Upcoming: Fall Conference | Missoula, MT | October 7-8, 2017
Since Ancient Greece, people have been considering the philosophical question: How do we live a good life together? Often this question is reduced to: What is right and wrong behavior in a particular situation in order to not cause unjustified harms?
To attempt to answer these questions, a common starting point is morality. Morality can be defined as societal or group codes of conduct about right/wrong (or good/bad) behavior that individuals who live in those societies and groups agree to in order that all can live a flourishing life. These codes of conduct are either legal, ethical, or customary to specific groups. How does this affect physical therapy practice?
First, we have a plethora of laws to follow. From local laws to our state practice acts to CMS’s national billing and utilization laws with many other laws in between. As practicing physical therapists, we are required to follow these laws. If we don’t, whether by ignorance or choice, then we can be punished for breaking these laws. Everyone seems to know this and yet, some still break laws and suffer the societal consequences.
Legal behavior is our minimal standard of behavior. Societal rules become laws through legislation and are enforced by a society with punishment to those members who break the laws. Ethical behavior is a higher standard that is based on the theories, principles, and rules set out by ethics as a branch of the academic discipline of philosophy. Ethics is “a systematic study of and reflection on morality” (Doherty & Purtilo, 2106). Within ethics, there are judgments delineating which behaviors are prohibited, permitted, required, and ideal.
Second, ethical standards of physical therapy practice are particularly laid out in the APTA’s “Code of Ethics” and its accompanying “Guide to Professional Conduct” (APTA website). Our professional code, like most professional codes, is based on a philosophical concept called principlism which simply sets forth principles that govern right and wrong behaviors. The ATPA Code of Ethics lists eight principles with each principle containing a set of sub-principles. Professional Codes of Ethics are written by professionals within an organization to protect the profession and to guide the professionals. While our state practice acts are the legalized agreement that our profession has with the society we serve, our Code of Ethics is our social agreement with the society we serve. Both are the way we, as a profession, foster trust with the public.
Last, all of us have specific groups that we belong to such as a church community, a political party, or an activist group that has their own codes of conduct aligned with an ideology or perspective toward community life. It is our preference and choice to join or leave these groups according to our agreement with their codes of conduct.
These different types of codes of conduct rarely align and more often create tensions within individuals. One may personally agree or disagree with any of them in varying degrees. However, in our society, a physical therapist as a citizen must follow the laws. As a professional, they should follow the Code of Ethics, and as a member, they may follow their chosen group’s rules. However, all three types of codes of conduct change in historically and culturally significant ways. Practicing physical therapy today is very different than in the 1970’s because many of the legal changes reflect the professional development of physical therapy practice. Also, our current APTA Code of Ethics which was updated and passed in 2009 is very different from the original American Physiotherapy Association’s Code of Ethics and Discipline passed in 1935.
An ethical person is self-aware, self-critical, and self-reflective. Feel free to send comments to email@example.com. Debra Gorman-Badar, PT, MA, PhD student, Chair, MAPTA Ethics Committee
The Comprehensive Addiction and Recovery Act (CARA) is now a federal law whose purpose is to advance treatment and prevention measures to reduce opioid use. APTA has jumped on board with the very successful #Choose PT campaign to educate the public, healthcare professionals and state legislators on how PT’s are at the forefront of this effort. Currently, 22 states have used TV Public Service Announcements, with over $1.8 million of donated time and an estimated 146 million potential viewers. Printed public service announcements have appeared in over 950 papers with an estimated viewing by 149+ million Americans. We are starting up our program in Montana and hope to have the same level of success that other states have enjoyed.
But are we ready for the potential influx of new referrals from the publicity? There were many therapists I visited with in San Antonio at the Combined Sections Meeting a few weeks ago, that were worried about the limited number of physical therapists that have advanced training in pain. Consider the following:
In rehabilitation, there is a growing body of research that suggests our models of explaining pain are outdated (Mosely 2003; Mosesly 2007; Louw and Butler 2011; Nijs, Rousell et el. 2012). The biological model of explaining pain in relationship to tissue and tissue injury that is the cornerstone of traditional pain education has been shown to have limited efficacy and can increase fear in patients ( Green, Appel et al.2005: Morr,Shanti et al.2010. Using a word such as wear and tear, disc space loss, and deterioration has been associated with a poor prognosis (Sloan and Walsh 2010).
As discussed in the last newsletter, there is good evidence that PT’s can help with pain through exercise, manual therapy, and education. Are we offering quality education to our patients with pain? We get plenty of opportunities to improve our hands on skills, but do we seek out programs that focus on pain? Considering that almost all of our patients in the outpatient setting are dealing with some level of pain, it would appear to be a good idea.
Thanks to Caressa Benjamin, our programs chairperson, you have an opportunity to get the most current education this spring in Whitefish at the Explain Pain education course. The NOI group is recognized worldwide as a leader in pain research and treatment. This is a great opportunity to improve your knowledge of pain education and treatment.
Let's continue to work to decrease the use of opiates with treatments that are based on good research. The gift is ours. Let's make sure we use it wisely.
As treating physical therapists we are well aware of the positive effects we can have on facilitating symptom management and improving overall function in a collaborative effort with our clients. Working with clients, who are in chronic pain, we are also aware that the drugs prescribed are often not solely effective in managing pain and do little to normalize movement, restore function and/or address fear of re-injury. The Center for Disease Control and Prevention (CDC) has urged health care providers to reduce the use of opioids in favor of safer, and often more effective, treatments such as physical therapy. The APTA has taken an active role in educating the public and health care providers in the benefits of physical therapy in the treatment of pain and dysfunction. It has done this most recently in its #Choose PT campaign. “Opioids come with numerous serious side effects and only mask the sensation of pain,” stated #ChoosePT campaign spokesperson Joseph Brence, PT, DPT. “Research shows that physical therapist treatment can reduce or eliminate the need for opioids by improving physical function, increasing range of motion, and decreasing pain."
However, treating persons in chronic pain can come with many challenges. Living with chronic pain is miserable. If you are living with chronic pain it makes sense that you are often also depressed, sleep deprived and anxious. As a relatively healthy person, I am grateful for an acute/painful injury sustained during a recreational activity or the isolated headache to have the physical reminder of how brutal pain can be. I am also grateful that the pain I experience is usually temporary and that I have an above average understanding of pain physiology. During my final clinical rotation as a physical therapy student, I had the opportunity to work with a Clinical Instructor who was part of an interdisciplinary team for the treatment of clients with chronic pain. We had weekly meetings with the treating physicians, the anesthesiologists, cognitive-behavioral psychologists and nurse practitioners/case managers. Utilizing a team approach is essential when working with this population and I learned a lot. In addition to these team meetings, my CI had me read just about everything in the literature published by Lorimer Moseley and David Butler particularly, the research relating to complex regional pain syndrome. As a student project, I painstakingly posed for, photographed and printed a series of photographs of my left and right hands in various postures that were then laminated and cut into “flash cards” to be used by client's for laterality recognition tasks and imaginary (mass) practice for the primary purpose of cortical de-sensitization, symptom management and improved function.
If any of this sounds familiar you have likely read Explain Pain or other published works relating to graded motor imagery, neurodynamics or pain neuroscience education (PNE). Things have come a long way since homemade flash cards. There is now an online laterality recognition program called Recognize to assist in the treatment of chronic pain conditions like CRPS. In addition to the books like Explain Pain and Painful Yarns, resources abound for the treatment of chronic pain conditions. The Neuro-Orthopedic Institute (NOI) group website offers online resources, programs as well as live lectures on topics ranging from the Sensitive Nervous System, Graded Motor Imagery and the Mobilization of the Neuro-Immune System. However, it all started with the book Explain Pain and the lecture series that accompanies it. It also remains as one of the most sought after lectures and will be coming to Whitefish, MT for the Spring MAPTA conference on April 22-23. You can learn more about the course from either the MAPTA (http://www.mapta.com/event-2388660) or NOI (http://www.noigroup.com/en/Courses) website. In addition, you can check out this Explain Pain “trailer”: https://www.youtube.com/watch?v=zCGvNwJDtvU, or this Ted Talk by Moseley called Why Things Hurt?: https://www.youtube.com/watch?v=gwd-wLdIHjs.
Looking forward to seeing you in Whitefish!
Since January, 2016, Montana Chapter members and friends have graciously contributed funding to provide three customizable wheelchairs and approximately 300 additional hours of local Physical Therapist services for children with unmet needs in Ecuador. That is incredible and worth noting! Thank-you from the children of Ecuador and Families With Heart based in Helena and Puerto Quito, Ecuador.
Social events have been sponsored by your Montana Chapter of APTA at each of the quarterly meetings held around the state. Activities have included silent auction fundraisers, short stories told by colleagues called “Snap Shots,” Oxford Debates and even a biker gang meeting. More recently the Chapter sponsored Global Health Receptions. These have provided a way to learn about local and international public health initiatives presented by your colleagues. I wish to acknowledge everyone that has participated in these events, given time and money to projects that often go unnoticed as we engage in our busy clinical lives.
Your MAPTA program committee is eager for your suggestions. Saturday evenings during our quarterly meetings will only get better as the goal is to entertain, inspire and think something new. As we plan for upcoming meetings, you are invited to submit your ideas for events. Contact Carissa Benjamin, MAPTA Board of Directors, Education Services at firstname.lastname@example.org.
During a conversation with a physical therapy student, who is completing his clinical rotation with me as his clinical instructor, I admitted that I had recently caught myself being guilty of already “knowing everything” about anterior cruiciate ligament injury, reconstruction and rehabiliataion. That I, in fact had become, that therapist who was resting on her laurels regarding this particular matter. After all, I have treated countless clients “successfully” over the last ten years. Overall, most do great, most of the time. Then there are those who don't do quite as great as you would like. It's easy to chalk it up to relative non compliance on the client's part or perhaps their slow progress or lingering knee pain is the result of their genetic make up, pre injury condition or current activity level. But again, all in all, come the anniversary of their injury or surgery, they are doing pretty darn well. So, I never really was drawn to pursuing the matter further from a treatment persepctive.
Then, this past winter, my husband injures his ACL. The words from the orthopedic physician, if I remember correctly, was that his ACL was “gone-zito.” Now, all of sudden, I am no longer entirely confident just how to proceed. I mean, this is not only my ski buddy, he is the father to our two young budding skiers. He is also the one that I am counting on to keep up with them when they leave their Momma in the (powder) dust. Could he “cope” without his ACL. Did he “need” surgery? If he did have surgery, how would he fair. How do we set him up for success!
The timing of it all was quite serrendipitous as I was already in discussions with Dr. Ryan Mizner to offer a continuing education course, regarding that very topic, at one of our MAPTA conferences. Unfortunately, for me and my husband, the course would have to be postponed until the Fall – months after his surgery and rehabiliataion. Regardless, Dr. Mizner was very gracious in offering his advice based on his clinical expertise, research and vast knowledge base on the subject. And I realized, that perhaps, I didn't know everything about the subject. Things change over time, research reveals new ideas and we have the opportunity to improve our skills and clinical decision making to provide more efficient and effective care for our clients. The kind of care you want to provide for your closest loved ones. Thankfully, through the combined efforts of his physical therapist (not me) and his own dedication to his rehabilitation, my husband is doing great and has confidently returned to all pre-injury activities – even the ones that make me cringe a little bit. Even so, you can bet that I will be in attendance in Dr. Mizner's course this fall, Contemporary Topics in Physical Therapy Practice for Athletes with ACL Injury. There is a downside though. Attending this course means that I am not available to also attend Therapeutic Neuroscience Education and Pain Approach to Headaches, presented by the International Spine and Pain Institute, as it is happening that same weekend at the MAPTA Fall Conference. These are, undoubtedly, first world physical therapist problems and I welcome them with open arms.
We hope to see you in either of these fantastic courses this Fall. If, however, you are unable to travel to Missoula or have a scheduling conflict that weekend, you may still have time to take advantage of the online course, Primal Reflex Release Technique (PRRT), which is being offered at a significantly discounted price with a MAPTA coupon code which can be found on our website. Those who complete the online course will be eligiable to take a live PRRT course which we hope to bring to Montana. So check it out! You can learn more about PRRT at their website http://www.theprrt.com.
Keep learning and we will see you in October!
The Promoting Integrity in Medicare Act was reintroduced again this year in the US House of Representatives. This bill seeks to exclude Physical therapy from the Inter Office Ancillary Service Exception on the Stark Law (IOAS). Although this bill is well intentioned, I feel it does little for Montana and other rural areas.
The Stark Law was written to stop referral for profit, and decrease overuse of medical services. The original Stark legislation was passed by congress in 1995. There were many exceptions to the original Stark law, including IOAS. This was created to allow for same day services to be provided in a physician office as a convenience for patients. In effect this allowed physicians to have ownership in physical therapy practices within the same facility as the physicians. While the intent may have been honorable, a GEOstudy found that only 3% of all scheduled physical therapy visits were on that same day as those of a referring physician visit.
The IOAS has lead to overutilization of treatments, not just in PT, but also in other ancillary services including clinical labs and imaging. The Alliance for Integrity in Medicare (AIM) coalition was formed by professional organizations to promote and support this legislation, and APTA is a member of this coalition.
Unfortunately, as important as this legislation is, the rural exception to the original Stark law was left intact. Section 2.(a) 17 states “the exception to the ownership or investment prohibition for rural providers in the “Stark” rule is not affected by this legislation.”
What this means is that the proposed legislation only effects metropolitan areas. So sorry Bozeman, Kalispell, Darby, and Havre. Integrity defined by this legislation is only for the big cities. The rural exception was initially intended to make sure that rural areas had ac-cess to medical services. This may have made sense in 1995, but I feel it is no longer practical. PT departments are thriving in areas outside of metropolitan areas. And alt-hough there are a numerous shortages of physical therapy services in some rural are-as, physician owned parties are not helping to fill the gap.
So why is the rural exception safe? No one has been able to answer this ques-tion. It is not mentioned in any of the APTA publications supporting this legislation. It is not mentioned in the AIM publications. When the question has been brought up, and it has been many times to the APTA , the response has been vague at best. “We’ll get back to you”, has been the battle cry, but my phone isn’t ringing. My best guess is that this is being left in place as a compromise to those legislative areas that are rural or micropolitan to garner more support.
Politics are full of this type of arrangement. But with this compromise, rural and micropolitan PT’s are being thrown under the bus in hopes that a watered down bill might pass. But if it is integrity that we want, then it needs to include all providers of ancillary services. We are physical therapists. We should not be defined by the popula-tion of a town we chose to live in, by our gender, sexual orientation, religion preference, or skin color. If it is good legislation, then it is good for all of us.
Let’s have a discussion on the merits of this legislation not for a few, but for all PTs. And let’s not allow national endorsements to hide the fact that this legislation is not for all PTs. This needs to be heard in all rural states and regions. Rural means small, but we are an important part of health care from border to border. And if APTA chooses to continue to support this legislation as it is written, I believe they need to get rid of the word integrity - it doesn’t fit.
As hard as it is to see the snow melting off the mountains, I’m happy to welcome spring in my garden. Last issue, I talked about assessing readiness for and supporting change. Gaining that “buy in” with assisting patients in moving forward with a healthy life decision felt comparable to talking to fellow physical therapists about getting involved with APTA and MAPTA to progress our profession. Following that branch, I wanted to remind readers of the many benefits of membership. As we work in the ever shifting field of healthcare, we need the power of our voices to guide local and national issues toward our vision.
APTA, including Montana members and legislators, advocates year after year at the national level on big issues including healthcare reform and the Medicare therapy cap. Check out the Legislative Action Center for a quick and easy way to stay in touch with our representatives on Capitol Hill including prewritten letters on current concerns. Website: http://www.apta.org/TakeAction
Everyone is rightfully anxious about reimbursement. Ensuring physical therapists receive proper payment is a major component of APTA’s Strategic Plan. The Payment section is a great place to stay up to date on critical payment topics. http://www.apta.org/Payment.
MAPTA is also welcoming John Zakrzewski, PT, MT, OCS as our new resource for reimbursement questions and concerns.
The healthcare system is becoming more competitive every year. APTA offers marketing, public relations and branding ideas to communicate effectively with patients and other healthcare professionals.
http://www.apta.org/PRMarketing and http://www.moveforwardpt.com
Sometimes you have to spend money to save money. Your membership gets you a discount on great conferences, publications and continuing education courses throughout the year. The APTA Learning Center also offers free courses. Also, MAPTA is now partnered with Medbridge for a discount on over 400 accredited online courses.
http://www.medbridgeeducation.com and http://www.learningcenter.apta.org
Locally, MAPTA is gearing up for grassroots efforts to protect and advance our practice. Contribute to the Montana Physical Therapy Pact, http://mapta.com/PAC, and contact Christian Appel on how you can get more involved.
I hope this fertilizes your understanding of the many reason to stay a member. All the more, pass this information onto a colleague to begin or reinitiate membership.
Greetings from the Flathead Valley Community College’s PTA program. This past February, Julie Robertson, ACCE and I ventured off to California to attend the Combined Sections Meeting in Anaheim. Anyone who has been to CSM knows that it has great energy, excitement and hype as part of its atmosphere. It is also a wonderful place to network with peers from around the country. Being a PTA educator, I was especially interested in a session titled: Transforming the Role of the PTA to Meet the Vision of the Physical Therapy Profession, presented by Jennifer Jewell, PT, DPT, Beverly Labosky, PTA, Gina Tarud, PT, DPT and Pamela Pologruto, PT, DPT from Penn State University.
They analyzed survey data from around the country from both approximately 50% each of PTA’s and PT’s, both APTA and non-APTA members. They sought data regarding: educational requirements for the PTA, work analysis for the PTA, scope of practice issues amongst states, CE requirements for the PTA, career advancement opportunities for the PTA, workplace and academic education on the PT/PTA relationship, and job satisfaction of the PTA, to name a few. I won’t go into each item but I encourage those of you who work with and educate PTA’s to keep a look out for this article in the next few months. I will however, provide a bit more depth of the topic of the PTA education.
The role of the PTA has evolved since the career began in 1967. Next year will be the 50th birthday of the first PTA class in the US…Happy Early Birthday PTA’s! The skill level and knowledge demands of the PTA have progressed with the advancement of the DPT degree, but the timeframes for PTA education have confined PTA educators to try and pack in as much information as they can in a short amount of time to meet the knowledge expectations of our profession as a whole. This can be a challenge both for the student and the educators. Personally thus far, I have found the high caliber students that we have had at FVCC, has minimized this obstacle for me as an educator. Most students have come in with a strong work ethic, entry level knowledge and experience that have made meeting the demands of PTA education a quite rewarding experience.
That being said, there are notable issues that will need to be addressed in the near future pertaining to PTA’s and PTA education. Here in Montana, I see a need to continue to educate on the value of the PTA and their role in the patient care continuum. Nationally, prominent issues are: strengthening the PT/PTA model to meet the changing healthcare needs, developing career paths to allow advancement of the PTA and reinforce the lifelong learning and passion for the field of physical therapy, continuing to assess the PTA education model to ensure our current model is meeting the needs of all stakeholders, and most importantly remembering that the most vital stakeholder in all of this are the patients we serve.
Please remember to email, call or stop on by FVCC with any feedback that you may have about the utilization of PTA’s in your area or PTA education.