Florida Launch of
Major League Lacrosse (MLL).
Coppersmith says, “I’ve had numerous
sports injuries, but the muscle group
that has given me the most problems
are my hamstrings. I’ve pulled both of
my hamstrings many times and I’ve
required extensive therapy. The treat-
ment helped me recover faster and
become stronger than even before my
injuries occurred. For my hamstrings, I
had to train the imbalances in my legs,
increase flexibility through stretching,
and making sure to strengthen my
hamstrings and surrounding muscles.
I feel my injuries occur when I’m not
training properly or when my nutri-
tion/hydration are sub-par.”
Rosenblatt adds, “I also perform dry
needling. And then once they’re out of
pain, we’ve got to figure out how they
are playing within lacrosse. Are they
cutting appropriately? Are they able
to plan appropriately? Are they able
to stop on a dime? Are they able to get
down for a ground ball? Are they able
to explode through the hips?” he asks.
“I look at that entire kinetic chain. You
need to understand the lacrosse shot
or—with a goalie—understand reach-
ing the top corners and the bottom
corners. Only then can you really put
together a full-fledged lacrosse-specif-
ic rehab program.”
For female players, Rosenblatt encoun-
ters higher rates of acetabular labral
injuries.
“I see more hip problems with my
female athletes and, to be expected, I
see more ACL tears,” he says. “When
I look to rehab the lacrosse athlete,
Adam Thomas, PT, DPT, ATC, says that the most common injury he deals with is hamstring
strains, typically as a result of an imbalance, or improper warm-up or poor off-season training.
34. 32 PTinMOTIONmag.org / February 2015
there’s certainly a difference between
female and male, obviously, in an-
atomical makeup, but also in their
expectations and their seasons. Each
athlete is individual in terms of his or
her long-term goals. All that has to be
considered when putting together a
rehab program.”
Jessica Hettler, PT, MSPT, ATC, Cert
MDT, SCS, meanwhile, says the more
common injuries she encounters
among women players include lower
extremity sprains and strains (ankle,
knee), low back pain, quad contusion,
and ACL injuries (more noncontact
then contact injuries).
Managing the Clock
PTs who work with lacrosse players,
especially the professional players,
face a number of challenges dealing
with time.
“What we’re finding is that we have
about 4 to 6 weeks if it’s in season to
get a player better. Usually we have 1
chance of getting that player better.
If he is reinjured during that same
season, it’s very hard to get him back
on the field,” Tyler says.
Further, due to the nature of profes-
sional lacrosse, many players have
full-time jobs and do not live in the
market in which they play. As a result,
PTs often see their lacrosse patients to
monitor their progress only the day be-
fore a game, PTs interviewed for this
article explained. That, in turn, affects
the PT’s involvement with the patient.
The Game Matters
Lacrosse consists of a lot of running
and cutting. For face-off specialists, it
requires a lot of explosiveness when in
a crouched position.
Hettler has covered middle school,
high school, college, and men’s la-
crosse leagues, plus girl’s high school
lacrosse over the past 10 years, and
has seen many lacrosse athletes in her
clinic. She also worked with the wom-
en’s Irish National team during the
European Championship in 2012.
Lacrosse is a team sport played using a small rubber ball and a
long-handled stick called a crosse or lacrosse stick. The head of the
lacrosse stick is strung with loose mesh designed to catch and hold
the lacrosse ball. Offensively, the objective of the game is to score by
shooting the ball into an opponent’s goal, using the lacrosse stick to
catch, carry, and pass the ball to do so. Defensively, the objective is to
keep the opposing team from scoring and to gain the ball through the
use of stick checking and body contact or positioning.
The sport has 4 major types: men’s field lacrosse, women’s lacrosse,
box lacrosse, and intercrosse. The sport consists of 4 positions:
midfield, attack, defense, and goalie. In field lacrosse, a men’s team
includes 9 players, plus a goaltender; a women’s team has 11 players,
plus the goalie.
Lacrosse games consist of 4 quarters, with length of the quarters
increasing from 8 to 15 minutes as the levels go up from youth to pro
international. Teams trade ends of the field at the end of each quarter.
The field itself is slightly larger than a football field, measuring 60 yards
wide by 110 yards long.
Lacrosse is believed to date back at least a thousand years. In 1637,
French Jesuit missionary Jean de Brébeuf saw Iroquois tribesmen play
the game in present-day New York. He called it la crosse (“the stick”). In
1855, William George Beers, a Canadian dentist, founded the Montreal
Lacrosse Club. In 1867, Beers codified the game, shortened the length
of each game, and reduced the number of players to 12 per team.
From Canada, lacrosse spread to the United States, Great Britain, and
Australia. The first international lacrosse match was played in 1867
between Canada and the United States. Olympic medals in lacrosse
were awarded in 1904 and 1908. Though lacrosse was a demonstra-
tion sport at the 1928, 1932, and 1948 Olympics, it has not returned to
medal-sport status.
At the highest amateur level, lacrosse is represented by the collegiate
NCAA Division I in the United States. In 2001, a men’s professional field
lacrosse league, Major League Lacrosse (MLL), was inaugurated in the
United States. Initially starting with 3 teams, MLL has grown to 8 clubs
located in major US metropolitan areas.
References
http://en.wikipedia.org/wiki/Lacrosse
http://www.ehow.com/way_5454002_basic-
lacrosse-rules.html
http://www.sportsknowhow.com/lacrosse/
history/lacrosse-history.shtml
http://www.dummies.com/how-to/content/
understanding-how-lacrosse-is-played.html
About
Lacrosse
35. 33PTinMOTIONmag.org / February 2015
“Repetitive overuse injuries of the
hip and lumbar spine can occur
with repetitive shooting. A common
complaint in rotational and overhead
athletes can be lower back pain or hip
pain,” she says. “Think of the men’s
lacrosse shot and the amount of torque
and velocity of speed from draw of the
ball to the release phase of the shot.
During the follow-through phase (re-
lease), weight is moved to the lead leg.
The lead leg moves into IR, flexion,
and adduction, which can put the play-
er at greater risk for hip impingement
and labral pathology.”
Hettler’s rehabilitation program
focuses on a solid strength and stable
base (core) before addressing the ex-
tremities. A stable base and control of
motion will set the stage for progres-
sion to skill acquisition and safe return
to play, she says.
The Players Speak
One of Rosenblatt’s patients is Gen-
evieve Eby, who was considered the
best high school female player in the
country when she chose the Universi-
ty of New Hampshire for her college
career in 2012.
While in high school, Eby suffered a
concussion playing volleyball. Those
symptoms were reignited during a
college lacrosse contest.
Rosenblatt describes what followed.
“She was diagnosed with having
occipital neuroglia and received pe-
ripheral nerve release on her occipital
nerves in June of 2013. She had her
skull operated on 2 times and needed
to work on not just strength, endur-
ance, and posture, but also vestibular
rehabilitation and running progres-
sion in an effort to return.”
Rosenblatt has helped Eby strengthen
her neck and body as a whole.
Eby says, “I would not be where I am
today without Yoni. Before my second
surgery, he would needle my neck to
release the tight muscles caused by my
nerve pain. He also helped me with my
posture so I was not putting as much
strain on my neck,” she says. “He
Think of the men’s lacrosse shot and
the amount of torque and velocity
of speed from draw of the ball to
the release phase of the shot.
36. 34 PTinMOTIONmag.org / February 2015
there’s so much
rotation involved
when you throw—in
lacrosse you rotate
your whole upper body
would take a video and break down my
positioning to help correct me. Keep-
ing my neck in a neutral position while
exercising decreased my pain.
“After my second surgery, Yoni helped
me ease into becoming active again.
We started with body weight squats and
worked up to cutting and sprinting in a
couple weeks. Vestibular exercises also
were a main part of my rehab. I used to
get dizzy running, but these exercises
improved my vestibular system.”
Other players also speak of the bene-
fits of physical therapy. For example, in
2014, Duncan Hutchins made it back
to play for the UNC Tar Heels men’s
lacrosse team after a spinal fusion cost
him the previous season. Throughout
his athletic career, Hutchins has faced
everything from basic muscle tweaks
to reconstructive back surgery.
“My first PT visit came after an ar-
throscopic procedure to repair a badly
torn labrum in my shoulder. My reha-
bilitation program included mobiliza-
tion exercises and then strengthening.
Next were my back issues. I had stress
fractures on my L3-L4 vertebrae that
caused constant dull and achy pain
that refused to die down whether I was
sitting, standing, sleeping, working, or
playing. After attempting to avoid it, I
opted to have surgery.”
He lost 30 pounds and looked to his
PT for help. Soon, Hutchins was on
a regimen of box jumps, hip bridges,
core strengthening, stretching, and
dry needling.
“The exercises and rehab abso-
lutely was pivotal to me getting
back on the field. I basically
had to rebuild my body from the 30
pounds of muscle I had lost due to my
back fusion,” he says. “After I had that
base I was allowed to pick up a stick.”
Working With
Younger Players
Kevin McHorse, PT, SCS, Cert MDT, at
Central Texas Pediatric Orthopedics
and current chair of the APTA Sports
Section’s Youth Athlete Special Inter-
est Group, has been treating young
lacrosse players since the sport took
off 10 years ago.
“I’m seeing a lot more kids playing
club lacrosse and with travel teams.
Last year there were a lot more
lacrosse injuries specific to a popula-
tion that I treat, and they tend to start
coming in around 10 years old,” he
says. “I see a lot of overuse injuries
and so they get Osgood-Schlatters [an
overuse injury affecting the knee] just
from the constant running around and
playing year-round on travel teams.
Then, on the trauma side, you see the
typical ankle sprains, knee sprains,
and some back injuries.”
Genevieve Eby While in high school,
Eby suffered a concussion playing volleyball.
Those symptoms were reignited during a col-
lege lacrosse contest. Eby says, “I would not be
where I am today without [physical therapy].”
38. 36 PTinMOTIONmag.org / February 2015
Unlike other sports where athletes
do a lot of cutting and twisting, in
lacrosse the element of constant
running is combined with the contact
similar to what might occur in football.
“So you get the injuries from moving
all the time. Then there’s so much
rotation involved when you throw—in
lacrosse you rotate your whole upper
body—and almost every time you
throw you’re also running in 1 direc-
tion or switching directions,” McHorse
explains. The exception, he adds, is
goalies: “You don’t really see the over-
use stuff. Abrasions or contusions are
more common in the goalies.”
For kids with overuse injuries, McHorse
says rehabilitation is a 2-step process.
First, take care of the underlying prob-
lem. Then figure out why the player
ended up in a situation with a lack of
flexibility and a lack of core strength.
With lacrosse rising in popularity, chil-
dren are starting to play the game at
ever younger ages. Hettler says it’s im-
portant that young athletes participate
in multiple sports throughout the year
and focus on strengthening programs
appropriate for their age groups.
Preventive
Methods
When it comes to lacrosse, preven-
tion is key to successful seasons and
careers, the PTs interviewed for this
article said. Fatigue commonly plays a
large role in lacrosse injuries. For that
reason, they say, a program should
be developed based on individual
findings to address neuromuscular
control issues, length-tension issues,
and compensatory patterns.
“Although contact injuries cannot
be prevented, we can have a positive
effect on noncontact injuries and over-
use injuries,” Hettler says. “A proper
screening for each player should be
done to look at mobility at each joint,
isolated strength testing, trunk en-
durance, and dynamic motions. These
same dynamic tests should also be
looked at after the athlete is fatigued.”
Meanwhile, Cody Levine was a star
player at Cornell when he suffered a
herniated disk in his lower back, during
his senior season in 2013. With effective
rehab, he was able to get on the field for
the World Games this past summer.
Levine advises, “It’s extremely import-
ant to consult a PT because it only
takes the slightest movement in
the wrong direction to rein-
jure yourself. Coming
back too early from
an injury could
cause even
more
When it comes to
lacrosse, prevention
is key to successful
seasons and careers
damage,” he says. “As a midfielder, I
run all game long and need my entire
body in top shape. I would tell any [la-
crosse] player to see a sports PT to get
proper eyes on your injury and work to
get healthy the right way.”
Keith Loria is a freelance writer.
References
1. 2013 Participation Survey US Lacross. http://www.
uslacrosse.org/Portals/1/documents/pdf/about-
the-sport/2013-participation-survey.pdf. Accessed
November 19, 2014.
2. Bach BR, McCulloch, PC. Injuries in Men’s
Lacrosse. Orthopedics. 2007;30(1).
3. Xiang J, Collins CL, Liu D, et al. Lacrosse injuries
among high school boys and girls in the United
States: academic years 2008-2009 through 2011-
2012. Am J Sports Med. 2014;42(9):2082-2088.Cody Levine suffered a herniated disk in
his lower back while playing in college. He
advises, “It’s extremely important to consult
a PT because it only takes the slightest
movement in the wrong direction to reinjure
yourself.”
41. 39PTinMOTIONmag.org / February 2015
Nasal Cells Used in Spinal Cord Transplant
Scientists have reported that cell transplants
combined with other interventions have enabled
a man with a severed spinal cord to walk again.
The case involves a 38-year-old man who sus-
tained traumatic transaction of the thoracic spi-
nal cord at upper vertebral level Th9. There was
an 8-mm gap between the spinal cord stumps.
The stumps remained connected only by a 2-mm
rim of spared tissue. At 21 months after injury,
the patient presented symptoms of a clinically
complete spinal cord injury (American Spinal
Injury Association class A-ASIAA).
Researchers removed 1 of the patient’s olfactory
bulbs and used it to derive a culture containing
olfactory ensheathing cells and olfactory nerve
fibroblasts. Following resection of the glial scar,
the cultured cells were transplanted into the spi-
nal cord stumps above and below the injury. The
8-mm gap was bridged by 4 strips of autologous
sural nerve. The patient underwent an intense pre-
and post-operative neurorehabilitation program.
During the first 8 months after the operation, the
patient did not show any improvement. However, the
scientists report, in the period from 9 to 11 months
after surgery “there was an evident improvement
in the technique of exercise performance and an in-
crease in the values of the loads in exercises requir-
ing high degree of voluntary function of abdominal
and back muscles, gluteal muscles,
adductors and abductors, hip flex-
ors, and knee extensors.”
The scientists continued to
see progress: “Starting from
14 months the patient was able
for the first time to ambulate
with walker, long braces, and
the assistance of one person.
Additionally, in the last months of
observation the patient started to
walk both in parallel bars and with a
walker with short braces, locked only at
the ankles.” At 19 months postop, the patient
had improved from ASIA A to ASIA C.
The researchers noted that because they provid-
ed multiple types of treatments, “it is difficult to
determine which aspects of the interventions con-
tributed to the observed neurological recovery.”
However, they added, “Each single intervention
had its importance but in our opinion could not be
in itself sufficient, if applied without the others.”
Reference
Tabakow P, Raisman G, Fortuna W, et al. Functional regeneration of
supraspinal connections in a patient with transected spinal cord
following transplantation of bulbar olfactory ensheathing cells
with peripheral nerve bridging. Cell Transplantation. Published
ahead of print. http://dx.doi.org/10.3727/096368914X685131.
Researchers Modify Skin Cells for Brain Treatment
Researchers at Washington University School
of Medicine in St Louis have described a way to
convert human skin cells directly into a specific
type of brain cell affected by Huntington disease,
a fatal neurodegenerative disorder. Unlike other
techniques that rely on one cell type turning into
another, the new process does not pass through
a stem cell phase. The converted cells survived
at least 6 months after injection into the brains of
mice and behaved similarly to native brain cells.
The investigators produced a specific type of
brain cell called medium spiny neurons, which are
involved in controlling movement. The research
involved adult human skin cells, rather than more
commonly studied mouse cells or even human
cells at an earlier stage of development.
To reprogram the cells, the researchers put the
skin cells in an environment that closely mim-
ics the environment of brain cells. From past
research, they had determined that exposure to
2 small molecules of RNA could turn skin cells
into a mix of different types of neurons. The
researchers then started to modify the chem-
ical signals, exposing the cells to additional
molecules called transcription factors that they
knew were present in the part of the brain where
medium spiny neurons are common. When
transplanted into the mouse brain, the converted
cells demonstrated morphological and function-
al properties similar to native neurons.
The investigators now are taking skin cells from
patients with Huntington disease and reprogram-
ming them into medium spiny neurons. They also
plan to inject healthy reprogrammed hu-
man cells into mice with a model of
the disease to see what effect that
will have on the symptoms.
Reference
Victor MB, Richner M, Hermanstyne TO
et al. Generation of Human Striatal
Neurons by MicroRNA-Dependent
Direct Conversion of Fibroblasts. Neuron.
October 2014;84(2):311–323. DOI: http://
dx.doi.org/10.1016/j.neuron.2014.10.016.
42. 40 PTinMOTIONmag.org / February 2015
‘Game Changing’ New Devices Include Gait,
Pressure Wound Monitoring Systems
Never mind the latest iPhone 6—how about an
insole than can gather and transmit motion
data, or a monitoring system that can provide
detailed assessments of wounds to help thwart
the development of pressure ulcers?
Recently, Medscape published a list of 15 “game
changing” wireless health technology devices
selected by cardiac electrophysiologist David
Lee Scher, MD, clinical associate professor of
medicine at Penn State University, director of a
digital health consulting firm, and chairman of
the Healthcare Information and Management
Systems Society (HIMSS) Mobile Health
Roadmap Task Force. While cardiac, records, and
medications monitors made up much of the list,
Scher also included several devices that could
be of special interest to physical therapists and
physical therapist assistants.
WoundRounds combines a special app with
a dedicated device that allows providers to
record the state of a wound over time and share
that information with other providers. Though
intended for use in facilities, the device and app
also can be used in home care settings.
Moticon is a removable device that its devel-
opers describe as the world’s “first integrated
sensor insole.” Once slipped into a wearer’s shoe,
Moticon wirelessly transmits data on gait to a
special smartphone app and, according to Scher,
even could help providers track when a patient is
experiencing a growing risk for falls.
GrandCare Systems is a tablet-like device de-
signed for elderly patients. The software interface
includes medication schedules and reminders, as
well as lifestyle assessments and care coordina-
tion notes that wirelessly allow family members
and health professionals to exchange information.
The tablet mates with a variety of wireless devices
including a scale, pulse oximeter, glucometer,
blood pressure cuff, thermometer, motion sensors,
and pressure sensors. The portal also enables us-
ers to video chat, play games, and listen to music.
http://www.medscape.com/features/slideshow/wireless-devices?src=wnl_edit_specol;
www.woundrounds.com; http://moticon.com/en/; www.grandcare.com
43. 41PTinMOTIONmag.org / February 2015
www.indego.com
Robotic Exoskeleton Coming From Industrial
Equipment Manufacturer
According to a recent Wall Street
Journal article, the latest developments
in robotic lower limb orthoses are
coming from a manufacturer “whose
components have long helped propel
construction equipment, factory ma-
chinery, and airplanes” for companies
such as Caterpillar and Boeing.
The article describes how Parker Han-
nifin Corporation developed a proto-
type set of robotic leg braces designed
to allow individuals with paraplegia to
walk. The new device, named Indego,
is now undergoing trials with 40 peo-
ple at 5 rehabilitation centers.
Indego is an exoskeleton device that
weighs in at 26 pounds. Users control
walking speed by leaning forward
and backward, while “tiny gyro-chips
commonly used to rotate images on
cellphones” help users keep from
veering off-course, and serve as part
of a vibration-based alert system for
changes to speed and position.
Parker Hannifin is seeking FDA
approval for the device, which the
company says could come as soon
as 2015. If successful, Indego would
be only the second device to receive
FDA approval for a robotic orthosis for
home use by people with lower-body
paralysis. The company estimates
a $69,500-$100,000 pricetag for
the device.
44. 42 PTinMOTIONmag.org / February 2015
$
HHS Issues List of Top Management Challenges
The Office of Inspector General (OIG) of the De-
partment of Health and Human Services (HHS)
has prepared a summary of the most significant
management and performance challenges facing
HHS. These reflect what OIG says are continuing
vulnerabilities as well as new and emerging issues.
OIG is required to prepare the summary annually.
Among the challenges that HHS is facing,
according to OIG, are the following:
The Meaningful and Secure Exchange and
Use of Electronic Health Information. Issues
involved include the following:
Medicare and Medicaid EHR incentive
programs. OIG said, “Although program
interest has been high among those eligible,
recent data suggest that not all those currently
participating will continue in the program.
Challenges in program oversight also leave
the EHR Incentive Programs vulnerable to
inappropriate payments to participants that
do not meet program requirements.”
Interoperability. OIG said that health
information still is not commonly exchanged
between groups of health care providers who
use different EHR products.
Protecting sensitive information. OIG said,
“During our audits of hospitals and covered
entities, we identified weaknesses that
included inadequacies in access controls, patch
management, encryption of data, and website
security vulnerabilities.”
Addressing what needs to be done, OIG said,
“Given the magnitude of the investment in EHRs
and other health IT programs, it will become in-
creasingly important to demonstrate and measure
the extent to which EHRs and health IT have
actually achieved the Department’s goals, which
include improved health care and lower costs.”
Ensuring Effective Financial and
Administrative Management. Issues cited by
OIG include the following:
Financial statement audits. OIG said: “For
FY 2013, independent auditor Ernst & Young
identified a material weakness in the Depart-
ment’s financial management systems related
to IT security and a significant deficiency in
its financial reporting systems, analyses, and
oversight. Specifically, Ernst & Young recom-
mended that the Department bolster IT securi-
ty in its financial management systems.”
Improper payments. OIG observed, “Improper
payments cost federal programs billions of
dollars annually. For FY 2013, the Department
reported improper payments totaling almost
$50 billion in the Medicare program and $65
billion overall.”
Among OIG’s recommendations was the follow-
ing: “The Department should continue to leverage
technology to further prevent improper payments
and ensure responsible program stewardship.”
Fighting Waste and Fraud and Promoting
Value in Medicare Parts A and B. This includes:
Reducing improper payments. CMS reported
an error rate of 10.1% for Medicare fee for
service, corresponding to an estimated $36
billion in improper payments in FY 2013,
according to OIG.
Preventing and responding to fraud. OIG said,
“CMS’s contractors play a key role in fighting
Medicare fraud. However, CMS is not realizing
the full potential of this oversight tool.”
Fostering economical payment policies. OIG
said, “Medicare pays significantly different
amounts for the same services for similar
patients in different services for similar
patients in different settings.”
Addressing what needs to be done, OIG said,
“CMS needs to better ensure that Medicare
makes accurate and appropriate payments.
When improper Medicare payments occur, CMS
needs to identify and recover them in a timely
manner. CMS must also implement safeguards,
as needed, to prevent recurrence. CMS relies on
contractors for most of these crucial functions;
therefore, ensuring effective contractor
performance is essential.”
http://oig.hhs.gov/reports-and-publications/top-challenges/2014/2014-tmc.pdf
45.
46. 44 PTinMOTIONmag.org / February 2015
Tips to Control Technology Vendor Demos
An article in Physician’s Practice by Cheryl Toth recently listed 5 ways to control technology vendor
demos. She wrote, “Ever notice that most technology vendors don’t know much about your practice or
your specialty when they give you a demo? That they go full steam ahead through a rote presentation
without asking any questions about your needs or practice operations?” With some preparation, a
practice can avoid wasting time and can keep the demo more relevant, Toth wrote.
Here’s a brief summary of 2 of the tips:
Create a “Top-10 Must-See Features” list.
Different people and different functional areas
may have different priorities and interests.
Toth writes: “Get input from everyone in the
practice to create this list, and tell the vendor
you want these features covered.”
Give the vendor an “Off Limits” list.
Toth suggests, “Telling a vendor what you don’t
want to see during the demo is as important
as telling what you do want to see … Drive the
conversation by telling the vendor what your
priorities are.” She suggests terminating the
demo if a vendor begins addressing items on
your “off limits” list.
http://www.physicianspractice.com/technology/five-ways-control-technology-vendor-demos
Mayo Clinic Tests Telehealth Kiosks
The Mayo Clinic is testing a workplace-based
telehealth delivery system—the Mayo Clinic
Health Connection—that allows patients to con-
nect with Mayo Clinic and Mayo Clinic Health
System providers through a private walk-in kiosk
that provides high-definition videoconferencing
and interactive, digital medical devices.
The kiosks allow patients to walk up to the
kiosk without scheduling an appointment and
be treated for minor, common health conditions
such as colds, earaches, and sore throats. The
system uses the HealthSpot platform, which
combines cloud-based software with a private
walk-in kiosk.
http://mayoclinichealthsystem.org/local-data/press-releases/austin/
mayo-clinic-health-connection?year=0
47. 45PTinMOTIONmag.org / February 2015
Government Investigating Threat of Medical Device Hacking
The US Department of Homeland Security is investigating
about 2 dozen cases of cybersecurity flaws in medical
devices and hospital equipment that officials believe could
be exploited by hackers, according to a story distributed
by Reuters. The products include an infusion pump and
implantable heart devices.
Meanwhile, Kaiser Health News reports, “Concern about
the vulnerability of medical devices like insulin pumps,
defibrillators, fetal monitors, and scanners is growing
as health care facilities increasingly rely on devices that
connect with each other, with hospital medical record
systems, and—directly or not—with the Internet.”
Jay Radcliffe, a medical security expert, demonstrated in
2011 how vulnerability of an insulin pump could allow an
attacker to manipulate the amount of insulin pumped to
produce a potentially fatal reaction. Radcliff now is warning
of another threat—medical identity theft. He estimates
that medical identify information on the black market is
worth 10 times more than credit card information—$5-$10
per record. Thieves could use the information to apply for
credit, file false claims with insurers, or buy drugs and
medical equipment that can be resold.
Some institutions, including the Mayo Clinic, have begun
writing security requirements into their procurement
contracts, according to Kaiser Health News.
http://www.reuters.com/article/2014/10/22/us-cybersecurity-medicaldevices-insight-idUSKCN0IB0DQ20141022
http://kaiserhealthnews.org/news/pacemakers-get-hacked-on-tv-but-could-it-happen-in-real-life/
48. 46 PTinMOTIONmag.org / February 2015
IOM: Physical Activity Measures Should Be
Among Standard ‘Social and Behavioral’
Domains Tracked on EHRs
The Institute of Medicine (IOM) has
recommended that future electronic health
records (EHRs) include patient “social
and behavioral data”—including data on
physical activity—acquired through a set of
12 measures.
The 300-plus page report, “Capturing
Social and Behavioral Domains and
Measures in Electronic Health Records,”
urges the Centers for Medicare and
Medicaid Services (CMS) to include the
measures as part of the EHR certification
and meaningful use regulations.
Data on 4 of the domains—alcohol use, to-
bacco use and exposure, race/ethnicity, and
residential address—already are being widely
collected, the report states. But additional
domains should be included, each with its
own measures—education, financial resource
strain, stress, depression, physical activity,
social connections/isolation, exposure to
violence/intimate partner violence, and
neighborhood compositional characteristics.
The IOM report describes “a large body of
empirical evidence” around the dose-re-
sponse relationship between physical
activity and improved physical and mental
health throughout the lifespan, with “little
evidence that an upper threshold exists.”
Authors write that not only is the relation-
ship strong enough to be worth collecting
data, the very act of obtaining this infor-
mation from patients at outpatient visits
is associated with “significant, yet small,
changes in patient weight loss and [plasma
glucose concentration] levels compared
[with] those who were not asked about their
physical activity levels.”
The report recommends that 2 “Exercise Vi-
tal Signs” questions from the US Centers for
Disease Control and Prevention’s Behavioral
Risk Factor Surveillance System be used as
the standard measures for physical activity
in EHRs. The 2 questions are:
On average, how many days per week
do you engage in moderate to strenuous
exercise (like walking fast, running, jog-
ging, dancing, swimming, biking, or other
activities that cause a heavy sweat)?
On average, how many minutes to you
engage in exercise at this level?
The report noted that the additional do-
mains would likely add to costs, and that
these costs would largely be incurred by
providers. However, the report asserts, the
long-term benefits would be significant.
“The US health system has achieved tech-
nological advances but lags behind other
countries in population health outcomes,”
write the report’s authors. “Standardized use
of EHRs that include social and behavioral
domains could provide better patient care,
improve population health, and enable more
informative research.”
http://www.iom.edu/Reports/2014/EHRdomains2.aspx
APTA offers several resources on information technology and EHRs, including a
webpage devoted to the use of EHRs. Additionally, APTA has long supported the
promotion of physical activity and the value of physical fitness, and is involved with the
National Physical Activity Plan. (NPAP), where the association has a seat on the NPAP
Alliance board. The association also offers several resources on obesity, including
continuing education on childhood obesity, and a prevention and wellness webpage
that links to podcasts on the harmful effects of inactivity.
http://www.apta.org/EHR/
http://www.physicalactivityplan.org/
http://www.apta.org/Courses/Text/Pediatric/ChildhoodObesity/
49.
50. 48 PTinMOTIONmag.org / February 2015
Health Care Employment Rose 29,000
In November, 261,000 in Past 12 Months
Total nonfarm payroll
employment increased by
321,000 in November, and
the unemployment rate was
unchanged at 5.8%, the U.S.
Bureau of Labor Statistics
has reported. Job gains were
widespread, led by growth
in professional and business
services, retail trade, health
care, and manufacturing.
Health care added 29,000
jobs over the month. Employ-
ment continued to trend up in
offices of physicians (+7,000),
home health care services
(+5,000), outpatient care
centers (+4,000), and hospitals
(+4,000). Over the past 12
months, employment in health
care has increased by 261,000.
Within health care, ambu-
latory health care services
contributed 24,000 jobs in
November, after an identical
gain in October. Ambula-
tory health care services has
added 207,000 jobs in 2014,
accounting for approximately
80% of employment growth
in health care over the same
period. Year to date, hospitals
added 33,000 jobs. Nursing
and residential care facilities
added 19,000 jobs.
Employment in profes-
sional and business services
increased by The civilian
labor force participation rate
held at 62.8% in November
and has been essentially
unchanged since April.
http://www.bls.gov/news.release/empsit.nr0.htm
Datapoints
Average Annual Wages of Physical Therapists
Metro Areas With Highest PT Employment Levels
Economy
At A
Glance
Cha
nge in
Payroll
Emp
loyme
nt
Un
employ
ment
rate
243,000
321,000
5.8%
5.8%
Cons
umerP
riceIndex
-0.3%
0.0%
(All items)
0.2%
-0.2%
pro
ducerP
riceIndex
(Finished Goods)
Employment cost Index
0.7%
(Civilian workers)
All figures from October to November 2014, except Employment
Cost Index reflects 2nd quarter to 3rd quarter change.
Source: Bureau of Labor Statistics, Department of Labor.
www.bls.gov/eag/eag.us.htm
PT Employment Trends 2012-2022:
Offices of physical, occupational, and speech therapists
* Employment figures rounded
Source: Bureau of Labor Statistics, Department of Labor. www.bls.gov
54.3% change
2012
66,700*
2022
102,800*
NY
$84,670
IL
$76,630
CA
$88,010
MA
$80,710
PA
$78,580
US
$82,180
0.7%
Source: Bureau of Labor Statistics, Department of Labor. Available at www.bls.gov.
Professional
Pulse
Income/
Employee
Revenue/
Employee
Asset
Turnover
Receivables
Turnover
Current
Ratio
HLS 6,178 98,980 0.89x 8.75x 1.77
THC -424 154,580 0.96x 7.41x 1.26
USPH 6,664 104.920 1.25x 8.47x 2.44
KND -961 79,470 1.26x 5.01x 1.66
IND. AVG. 118,774 1,685,870 1.75x 12.91x 1.30
HLS: HealthSouth | THC: Tenet Healthcare | USPH: US Physical Therapy Inc | KND: Kindred Healthcare
All data are TTM (trailing twelve months). Information updated: 12/12/14
* Last 4 quarters + Rounded to nearest dollar
Source: Fidelity Investments: www.Fidelity.com
Operating Metrics of Selected Health Care Companies
Source: Bureau of Labor Statistics, Department of Labor. Available at www.bls.gov.
NY
New York-White Plains-
Wayne, NY-NJ MA
Boston-Cambridge-
Quincy, MA
IL
Chicago-Joliet-
Naperville, IL PA Philadelphia, PA
CA
Los Angeles-Long
Beach-Glendale CA US National/All
52. Professional
Pulse
50 PTinMOTIONmag.org / February 2015
Number of Hospitals Penalized for Readmissions Grows
The US Centers for Medicare and
Medicaid (CMS) has added about
400 hospitals to its list of facili-
ties that will be penalized in 2015
for having what CMS says are
excessive numbers of patients re-
turning to the hospital fewer than
30 days after being discharged.
The list of 2,610 hospitals covers
readmissions for heart attack,
heart failure, pneumonia, chronic
obstructive pulmonary disease,
total hip replacements, and total
knee replacements.
Thirty-nine of the most recently
listed hospitals will face the max-
imum 3% reduction in Medicare
reimbursements. CMS calculated
readmission rates on discharg-
es for all 5 categories that had
occurred from July 1, 2010,
through June 20, 2013. It took
into account the severity of the
illness, the age of the patient, the
patient’s additional medical con-
ditions, and other factors. States
with the highest percentage of
hospitals penalized were New
Jersey (98%), Connecticut (88%),
and Delaware (86%). The high-
est hospital penalties occurred
in Kentucky (1.21%), Arkansas
(1.02%), and Virginia (0.97%).
The readmissions penalty pro-
gram began in 2013 as part of a
quality improvement effort in the
Patient Protection and Affordable
Care Act.
Selected States Readmission Penalties
Percent of Hospitals Penalized Average Hospital Penalty
More info:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html
http://kaiserhealthnews.org/news/medicare-readmissions-penalties-by-state/
47%
1.02%
86%
0.22%
66%
1.21%
9%
0.44%
30%
0.14%
80%
0.73%
4%
0.18%
56%
0.52%
98%
0.82%
Arkansas
montana
north
dakota
64%
0.41%
Califo
rn
ia
kentucky
new jersey
texas
delaware
new york
oregon
53. 51PTinMOTIONmag.org / February 2015
Fewer Believe That Obesity Is a Medical Problem
Is obesity a medical problem,
a community problem, or a
matter of personal choice?
Recently, the opinions of
health care professionals and
the general population have
swung away from “medical
problem” and toward “com-
munity problem.”
Specifically, in February
2013, 34% of health care
professionals considered
obesity predominantly a
medical problem. That figure
steadily declined to 24% in
September 2014. Similarly,
18% of the general popula-
tion in February 2013 had
considered it a medical
problem. That figure shrank
to 15% in September 2014.
On the other hand, during
the same period, health care
professionals ranking obesity
as a community problem
grew from 26% to 33%. The
general population ranking
rose from 24% to 30%.
In 2014, younger and
higher-income respondents
more likely viewed obesity
as a community problem.
Older respondents more
likely viewed it as a medical
problem.
Rebecca Puhl, PhD, deputy
director at Yale University’s
Rudd Center for Food Policy
& Obesity, commented,
“These trends are encour-
aging because they suggest
a shift away from simplistic,
biased views that focus on
personal blame. The more
that people recognize shared
risks for obesity, the more
likely they are to support evi-
dence-based approaches to
reducing obesity’s impact.”
The findings were presented
at a session of The Obesity
Society Annual Meeting at
ObesityWeek 2014 in Boston.
The study is based on an
online survey of a represen-
tative sample of 54,111 US
adults and 5,024 health care
professionals. Responses
were collected in 5 time peri-
ods ranging from February
2013 to September 2014.
More info: http://www.obesity.org/news-center/americans-view-on-obesity-is-changing-fewer-adults-see-it-as-a-personal-
problem-of-bad-choices.htm
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