Written and submitted by APTANJ member, Yaffa Liebermann, PT, GCS

On our most recent excursion, we stopped in Bhutan. We visited the village “Simple Bhutan ” which encapsulates both past and present lifestyles in Bhutan. We had the opportunity to view traditional dancing and dress, cooking traditions, alcohol production and archery – all activities demonstrated the beautiful lifestyle in Bhutan. It was very interesting to see how the locals live – sustaining themselves in these mountains and welcoming all with open arms.

While visiting, we were fortunate to come upon a “foot” artist by the name of Pema Tshering. Diagnosed with Cerebral Palsy and abandoned by his parents when he was six, Bhutanese artist Pema Tshering had a chance meeting with Bhutan’s Queen Mother which changed his life forever. With her support, he was finally able to pursue his education and focused his studies on art. His full story can be found at https://goo.gl/T73rR2.

Our unexpected meeting with Pema was deeply touching for me as a Physical Therapist. Cerebral Palsy is one of the most prevalent diagnoses treated by Mobile Therapy Services which provides Physical Therapy, Occupational Therapy and Speech Language Therapy to those with developmental disabilities in New Jersey. Pema, though unable to utilize his upper body, was smiling and welcoming as he laid on his mattress on the ground. He had become accustomed to and skilled at utilizing his feet to create beautiful works of art including both wood carving and painting. We watched him paint with different styles of brushes and vivid colors. We purchased a wooden, painted piece and I asked him to sign it on the back which he was gracious enough to accommodate – even utilizing his feet to sort out bills and correct change for our purchase!

The entire experience with Pema was beyond inspirational – seeing, firsthand, how a person with so many limitations at the start of life can achieve so much. While so many with physical limitations struggle with their mental health, Pema is pushing forward and has created an independent life where he is able to support himself. He is a true testament to the power of positivity and resilience.

Acupressure Complementary & Integrative Medicine Approach

Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200

According to the National Center for Complementary and Integrative Health (NCCIH), a branch of NIH, pain is the most common reason for seeking medical care (Pain: Considering Complementary Approaches published by National Center for Complementary and Integrative Health, 2019). There is a rising clinical interest in Integrative medicine for non-pharmacologic treatment options as our healthcare system faces a crisis of pills and opioid use (Monson et al 2019). 

Integrative health is an evidence-based healing-oriented approach that takes into account the whole person, emphasizes lifestyle and the therapeutic relationship between practitioner and patient, and makes use of all appropriate therapies. The NCCIH further defines integrative health as bringing conventional health care 
approaches (medication, physical rehabilitation, psychotherapy, etc.) and complementary health approaches (acupuncture, yoga, probiotics, etc.) together with an emphasis on treating the whole person (Justice et al 2023).
One of the guiding principles of Integrative Physical Therapy is to create a therapeutic alliance between the clinician and the patient. The focus is on “whole person health” by regulating their nervous system, thereby creating resilience and overall well-being for the patient.

Anxiety is a very common psychiatric symptom and can also occur in many physical conditions. Due to the limitations of conventional pharmacotherapy, the discovery of nonpharmacologic treatments that alleviate anxiety effectively is clinically important. Research shows that Acupressure is very effective clinically as a mind-body practice for improving pain, anxiety, heart rate variability, nausea, chronic fatigue and a host of other conditions.

Acupressure is a type of Acupuncture in East Asian Traditional Chinese Medicine (TCM). It’s part of an integrative medicine that involves the application of pressure to specific points (i.e., Acupoints) or specific areas of the body using one’s hands or other Acupressure devices (Kwon et al). Acupressure has been used in Traditional Chinese 
Medicine for over 3000 years and is based on Meridian theory.

Acupressure can be performed by a clinician or self-administered for a variety of indications including reduction in stress-related symptoms. Among other things, acupressure has been shown to regulate activity of the hypothalamic-pituitaryadrenocortical axis, thereby modulating levels of cortisol, endorphins, and serotonin—hormones that affect mood, nociception, and stress (Abbott et al). 

Emerging research shows that these Acupoints are embedded in a three-dimensional fascial network throughout the body and have a high electrical conductivity on the surface of the skin. Histological studies show a high density of A and C afferent fibers at these points. Through a vast network of interstitial connective tissue, these Acupoints 
connect the peripheral nervous system to the central viscera. Heart 7 (H7) is the 7th acupoint of the heart meridian, which is located at the ulnar aspect at the end of the distal transverse crease of the wrist, between the flexor carpi 
ulnaris and the flexor digitorum superficialis. Yintang (EX-HN 3), is an acupoint located between the eyebrows. Both these acupoints are known to have a calming & mentally stabilizing effect in Traditional Chinese Medicine. 

Teaching our patients self-regulation skills fosters a sense of calm and helps them focus on the present in a mindful way. As the evidence continues to grow, both medical providers and patients are seeking effective non-pharmacological approaches for symptom relief. Clinically Acupressure shows promising results and adds value to an Integrative approach to Rehabilitation wherein we can combine holistic mindful-based 
interventions into our best evidence-based practices.

The course Acupressure: Integrative Healthcare for Stress & Pain Relief series is curated and taught by Rachna Mehta. It explores Acupressure as a powerful integrative practice and offers unique evidence-based daily wellness regimens. To learn how to integrate Acupressure into your clinical practice, please join us on April 6th, 2024.

References

1. Pain: Considering Complementary Approaches published by National Center for Complementary and Integrative Health, 2019 2. Monson E, Arney D, Benham B, et al. Beyond Pills: Acupressure Impact on Self-Rated Pain and Anxiety Scores. J Altern Complement Med. 2019;25(5):517-521
3. Justice C, Sullivan MB, Van Demark CB, Davis CM, Erb M. Guiding Principles for the Practice of Integrative Physical Therapy. Phys Ther. 2023;103(12):pzad138. doi:10.1093/ptj/pzad138
4. Kwon CY, Lee B. Acupuncture or Acupressure on Yintang (EX-HN 3) for Anxiety: A Preliminary Review. Med Acupunct. 2018;30(2):73-79. doi:10.1089/acu.2017.1268
5. Chen YW, Wang HH. The effectiveness of acupressure on relieving pain: a systematic review. Pain Manag Nurs. 2014;15(2):539-550.
6. Abbott R, Hui EK, Kao L, et al. Randomized Controlled Trial of Acupressure for Perception of Stress and Health-Related Quality of Life Among Health Care Providers During the COVID-19 Pandemic: The Self-Acupressure for Stress (SAS) Trial. Am J Med Open. 2023;10:100056. doi:10.1016/j.ajmo.2023.100056
7. Bal SK, Gun M. The effects of acupressure on pain, anxiety and vital signs in patients undergoing coronary angiography: A randomized and sham-controlled trial. Explore (NY). Published online July 4, 2023. doi:10.1016/j.explore.2023.07.00

The Federation of State Boards of Physical Therapy (FSBPT) reports, “Physical therapists (PTs) and physical therapist assistants (PTAs) whose home state is Arizona, Arkansas, Colorado, Delaware, Georgia, Iowa, Indiana, Kentucky, Louisiana, Maryland, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, and Wisconsin will be able to go to www.ptcompact.org to verify their eligibility and purchase compact privileges. Practitioners can purchase compact privileges for one or more of the other remote states, giving them the ability to provide physical therapy services in those states.”

Click here for more information on the NJ compact from the FSBPT.

PT Licensure Compact legislation in New Jersey was signed into law back in January 2018.

Healthcare Services in Office Practices

Updated Administrative Order

Dear Healthcare Licensee,

This notice is to inform you that the Division of Consumer Affairs (“Division”) has issued an Administrative Order (“AO”) modifying AO 2021-11, which governed the provision of health care services in office settings in light of the COVID-19 pandemic. The AO,  DCA-AO-2022-01, now requires health care professionals who provide care in office settings to monitor and adhere to any guidance issued by the Centers for Disease Control and Prevention (“CDC”), the New Jersey Department of Health (“NJDOH”), the Occupational Safety and Health Administration (“OSHA”), and local health departments. This change will help ensure that the provision of health care in office settings is consistent with prevailing health and safety standards, as they evolve over time.

Thank you for your continued efforts to protect public health and safety.

Cari Fais
Acting Director
Division of Consumer Affairs
Office of the New Jersey Attorney General

From the NJDOE proposal: 

Although the declared public health emergency has expired, P.L. 2021, c. 103 provides that rule waivers/suspensions/modifications adopted under the authority of EO 103 will expire on January 11, 2022. P.L. 2021, c. 103 also allows agency heads to terminate rule waivers/suspensions/modifications prior to the expiration date. Since all schools will be returning to full-time, in-person instruction for the 2021-2022 school year, the Department proposes to terminate modified N.J.A.C. 6A:14-1.1(d)5. If certain conditions require a school to be closed for in-school instruction for more than three school days, P.L. 2020, c. 27 will allow special education and related services to be provided through electronic communications, virtual, or other online platforms during the closure. Upon State Board of Education approval, the termination will be effective immediately.

 The Department has determined that modified N.J.A.C. 6A:14-3.9(a) and 5.2(f) should not be terminated at this time to continue to allow related services to be provided through telemedicine and telehealth or through electronic communications as appropriate and as required by the student’s IEP to the greatest extent possible. The Department also plans to pursue amendments to N.J.A.C. 6A:14 to make permanent certain provisions allowing related services to be provided through electronic communications or virtual or other remote platforms. Read more.

Throughout the year, there are several opportunities to engage your community. From partnering with small local organizations to joining larger national and global events, any involvement goes a long way. Some of the benefits of professional involvement outside of the clinic environment may include: It’s rewarding for those involved, helps improve our professional image, and educates the public about what we do and how we can serve. Here are two such events that are great opportunities to get involved in - at any level:

National Fall Prevention Awareness Week (NFPAW)

The National Council on Aging (NCOA) leads the Falls Free Initiative, a national effort to provide public education and support in addition to the promotion of evidence-based fall prevention programs and interventions that help government agencies, organizations, corporations and community members prevent falls. In 2008, the Falls Free State Coalitions on Falls Prevention Workgroup National Advocacy Workgroup requested that a national Fall Prevention Awareness Day (FPAD) be observed on the first day of Fall. Soon after, it gained bipartisan sponsorship in the U.S. Senate and has obtained bipartisan support every year since then. FPAD is observed by almost every State in the USA. Since 2020, the NCOA extended FPAD to a week-long event. Each year, the NCOA provides technical assistance and extensive resources to aid states and communities in observing the week. Be sure to check out their newest resources, including a Falls Prevention Awareness Week Promotion Toolkit and a webinar geared towards healthcare professionals. Click here for more information.  This year's annual NFPAW will be observed from September 20-24, 2021!

Global PT Day of Service (PTDOS)

In 2012, Efosa Guobadia, PT, DPT & Josh D’Angelo, PT, DPT had a vision where clinicians, students and staff of the PT profession from around the world would come together to volunteer on the same day. Since then, PTDOS has grown amazingly, with service projects occurring every year in countries all over the world. PTOD coincides with National Physical Therapy Month; this year PTDOS will be held on October 9th, 2021. Click here for more info including project ideas, how to participate and resources. There is no formal theme of PTOD; all volunteer projects from providing pro bono work (like balance screens and fall prevention) to collecting non-perishable food for your local food pantry are welcomed.

Barriers to Community Involvement

From talking to therapists and students about community involvement, I feel that there are common themes as to why there aren’t more of us engaging our older adults out of the clinical setting. Some felt community involvement is too time consuming while others said they don’t know how to get involved or don’t know how to turn their ideas into a reality. Several years ago, I felt this way too. My first efforts in falls promotion in my community were small, but important. I ordered STEADI toolkits for the therapists and students in my department along with brochures for our patients. I prepared a quick 2 minute spiel in case my colleagues were curious in the STEADI program and was ready to provide a detailed overview for those interested.  At the same time, I began encouraging my patients to share STEADI materials with their families, friends and healthcare providers. 

The results? Some colleagues were intrigued, some began implementing STEADI tools in practice and many unfortunately weren’t ready for professional nourishment at that point in time. Almost all my patient’s used some of the STEADI tools to reduce risk of falls. A month later, the Executive Director of our facility asked if I would be interested in presenting a falls prevention lecture at a local senior center based on the STEADI toolkit.

So, how do you start? The answer is simple - think about what YOU are passionate about. Are you interested in providing balance screens? Providing a (in-person &/or virtual) lecture or workshop on fall prevention awareness? Reaching out to other disciplines in your organization?  Organizing a meet and greet with local seniors? Providing an in-service to your colleagues? Organizing an exercise group for aging adults? The options are as wide as your imagination and creativity… as Walt Disney once said “If you can dream it, you can do it.”  

Have you seen the APTA Geriatrics Balance & Falls SIG Falls Prevention Awareness Toolkit? In 2019, I chaired a taskforce of the BFSIG that created the Falls Prevention Awareness Day Toolkit, the first of its kind for the APTA Geriatrics. The aim of the toolkit is to provide physical therapists all the resources they need to create a falls prevention event in commemoration of National Fall Prevention Awareness Day. We were thrilled by the overwhelming response. In less than ten months, almost 1,200 clinicians and students downloaded the toolkit. As the year progressed, the team decided they would update the toolkit to accommodate changes in the CDC’s STEADI material, to be more inclusive to students, and to promote falls prevention awareness events throughout the year. For our second edition, Falls Prevention Awareness Toolkit, A Comprehensive Guide to Professional & Community Engagement, the purpose is to provide clinicians and students all the resources they need to create falls prevention screening and/or awareness events throughout the year. 

The resources provided within this toolkit were designed by clinicians for clinicians of any skill set or experience level organizing fall prevention awareness events throughout the year. The toolkit was designed to assist clinicians and students in creating and/or improving their community-based falls prevention events by utilizing current evidence and gaining exposure to a wide-variety of quality resources. The toolkit is open access for ALL, FREE of charge; membership to the APTA and/or APTA Geriatrics is not required. Click here to access the toolkit.

Here are some other resources to get you started:

• Click here to check out the FPAD Impact Reports for a variety of ideas!
• APTA Geriatrics Balance and Falls SIG Conference Call for FPAD.
• 2020 BFSIG Falls Prevention Awareness Week Brainstorming Webinar.
• Virtual Balance Assessments – Helpful Links for Clinicians.
• The CDC’s new Still Going Strong campaign encourages ageing adults to age without injury and provides simple steps that ageing adults and their loved ones can take to prevent injuries.

Finding Key Partners in Your Community and/or State

I won’t lie, blindly contacting organizations and agencies can be time-consuming. However, the right partners can provide marketing and media coverage, help recruit attendees, and provide a location, resources and support for your event/activities. Below is a list of organizations, agencies and individuals that may be helpful. When going through this list, think about who would be most appropriate based on the type of involvement you're aiming to achieve. For example, a talk on healthy aging or fall prevention may be most appropriate for senior centers, local gyms/health clubs or senior living communities. Government agencies, community centers, senior centers and local fairs may be most beneficial for fall prevention events. Be prepared to synthesize what your intentions are and how you can benefit your community.If a contact isn’t interested in your ideas, ask how you can help the aging adult population in their organization or in your community. Believe it or not, this may lead to more exciting ideas!

This list is ALWAYS evolving, so please feel free to share your experiences with the group!

• Area Agencies on Aging (AAA)
• Community Centers
• Health Fairs
• Hospitals
• Fitness Centers
• Libraries
• Malls
• National Council for Aging (NCOA): Click here for programs and partners near you
• Older Adult Housing: ALF’s, SNF’s, senior communities
• Opticians Office
• Orthotist
• Places of worship
• PT Clinics
• Retailers: Specialty footwear, hardware and pharmacies
• Senior Centers
• Senior Meal Sites
• State Advocates, AGPT
  • They work at the local level to advocate for older adults. Advocates are responsible for providing two-way communication between the AGPT and the State chapter, so they may have access to resources that can assist you with your efforts. They are also responsible for holding at least two activities each year to promote increased awareness and knowledge of PT for the older adult in your chapter, which may be another way for you to get involved in your State and community. Click here to find your State Advocate.
• Volunteer Organizations

In closing, anytime is a good time to get involved in your community, though using national and global campaigns is a great way to ease yourself in as there are plenty of resources readily available. This month, please begin to think about how you would like to get involved in your community. No action is too small!  

Your colleague,

Haim D. Nesser, PT, DPT, CCI, CEEAA, CSRS, LSVT

Vice Chair, APTANJ Geriatrics SIGAPTA Geriatrics State Advocate for New Jersey

Clinical Co-Liaison, APTA Geriatrics, Balance & Falls SIG                      

Recommended Reading

Lusardi MM, Fritz S, Middleton A, et al. Determining Risk of Falls in Community Dwelling Older Adults: A Systematic Review and Meta-analysis Using Posttest Probability. Journal of Geriatric Physical Therapy. 2017;40(1):1-36.

Register Here

Written by: Yaffa Liebermann PT, GCS, CEO and Eli Liebermann, PhD, MBA, President

 Independence Day commemorates the victory that we had over the British rule, and made us independent. We would like to take this opportunity to thank everyone at Prime Rehabilitation Services that helped patients regain their health back providing them the freedom to live their lives.

We did not foresee that the disease would get to the dimensions it got. Only during the act itself, did everyone recognize that they were not walking on a side trail but were paving the main road with their courageous treatment of the infected patients.

Regrettably, some of our therapists on the front lines became infected with the Covid19 virus. Thankfully all have recovered and returned to work to continue and help their peers in helping the patients cope with the disease. Others have children who were out of school, or parents in a vulnerable condition, whom they need to support, but the corporate team found innovative solutions to help the therapists continue and provide care.

Therapists used their experience and wit to find ways to treat the patients with the care and skills they possess. The therapists worked closely with the nursing home staff to find safe solutions to provide the best treatment to the patients. Unfortunately, they had to go through the pain and agony of losing some of their patients.

The corporate staff continuously worked behind the scene to support the therapy teams by making sure that they could concentrate on their daily operation. This support included making sure that therapists are available in each location replacing those who could not work, providing gloves and masks, and when those were not available, our CEO sewed masks for everyone in the company.

When Telehealth became allowable, treatment protocols and procedures were immediately written to cover and regulate the new way of treatment. Information was continuously supplied to therapists who had to be quarantined and those who had to stay home because they needed to care for family members, to make sure they could survive financially and take advantage of the financial help provided by the government.

The impossible became possible; just like when the US untrained army of the people defeated the trained army of the British Empire to gain our independence!

We would like to salute all our employees at Prime Rehabilitation Services and the management and staff of the nursing homes that we service for their dedication, courage, and devotion to the nursing home residents.

The APTANJ has been a leader in assisting physical therapists in navigating the  provision of telehealth physical therapy services under the NJ Uniform Enforcement Act and also in accordance with the Department of Education directive that mandated physical therapy be provided to children with special needs in NJ schools during the state-wide school closure. While APTANJ has been the paramount source for accurate information for physical therapists, the association cannot provide specific direction on how we should address the potentially complicated decisions that implementation of telehealth creates.

Rather, it is our professional duty as physical therapists to reflect and re-examine the evidence as well as our moral compass when we make clinical decisions with respect to practicing via telehealth.  An APTA position statement (P03-03-12-28), articulated that “autonomous practice is characterized by independent, self-determined professional judgment and action. Physical therapists have the ability and responsibility to exercise professional judgment within their scope of practice, and to professionally act on that judgment.”  The pandemic and telehealth have not changed this extremely important approach to clinical practice.

During these truly challenging times, we as professionals are called upon to follow our Code of Ethics and Professional Core Values as we strive to utilize the best evidence to serve our patients/clients and practice autonomously. Recent questions have been posed that indicate we are reflecting and working hard to determine the best course of care for those we serve.   At the core of these questions is to determine whether to practice telehealth at all, or to do so in a more selective, case by case basis.  Colleagues are clearly exploring that because we can treat our patients via telehealth does not mean we should in all circumstances. 

We need to exercise our professional judgment with respect to all of the individuals we serve and determine what is truly in their best interest as we always have. We cannot base our practice decisions on direction from practice owners, supervisors or the like. Rather, we need to reflect and use our independent professional judgment. We need to ask ourselves whether a particular patient will decline without our services?  Can or should an individual wait to be appropriately or optimally managed when the pandemic ends, and we return to face to face practice? Can the patient be managed during the pandemic with a home exercise program? Also, how do we appropriately bill for our services via telehealth? Is it only the time we are delivering physical therapy services, or can we bill for setting up the services?  How do we ensure patient confidentiality and be HIPAA-compliant using a variety of virtual platforms?  And perhaps the most important clinical decision: given the patient’s or client’s situation, can we effectively and safely provide skilled physical therapy services via telehealth? 

All of these questions cause us to reflect and explore options for each individual patient/client. They may be of varying difficulty for physical therapists depending upon the personal and practice situations in which you find yourself.  Where do you practice?  What stressors on practice viability and your own productivity or even employment status are there?  Are these factors working to inform or perhaps even dictate your clinical decisions during this pandemic?  Some physical therapists are fortunate in that by virtue of an employment situation and/or experience, they are able to continue to practice and support themselves and their families.  Others may be challenged by their practice on a daily basis to remain productive and meet their personal needs while exploring the delivery of telehealth services.

Despite the unforeseen dynamics that Covid-19 has brought to us, I truly believe physical therapy professionals in New Jersey can effectively navigate this situation with skill by maintaining the high level of autonomous practice we standardly deliver and that consumers of our services have come to expect. 

In these trying times, rely on your professional association, your colleagues, the best evidence and key professional documents beyond the NJ Practice Act, like the Code of Ethics and Core Professional Values, to assist in your clinical decision making with respect to telehealth. Explore the appropriateness and effectives of the services you are able to provide for each individual you treat. Covid-19 and telehealth have challenged how we practice currently and may change the landscape of our practice when we return to on-site delivery of care. Now and moving forward, we are in this together, and we will be better as a profession as we face these challenges/questions together.

I wish you well. Be safe. Be strong.  I hope to see you at an APTANJ conference in the (near) future.

Lee Ann Guenther

Lee Ann Guenther PT, DPT, MS

Associate Professor of Physical Therapy Stockton University

NJ School Certified PT

Lee Ann is a member of the APTANJ Ethics Committee and has presented Ethics courses  in New Jersey approved by the New Jersey State Board of Physical Therapy Examiners 

By: Stephanie Wakeman

What is telehealth/telemedicine? Telemedicine is the delivery of a health care service using electronic communications and/or information technology to provide services between a healthcare provider and patient at a different site.  These services must be provided according to state practice act and state laws just like an ‘in person’ visit.

Globally, the term ‘digital practice’ is being used since it is viewed as more encompassing of the range of technologies on current and future practice.  Therefore, the task force of the World Confederation of Physical Therapy has proposed the following definitions:

Digital practice is a term used to describe health care services, support, and information provided remotely via digital communication and devices.

Purpose: The purpose of digital physical therapy practice is to facilitate effective delivery of physical therapy services by improving access to care and information and managing health care resources.

Digital PT has become all the rage with the onset of COVID-19 and people are clamoring to get onboard with this technology.  The purpose of this article is not to advise on how to get started with your own digital PT gig, but if that is your desire there are some great resources out there. Here is a link to a course to get you started by the real guru, Rob Vining.  The resources can guide you on the ‘how’ of establishing a HIPPA compliant platform and scheduling software as well as EMR options.  APTA also has plenty of resources on compliance and insurance matters regarding telehealth including This article which also has links to other resources. Here is another resource to the specifics on how to start a digital practice.  Finally refer to this resource Compiled by HPA section of APTA for more  updates and resources.

NJ is a parity state meaning legislation has been passed that requires private insurance companies to pay for telehealth service rates similar to in person medical care.  However, this does not mean that all insurance companies that you are contracted with WILL reimburse you.  You have to call each insurance company and ask directly and document the conversation.

How to conduct a digital visit:

When conducting a digital visit, keep in mind best practices and evidenced based intervention. It is vitally important that you conduct a thorough evaluation.  This includes a history of the current problem, systems review, past medical history, and review of work and home environment that may be contributing to the problem.  Use of digital PT has an advantage over in person visits in this way because you can visually see the environment in which the patient lives/works and can assess how their daily set up is affecting a particular impairment.  It is vitally important to rule out for yellow and red flags.  Presence of yellow flags may indicate this person is not appropriate for a digital visit but may benefit from a face to face interaction.  Impairments such as falls risk, some neurological impairments, and suspicion of fractures or infections will warrant an in person visit.  Some yellow flag indicators such as high levels of depression or anxiety, complicated co-morbidities, or significant loss of mobility/function may also warrant an in person visit and/or referral to appropriate healthcare provider.  Any presence of red flag indicators is a signal for immediate referral to MD. Providing an accurate diagnosis, prognosis, and comprehensive education is necessary.  Establishing patient goals and developing a plan of care with evidenced based intervention is key to success.  Services provided must be skilled and effective in accordance with APTA guidelines to practice.  Documentation of each visit is required.

Assessment:

You may be wondering how to determine strength of a particular area/muscle.  This is where you need to get creative and think functionally. Here are some tips for functional assessments in a virtual world:

• I like to assess overall lower body strength through squats, single leg squats, single leg heel raises and 5x sit to stand test.  Assess the squat from frontal and sagittal planes and take note of lumbo-pelvic motion in the sagittal plane. Look at heel raises from posterior view and assess for calcaneal varus/valus that can clue you into eversion and posterior tibialis function. 

• Assess singe leg balance/squat and focus on femoral rotation, knee varus/valgus and excessive pronation/supination at the foot for stability. 

• Observe a step up and a step down and assess for movement quality. 

• For the upper extremity look at a tall plank and push-ups from knees or toes.

• Ask the patient to resist their own bicep curl or front/lateral raise or perform these actions as an isometric against a wall and get their input on right/left differences.  

Special tests:  When performed in clusters, special tests can have a higher likelihood ratio and be more efficacious.  Therefore, performing one or two modified tests is not very reliable, but it may give you information on symptom modification with movement.  A patient can self-perform an empty can test and you can ask them to give themselves overpressure for end range flexion for a modified Neers and cue them into a Kennedy Hawkings position.  Asking the patient to move in specific directions and cueing them on nuanced changes may provide helpful information.

Special tests for ligamentous injuries can be more challenging.  This is an example of the need to refer out for to other provider if you suspect a grade IV tear and/or notice excessive instability of the joint especially when combined with a history of trauma.  It is helpful to review Ottawa ankle/knee rules and Canadian C spine rules. 

Wrap Up: Although there is a plethora of resources out there now on how to start digital visits, it’s really not something you can just setup and be ready for tomorrow.  This new frontier of healthcare takes planning, training and preparedness to ensure compliance with all regulations and deal with emergencies should they arise.  I have found digital PT to be very rewarding because it allows for more one on one in a private, undistracted setting.  Digital PT is NOT for everyone or every impairment, but it really works well for the right person who been properly evaluated and screened.  It has allowed for improved connection with someone because you are ‘invited’ into their homes/offices thus making the visit a bit more personal.  This undistracted space allows for more opportunities to have discussions about areas of health such as sleep, nutrition, mental wellness, and overall exercise habits that can greatly contribute to the person’s sense of wellbeing. 

Stephanie DeShano Wakeman is a doctor of physical therapy and licensed in multiple states including NJ. She is a long time member of APTANJ and currently serves as Delegate.  She has over 20 years of experience in multiple settings but is focused on orthopedics and dance medicine. She has been involved in digital physical therapy since December of 2019 working for Physera Physical Therapy. 

https://ptonice.com/rob-vining

http://www.apta.org/PTinMotion/News/2020/03/23/QuestionsToAskAboutTelehealth/

https://www.telehealthpt.com/telehealth-starter

https://www.aptahpa.org/page/COVID19#InteractiveAudio

You can read the statement from Horizon BCBSNJ here

APTANJ is pleased with NJ DOBI’s response.  Moving forward, we will continue our dialogue with Horizon BCBSNJ’s leadership in a productive and positive manner to make sure that New Jerseyans have full access to their physical therapy benefit.

We wish to thank all of our members who advocated on behalf of the physical therapy profession in New Jersey, but more importantly, for your patients!

Brian Mason, PT, DPT, President

American Physical Therapy Association of New Jersey

On September 1, UHCCP will implement a new policy concerning authorization for outpatient physical, occupational and speech therapy with a particular focus on site of care. Below are some key concerns with the policy.

•        It is unclear which freestanding outpatient PT/OT providers are able to serve children with special needs.  Access to care concerns are arising, specifically for this population especially in Newark, Jersey City, New Brunswick, Toms River where there are no or limited freestanding locations accepting managed Medicaid reimbursement.  To date, UHCCP has not provided a list of in-network providers that will be able to care for these children.

•        The documentation burden on therapists and physicians is unreasonable and unnecessary to achieve the goal of improved overall management of the therapy benefit.  This paperwork burden will be a barrier to access by having a chilling effect on referrals.  Therapists are highly trained and skilled professionals who evaluate and design plans of care for thousands of patients every day.  Forcing them into an additional step with the referring physician will only serve to delay care for patients. National data on utilization of these services compared to New Jersey only tell part of the story and cannot account for the diversity of population, social determinants affecting health status and other local issues affecting our communities.

•         Under the Medicaid Managed Care contract, a readiness review is required for changes in service authorization policy. UHCCP has acknowledged that the questions raised during their Aug. 23rd education session will require them to produce further guidance.  It is not productive to incrementally add guidance because it adds confusion to the process.  The policy implementation should be delayed until UHCCP can demonstrate readiness and has engaged in more robust provider education.